Case History Quiz Flashcards
(7 cards)
Define “chief complaint/concern”.
A brief statement, in the patient’s words, regarding the complaint/symptom or concern that prompted them to seek care.
List order of ten typical steps of patients evaluation and management from initial presentation to final outcome.
I. PATIENT MOTIVATION (“chief complaint”)
II. INTERVIEW – CASE HISTORY
III. PHYSICAL EVALUATION
IV. TECHNOLOGIC EVALUATIONS AND CONSULTATIONS
V. CLINICAL ASSESSMENT
VI. CLINICAL IMPRESSION AND COMPLICATING FACTORS
VII. FORMULATE A MANAGEMENT PLAN
VIII. REPORT OF FINDINGS AND RECOMMENDATIONS
IX. CLINICAL TRIAL
X. PERIODIC STATUS REPORTS & RECOMMENDATION POSSIBILITIES
Define “present illness/problem”.
The detailed data collected from the clinical interview regarding the patient’s chief complaint(s).
List four major topics of “past Health History”.
Illnesses, Medications, Injuries, Surgeries & Transfusions (IMIST)
AoDL that might lead to TTTs, causing subluxation
Examples: Drinking, Smoking, Sleeping, Diet, Work, Physical Activity
Explain “review of systems”.
Ask the patient to check symptoms they’ve had recently that are associated with various systems of the body.
18 generic questions regarding “present illness” in your own words.
- What do you think caused your_________?
- When did first appear?
- Did they begin gradually or suddenly?
- Have you had anything like this before?
- Can you point to where it’s bothering you?
- Does I radiate from there? (Where)
- Can you describe the feeling?
- Do you have any discomfort anywhere else?
- How would rate the intensity? (1-10 scale)
- Is it present 100%, 50%, 25% of a day?
- Is it getting better, worse or staying the same?
- Is there anything that makes it better?
- Is there anything that makes it worse?
- Any change in other bodily functions? 15. Has it affected your daily activities?
- Have you tried o.t.c. remedies?
- Have you tried other professional care?
- Is there anything else you would like to discuss or add?
