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Comprehensive Health History Flashcards

(71 cards)

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1
Q

Comprehensive Pt Assessment

A

New Pts or Hospital admission
-whole knowledge about the pt
-rule out physical causes related to the concern
-baseline

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2
Q

Focused Pt assestment

A

established pts or urgent care
-focuses on specific concerns
-ROS over only pertinent systems

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3
Q

subjective

A

“symptoms” “spoken”
what the patient tells you
CC, ROS

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4
Q

Objective

A

“signs”
physical examination findings
Diagnostic testing results
Personal observations (odor, language, gait, etc)

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5
Q

Subjective data

A

Initial info
CC
HPI
PMH
FH
Personal/social HX
ROS

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6
Q

Initial information

A

Date and time
Pt initials, age, gender
Source of Info and Pt reliability

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7
Q

CC

A

always in “x”
select one CC that predominates

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8
Q

HPI

A

the story
OLDCARTSS
(include an intro sentence w Pt initials, age and gender and PMH)
-pertinent + and - symptoms

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9
Q

Onset

A

When did it start? What setting did it start in

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10
Q

Location

A

Where on the body is the problem, symptom or pain at?

(point)

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11
Q

Duration

A

How long has it been present?
How long does it last?

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12
Q

Character

A

Adjective describing the problem, symptom or pain
-dull, sharp, burning, tingling etc

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13
Q

Alleviating and Aggravating factors

A

what makes it better or worse?

any meds?

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14
Q

Radiation

A

Does the pain move to other areas?

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15
Q

Timing

A

How often does it occur?
Constant or Intermittent

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16
Q

Severity

A

pain scale (1-10), comparison to other experiences

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17
Q

Symptoms associated

A

(+) or (-) symptoms

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18
Q

Allergies

A

Drug, food, environmental

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19
Q

true allergy

A

anaphylaxis
hives
immune response

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20
Q

Side effect

A

stomach pain
rash
(known Rx of a drug)

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21
Q

Current Medicaitons

A

Rx, OTC, herbal supplements, vitamins

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22
Q

Order for recording a medicine

A

Name, dose, route, frequency, (as needed?)

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23
Q

PO

A

oral

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24
Q

PR

A

per rectal

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25
SQ
subcutaneous
26
OS
left eye
27
OD
right eye
28
OU
both eyes
29
AS
left ear
30
AD
right ear
31
AU
both ears
32
childhood illness
acute illlness (measles, mumps, rubella, whooping cough, chickenpox, rheumatic fever, scarlet fever, polio) Chronic illness
33
Adult medical HX
Acute or chronic hospitalizations
34
Surgical HX
name of surgery, date, indication -problems with anesthesia -complications?
35
OB/GYN
age at menarche current period (duration, frequency, regularity of meneses) Age at menopause? G#PTPAL Contraception? Pap smear? Results? Mammogram? Results?
36
G#PTPAL
Gravida- number of pregnancies Term- Number of term pregnancies Preterm- number of preterm pregnancies (20w-36.6w) Abortion- spontaneous or induced abortions (under 20w) Living- Number of children living
37
Psychiatric history
Diagnoses (date and age), Treatment, or hospitalization
38
Health maintenance
Immunizations Screenings and other tests -Dental, Eye exam, low dose ct, ekg, colonoscopy
39
Family history
3 generations list age, health or age and cause of death Specific disease: HTN, DM, Hyperlipidemia, thyroid, cancer, Heart disease, stroke, renal, mental illness
40
SOGI
Sexual orientation Gender identity Sex on Birth certificate
41
Social HX
Place of birth occupation education household significant relationships exercise diet leisure/hobbies safety alcohol/tabacco/ caffeine, illicit drug use ADLS Spiritual history sexual history
42
CAGE
alcohol cutting down? annoyance when criticized? guilty feelings? Eye openers?
43
pack years
of packs smoked per day X # of years person has smoked
44
Basic ADLS
ambulating feeding dressing toileting bathing transferring
45
Instrumental ADLS
using the phone shopping preparing food cleaning doing laundry driving taking medicine managing money
46
FICA
Faith or beliefs Importance and influence Community Address (how you would like it address)
47
ROS
series of Yes or no questions -go head to toe
48
ROS skin
Rashes lumps sores itching dryness changes in color changes in hair or nails changes in moles
49
ROS Head
headache head injury dizziness lightheadedness facial pain facial swelling
50
ROS eyes
Vision glasses/contact eye pain redness excesssive tearing double or blurred vision spots/floaters glaucoma cataracts
51
ROS ears
hearing aids? tinnitus vertigo earaches/pain HX ear infections discharge/drainage
52
ROS Nose and Sinuses
nasal stuffiness/congestion discharge hay fever/allergies Sinus pain/pain sinus infections
53
ROS Throat
Teeth/gums bleeding gums Dentures sore tongue dry mouth sore throat hoarseness
54
Neck
swollen glands goiter lumps pain stiffness
55
ROS breasts
lumps change in breasts Change in the nipples pain or discomfort nipple discharge
56
ROS Respiratory
cough Sputum (color, quantity) Hemoptysis shortness of breath wheezing pleuritic pain snoring
57
ROS Cardiovascular
chest pain angina pectoralis SOB Orthopnea (trouble breathing while laying down) Paroxysmal Nocturnal Dsypnea Edema Hx of Heart murmurs
58
ROS GI
Dysphasia appetite bowel habits rectal bleeding defecation pain diarrhea flatus or belching heartburn nausea and vomiting melena hemorrhoids constipation abdominal pain jaundice
59
ROS urinary
frequency polyuria nocturia urgency dysuria hematuria flank pain suprapubic pain incontinence
60
ROS Urinary additional for males
reduced caliber or force of stream hesitancy dribbling
61
ROS genital male
hernia discharge sores testicular pain scrotal pain or masses sexual interest, satisfaction, function
62
ROS Genital (female)
discharge itching sores, lumps dyspareunia bleeding between periods/after intercourse dysmenorrhea PMS menopausal symptoms sexual interest
63
ROS peripheral vascular
claudication (leg pain with exertion) leg cramps varicose veins past clots in the veins swelling in calves, legs, or feet Raynoids syndrome hair loss on extremities
64
ROS Musculoskeletal
Muscle or joint pain (hx of trauma) Joint swelling/redness stiffness arthritis gout back or neck pain
65
ROS psychiatric
changers in mood tension anxiety depression memory change Suicidal ideation homicidal ideation suicide plans
66
ROS neurologic
weakness paralysis numbness paresthesia tremors seizures headaches dizziness syncope change in memory, orientation, speech, judgment, insight
67
ROS hematologic
anemia easy bruising abnormal bleeding past transfusion transfusion reaction
68
ROS endocrine
heat or cold intolerance excessive sweating polydipsia polyphagia polyuria change in glove or shoes size
69
Q
every
70
Fishbone documentation (4)
.......Hgb...... Wbc.......Plts .......Hct.......
71
Lab documentation with fishbone (7)
Na|Cl |BUN K |CO2 |Cr ....Glucose

Patient Assessment (20 decks)

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