course 3 Flashcards
1
Q
Subjective
A
Based on the Patient’s feeling(HPI, ROS)
2
Q
Objective
A
Factual information from provider (PE)
3
Q
History of present illness
A
The story of the patient’s chief complaint.
4
Q
Review of systems
A
head to toe list of patient’s symptoms .
5
Q
intermittent
A
comes and goes
6
Q
Waxing and waning
A
always present but changing with intensity
7
Q
modifying factors
A
something that makes a symptom better or worse.
8
Q
Exacerbate
A
to make worst .
9
Q
Element
A
description
10
Q
onset
A
when did the complaint begin
11
Q
timing
A
has it been constant, intermittent, waxing or waning.
12
Q
location
A
where is the discomfort
13
Q
quality
A
Does it feel sharp, dull, aching, cramping….?
14
Q
severity
A
How bad is it? Mild, mod, severe or 0-10
15
Q
modifying factors
A
What makes it better? What makes it worse?
16
Q
Associated Sx
A
Do any other symptoms accompany the complaint?
17
Q
context
A
Is there anything else that’s important?
18
Q
A complete HPI requires atleast..
A
4 complete elements
19
Q
Outline for HPI
A
- complaint + onset
- Timing, quality, severity
- What makes it better or worse
- Associated symptoms
- Pertinent negatives
- Context
20
Q
I took tums and it didn’t help
A
the symptoms were unchanged by tums
21
Q
I have low back pain, but always have that
A
He notes chronic back pain, unchanged from baseline
22
Q
It hurts when I touch it
A
The symptoms worsen with palpations in the area
23
Q
Nothing makes it better or worse
A
the symptoms are unchanged by any position or activity
24
Q
My sister has the same cold
A
positive sick contact with sister who has similar symptoms.
25
If I try to eat or drink anything, I throw it back up
The vomiting exacerbated by PO
26
it feels like a fizzing soda in the middle of my chest
He describes the Sx as a "fizzing soda" in his central chest.
27
don't s of HPI
Use days of week, use got, start sentences the same, write self diagnoses, include Hx that is no relevant.
28
Key to writing a trauma HPI
focusing on the MOI
29
Four most important Sx to document for any trauma pt.
LOC, Head injury, Neck pain, back pain
30
A complete ROS requires..
At least ten elements. If cannot make a complete ROS, state and explain why. When all other systems are negative only require 2
31
Constitutional .
Fever, weight loss, swets
32
Eyes
change in vision, eye pain, double vision.
33
Ear/nose/throat
Ear ache, Nose bleed, Congestion, Sore throat
34
cardiovascular
Chest pain, Palpitations, Leg swelling
35
respiratory
SOB, Cough, Sputum, Wheezing
36
gastrointestinal
Abdominal pain, N/V/D, Black or bloody stools
37
Genitourinary
Dysuria, Frequency, Urgency, Hematuria
38
Musculoskeletal
Joint pain, Muscle pain
39
integumentary/skin
Rash, Itching, Abrasion, Laceration
40
neurological
Headache, Syncope, Seizure, Numbness, Focal weakness
41
psychiatric
Depression, Anxiety
42
endocrine
Polyuria, polydipsia
43
hematologic/lymph
Bleeding gums, easy bruising, swollen lymph nodes
44
immunologic
HIV/AIDS, Splenectomy
45
worse with physical exertion-cp
MI
46
worse with deep breaths -cp
PE
47
radiation to the back -cp
aortic dissection
48
recent trauma- cp
PTX
49
SOB -cp
MI, PE, PTX
50
Diaphoresis, Nausea, vomiting -cp
MI
51
Pleuritic pain -cp
PE, PTX
52
Calf pain -cp
DVT` causing PE
53
Minor DDx of Cp
chest wall pain, costochondritis, Pleural effusion, GERD
54
Associated Sx - Cp with minor DDX
pain with torso movement or palpation(chest wall, costo-), burning (GERD)
55
MI risk factors
CAD, HTN, HLD, dM, Smoking, FHx CAD <55 y/o
56
PE risk factors
Hx DVT/PE, known DVT, recent surgery, mobilization, A-fib, cancer, pregnancy/BCP
57
Hx of tobacco abuse -SOB
COPD
58
Chest ain-SOB
MI, PE, PNA
59
minor DDx of SOB
Bronchitis, URI
60
Associated Sx of Bronchitis, URI
cough, sputum, Nasal congestion, Sore throat.
61
Mi risk factors
CAD, HTN, HLD, DM, Smoking, FHx CAD < 55 y/o
62
PE Risk factors
Hx DVT/PE, Known DVT, Recent surgery, Immobilization, A-Fib, Cancer, Pregnancy/Birth Control
63
Abd pain -RLQ
appendicitis
64
RUQ pain
cholecystitis
65
LLQ pain
diverticulitis
66
LUQ pain
Pancreatitis
67
Fever - Abd pain
appendicitis, cholecystitis, diverticulitis
68
Blood in vomit or stool
GI bleed
69
Melena
GI bleed
70
Dizziness - Abd pain
GI bleed, AAA - (anemia, low blood volume)
71
Minor DDx of Abd pain
gastroenteritis, gastritis, constipation
72
Associated Sx with Gastroenteritis, gastritis, constipation
Dysuria, Nausea/Vomiting, Diarrhea, Constipation
73
Diarrhea risk factors
Recent foreign travel, recent camping, bad food exposure, sick contacts, recent antibiotics, recent hospitalization
74
Suprapubic pain
ovarian torsion
75
pregnancy - with lower abd pain
ectopic pregnancy
76
Fever, RLQ pain for femail
appendicitis
77
minor DDx for female Lower abd pain
Ovarian Cyst, UTI, STD
78
Associated Sx with female lower abd pain
Nausea/Vomiting, Vaginal Spotting, Vaginal Discharge, Dysuria, Flank pain
79
Female Abd pain risk factors
Possibility of Pregnancy, Unprotected Sex, History of STD
80
Weakness/numbness in lower extremities
spinal cord injury
81
numbness of the groin
spinal cord injury or cauda equina
82
loss of bowel or bladder control
spinal cord injury or cauda equina
83
History of IVDA - w/ lower back pain.
Spinal abscess
84
Fever - with lower back pain
spinal abscess
85
Abdominal Pain- with lower back pain
Abdominal Aortic Aneurysm (AAA)
86
Minor DDx of Low back pain
Musculoskeletal back pain, Back Strain, Sciatica
87
Associated Sx of Low back pain
Radiating pain down the backs of the legs (sciatica)
88
Back pain risk factors
Recent trauma, hx of IVDA, spinal hardware
89
Weakness/numbness/tingling W/ Dizziness HA
CVA
90
Changes in speech or vision
| w/ Diz/HA
CVA, SAH
91
difficulty with balance w/ Diz HA
CVA, SAH
92
fever W/ Diz/HA
Meningitis
93
neck pain w/ Diz/HA
Meningitis
94
AMS w/ Diz/HA
meningitis, CVA, SAH
95
Worst headache of life/ thunderclap onset
Hemorrhagic CVA, SAH
96
syncope or seizure w/ Diz/HA
CVA, SAH
97
Minor DDx of Dizziness and HA
Dehydration, Benign Positional Vertigo (BPV), Migraine HA, Tension HA, Sinusitis,
98
Associated Sx Minor DDx for Dizziness/HA
Nasal congestion, runny nose, nausea, vomiting
99
CVA risk factors
HTN, HLD, DM, Smoking, FHx CVA, Hx TIA/CVA, AFib
100
tongue bit wound
Sz
101
SAH
Subarachnoid Hemorrhage
102
Numbness/weakness/Tingling with syncope
CVA
103
Changes in speech or vision w/ syncope
CVA
104
chest pain w/ syncope
MI
105
SOB w/ syncope
PE
106
Palpitations w/ syncope
Arrhythmia
107
Minor DDx of Syncope
Vasovagal syncope, dehydration
108
Associated Sx with with vasovagal syncope, dehydration
Associated Symptoms: Feeling “about to pass out” (near-syncope), sweating, dizziness, lightheadedness
109
Associated Sx with with vasovagal syncope, dehydration
Associated Symptoms: Feeling “about to pass out” (near-syncope), sweating, dizziness, lightheadedness
110
Fever with AMS
Sepsis
111
Numbness/Weakness/Tingling w/ AMS
CVA
112
HA w/ AMS
Hemorrhagic CVA
113
Hx of depression or drug abuse w/ AMS
Drug overdose
114
Hx of DM w/ AMS
hypoglycmia
115
Minor DDx of AMS
UTI (Elderly), ETOH abuse, Narcotic abuse, drug abuse
116
AMS risk factors
Dementia/Alzheimers, DM, Psychiatric history, Substance abuse
117
LOC w/ Trauma
Hemorrhagic CVA, Subdural Hematoma
118
Unilateral numbness/weakness/tingling w/ trauma
Hemorrhagic CVA, Subdural Hematoma
119
Bilateral Numbness/weakness/tingling w/ trauma
spinal cord injury
120
Neck pain or back pain w/ trauma
spinal cord injury
121
SOB or CP w/ Trauma
PTX, cardiac contusion
122
Abd Pain w/ trauma
Splenic or Liver Laceration
123
Minor DDx W/ trauma
Closed Head Injury, simple fracture, dislocation, strain/sprain, laceration
124
Trauma risk factors
Blood thinners (Coumadin/Warfarin, Plavix, Aspirin), Severe Mechanism of Injury
125
General PMHx
• HTN, HLD, CA, DM (IDDM/NIDDM)
126
Cardiovascular PMHx
• MI, CAD, Angina, CHF, AFIB
127
Pulmonary PMHx
• PE, PNA, COPD, Asthma
128
GI PMHx
• GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis
129
Genitourinary PMHx
• Kidney stones, UTI, Renal insufficiency/failure
130
Neurological PMHx
• CVA, TIA, Epilepsy/Seizure, Migraines, Dementia, Alzheimer’s
131
Psychological PMHx
• Depression, Anxiety, Bipolar, Schizophrenia
132
Other PMHx
• DVT, MRSA, RA (Rheumatoid Arthritis), CBP (Chronic Back Pain)
133
ENT PSHx
• Tonsillectomy, Adenoidectomy, PE tubes
134
Cardiac PSHx
• CABG, Coronary Stents, Pacemaker, AICD, Catheterization, Angioplasty, Valve replacement
135
Abd PSHx
• Appendectomy, Cholecystectomy, Herniorrhaphy, Gastric Bypass, Colectomy, Colostomy, Nephrectomy
136
GU PSHx
• Hysterectomy, C-section, Oophorectomy, Salpingo- oophorectomy, Tubal ligation, TURP
137
Ortho PSHx
• AKA/BKA, Hip Arthroplasty, Spinal fusion
138
Neuro PSHx
Carotid endarterectomy, craniotomy, VP shunt
139
Other PSHx
• Mastectomy, PICC line
