Health and History Part 1

Question 1

for new patients in offices or hospitals you will complete a _________ exam

Answer 1

comprehensive exam

Question 2

for established patients during routine or urgent care visits you will complete a ________ exam

Answer 2

focused exam

Question 3

What type of exam includes past history, medications, extensive physical exam, and allows the patient to develope repor with you (their opinion)

Answer 3

comprehensive exam

Question 4

an assessment that is specific to one or two concerns/problems

Answer 4

focused exam

Question 5

a patient is complaining of ear pain. you then examine the patients head, ears, eyes nose and throat. What type of exam is this

Answer 5

focused exam

Question 6

A ________ exam should be performed annually and are a review of previous exams.

Answer 6

A routine exam should be performed annually and are a review of previous exams.

Question 7

what exam is primarily to prevent illness or catch illness in early stages

Answer 7

routine exam

Question 8

The _____________ information is the information the patient tells you during the history.

Answer 8

The Subjective information is the information the patient tells you during the history.

Question 9

the _________ information is what you identify in the physical exam, and diagnostic testing

Answer 9

the objective information is what you identify in the physical exam, and diagnostic testing

Question 10

the objective information is what you identify in the _________, and _______________

Answer 10

the objective information is what you identify in the physical exam, and diagnostic testing

Question 11

What information should NOT be included in the history

Answer 11

the objective findings.

Question 12

aqcuiring the ______________ is one of the most important skills in medicine

Answer 12

health history

Question 13

A good health history allows you to ____________, gain ______ and ______, and formulate a good _____________.

Answer 13

A good health history allows you to get to know the patient, gain trust and respect, and formulate a good differential diagnosis.

Question 14

what is a differential diagnosis.

Answer 14

An analysis of exam findings and pt history that gives a hypothesized diagnosis for further testing

Question 15

patients name, age, gender, sex, medical record number and DOB is known as ______________

Answer 15

identifying data/demographics

Question 16

where the history of the patient comes from is known as

Answer 16

the source of history

Question 17

Where is the patients story told

Answer 17

HPI

Question 18

Documentation of the HPI is taken in ___________ form and using __________________. If a number is used you must ___________ if the number is less than _______

Answer 18

HPI is taken in paragraph form and using correct English. If a number is used you must spell it out if the number is under 10

Question 19

What part of the HPI is always in quotes

Answer 19

the chief complaint

Question 20

Other than the chief complaints what else could be documented in quoatations

Answer 20

anything that is difficult to describe such as “i have bugs crawling under my skin.”

Question 21

If the patient does not have a chief complaint what goes in quotes

Answer 21

the reason the patient is there, “I am here for lab work. “ “ i am here for a routine checkup”

Question 22

Do not put any _______________ in the HPI

Answer 22

Physical Exam Findings

Question 23

Only use medical abbreviations in the HPI that you know have been_________

Answer 23

approved

Question 24

The first sentence of the HPI should include _____________ and _____________if someone is giving history other than the patient.

Answer 24

The first sentence of the HPI should include patient identifiers and historian if someone is giving history other than the patient.

Question 25

what does the pneumonic LOCATES stand for

Answer 25

Location Onset Character Aggravating and Alleviating factors and associated symptoms (Factors/Symptoms) Timing environment severity

Question 26

Location includes ____________ and whether it __________.

Answer 26

Location includes where is it and whether it radiates

Question 27

Onset includes ___________________, do NOT put _______________________________ because this is not ___________________________.

Answer 27

Onset includes when did it start, do NOT put that this started "monday" or "December 24th" because this is not specific as to how long this has been happening.

Question 28

Character includes ____________________/___________________You may need to give examples

Answer 28

Character includes How the illness feels, descriptions of the symptom. You may need to give examples

Question 29

Aggravating and alleviating factors includes anything that makes the symptoms ______________________. you may need to give the patient examples

Answer 29

Aggravating and alleviating factors includes anything that makes the symptoms better or worse. you may need to give the patient examples

Question 30

Associated symptoms include ___________________________________. These are usually based on questions provided by you as the provider. ex. if patient is having runny nose you ask "are you having fever?"

Answer 30

Associated symptoms include anything that could be connected to the current illness. These are usually based on questions provided by you as the provider. ex. if patient is having runny nose you ask "are you having fever?"

Question 31

Timing includes whether the illness is _____________, _____________, ______________and _________________

Answer 31

Timing includes whether the illness is constant, waxing and waning, intermittent and how long it lasts

Question 32

Environment includes _________________________________________Sometimes the patient does not remember, this is okay, just document it as such

Answer 32

Environment includes what the patient was doing when the illness began. Sometimes the patient does not remember, this is okay, just document it as such

Question 33

Severity includes a ______________________________. non pain related symptoms can be assessed by determining _______________________________________

Answer 33

Severity includes a pain assessment on a scale of 1-10. non pain related symptoms can be assessed by how much the illness is effecting quality of life

Question 34

what are pertinent positives and negatives

Answer 34

symptoms the pt admits to having or not having that are related to the differential diagnosis

Question 35

What is the order of the HPI 1. _________________ 2. _____________________ 3. _____________________ 4. ______________________

Answer 35

What is the order of the HPI 1. Cheif complaint 2. 7 attributes 3. pertinent negatives 4. History/risk factors.

Question 36

Past medical histroy includes ________________, ______________, _____________, and past _________________

Answer 36

Past medical histroy includes adult/childhood illnesses, OBGYN, Psych hx, and past hospitalizations

Question 37

Surgical history includes ________________ and ________________

Answer 37

surgical histroy includes date of surgery and type of surgery

Question 38

Health maintenance history includes _______________ and ______________that have been completed.

Answer 38

Health maintenance history includes immunizations and screenings that have been completed.

Question 39

Medication history (prescriptions, OTC, and herbal) should be known in ____________, _____________, ________________, and _______________

Answer 39

Medication history (prescriptions, OTC, and herbal) should be known in dosage, route, frequency, and compliance

Question 40

Allergic history should includes ______________ and how _____________. If ____________is not known then "__________unknown" is documented

Answer 40

Allergic history should includes allergies if any and how they react to them. If reaction is not known then "reaction unknown" is documented

Question 41

Family hx should at least include _______, ______, __________ and ________. You can also include______________ but not required

Answer 41

Family hx should at least include mom, dad, brothers and sisters. You can also include extended family but not required

Question 42

personal and social history includes ______________, _____________________ and _____________ use MANDATORY. Every other personal/social is not required but may be necessary.

Answer 42

personal and social history includes alcohol, smoking/tobacco and illicit drug use MANDATORY. Every other personal/social is not required but may be necessary.

Question 43

review of systems is a brief review of ___________in a _______________ fashion. questions are asked on organs systems related to the ________________

Answer 43

review of systems is a brief review of all organ systems in a head to toe fashion. questions are asked on organs systems related to the chief complaints

Question 44

You should at least ask and document about____________ symptoms for each organ system.

Answer 44

2

Question 45

Pertinent positives and negatives are documented in both the _______ and the _______

Answer 45

HPI and ROS

Question 46

Pertinent systems are documented ________ first and _______second

Answer 46

positive first negative second

Question 47

Aside from the HPI what other portion is wirtten in paragraph form

Answer 47

social histroy

Question 48

If you go over at least two systems from the organ system in the __________you may put __________ under that organ system in the ROS

Answer 48

"in HPI"

Question 49

must pull up rubric and make copy into google drive and then pul up the health histrory and review it to see if its correct or incorrect. then make note of it or highlight it for discussion next week and give it a grade. there are like three of them. we will discuss them next week during class.

Answer 49

okay cool

Question 50

_______________________ includes anything that makes the symptoms better or worse. you may need to give the patient examples

Answer 50

Aggravating and alleviating factors includes anything that makes the symptoms better or worse. you may need to give the patient examples

Question 51

___________________________include anything that could be connected to the current illness. These are usually based on questions provided by you as the provider. ex. if patient is having runny nose you ask "are you having fever?"

Answer 51

Associated symptoms include anything that could be connected to the current illness. These are usually based on questions provided by you as the provider. ex. if patient is having runny nose you ask "are you having fever?"