How detailed does the CS history need to be.

[Modeselektor]

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Basically I came up with a pretty thorough and modular history setup, but I'm concerned its too long and I should scale it the hell back.

I start off asking the chief complaint, and then go into my HOPI.
Onset, course, duration, (IF pain then Place, Quality, Radiation, Severity), Timing, Effect, Prior episodes

After this it will be specific to my D/D.
Migraine: auras, photophobia, relation to food/emotions/stress/menses,
Tension: stress, depression
Cluster: red eye, tearing, runny nose, ptosis

Then I've got some standardized Review of systems questions. So lets say the C/C is Headache, well then I'm gonna ask about:

General: Fever, SOB, Cough, N/V, Bowel changes, Fatigue, Weight changes,
CNS: Loss of consiousness, weakness, paresthesias, seizure,
HMF: orientation, memory, conciousness,
CN: speech, swallowing, vision, hearing,

Then the standard PAMHUGSFOSS.

Going through this takes about 8 minutes on my own, but I'm feeling this is too much for the CS and I can end up screwing up my physical/closure like this.

Any thoughts/advice would be greatly appreciated. Thanks.

 

[thehundredthone]

Either your HOPI or your ROS is going to have to include the negative history pertinent to the different types of headache in this case. Similarly, most CNS related ROS will actually be part of the HOPI in this case, so remember to bring directly relevant ROS components into your HOPI (as positive or relevant negative history). Higher mental functions are something best left for the MMSE rather than your history. For a lot of symptoms, grouping is possible to make things easier on the note (you'll still have to ask about each one). Don't get into ROS minutae, e.g. don't ask about both SOB and cough in a patient with a headache unless you think it's warranted.

8 minutes sounds okay for the full history, of course you will go over in some of your cases and will have to adjust your examination accordingly. Just remember that CIS is important so it's okay to have a more abbreviated examination in a case where the patient required a lot in terms of CIS (both during history and during closure).

 

[Modeselektor]

Thanks a lot @thehundredthone. That clears a lot of stuff up for me.