History Flashcards
(35 cards)
1
Q
Components of history
A
CC HPI PMH PSH Gyn Hx Medications Allergies FH SH ROS
2
Q
Components of HPI
A
- last time felt well/illness started
- 7 dimensions: Location, quality, severity (quantity), timing, setting/context, modifying factors, associated symptoms
- Anything you’re worried about?
- How has this affected your life?
- risk factors pertaining to CC
3
Q
PMH
A
- Hospitalizations, Injuries, Childhood illnesses
- Exposures: environmental (chemicals, dust, fumes), animal (pets, livestock, lab animals), Travel, blood transfusion.
- Health maintenance: periodic exams, immunizations, exercise, nutrition, injury prevention, STD prevention/pregnancy prevention, health insurance coverage
4
Q
PSH
A
-kinds and dates
5
Q
Gyn Hx
A
- How many pregnancies?
- Term, premature, abortion, live
6
Q
Medications
A
Prescription: name and dose
OTC
Supplements – herbs and vitamins
7
Q
Allergies
A
Medications, Food, Environmental (what is allergen and what is reaction?)
8
Q
FH
A
first degree relatives: who, state of health, any illnesses (DM, heart disease, HTN, stroke, obesity, cancer and type)
-other relatives
9
Q
SH
A
- marital/partner status, family situations
- Work (type), disability etc
- alcohol, tobacco, drugs
- sexual history
- sources of stress/sources of support
10
Q
ROS
A
General Skin Head Eyes Ears Nose Throat/dental Neck Breasts (women) Cardiovascular Lungs GI GU Heme Allergy/Immuno Endocrine Musculoskeletal Neuro Psych
11
Q
ROS General
A
Weight change
Appetite
Fevers/chills/sweats
Excess fatigue/Exercise intolerance
12
Q
ROS Skin
A
primary: Skin problems? What? Itching/dry skin Rashes secondary: Eczema changes in moles scaling
13
Q
ROS Head
A
Headaches
Loss of consciousness/fainting
Seizures
Hx of head trauma
14
Q
ROS Eyes
A
primary: Eye problems? What? Corrective lenses pain blurry vision double vision secondary: Scotomata/floaters VFDs Red Yellow (icterus) pain drainage
15
Q
ROS ears
A
primary: pain hearing loss tinnitis vertigo secondary: discharge
16
Q
ROS Nose
A
primary: discharge or congestion Post-nasal drip secondary: epistaxis obstruction abnormal odors
17
Q
ROS Throat/dental
A
primary: sore hoarseness/change of voice ulcers secondary: cavities missing teeth toothache sore tongue
18
Q
ROS Neck
A
lumps
goiter/big thyroid
stiff nect
19
Q
ROS Breasts (women)
A
Monthly self exam?
Lumps or bumps?
Discharge
pain
20
Q
ROS CV
A
Chest pain or pressure orthopnea paroxysmal nocturnal dyspnea peripheral edema cyanosis palpitations/sensations of rapid/skipped heart beats Hx heart murmur Intermittent claudication
21
Q
ROS Lungs
A
dyspnea
cough (mucus? color?)
wheezing
hemoptysis
22
Q
ROS GI
A
primary: pain? where? change in bowel habits nausea/vomiting blood in stool melena Hx liver disease secondary: dysphagia (solids, liquids) odynophagia clay-colored stools change in bowel habits Hx ascites Jaundice
23
Q
ROS GU
A
primary: dysuria urinary freq urgency/hesitancy incontinence flank pain impotence secondary: discharge bleeding penile ulcers/fissures testicular swelling/pain/lumps
24
Q
ROS Heme
A
Easy bruising
Easy bleeding
25
ROS Allergy/Immuno
```
Secondary:
lymphadenopathy
urticaria
hay fever
sensitivities to foods, pollens, mold, dander
```
26
ROS Endocrine
primary:
Diabetes (secondary: polyphagia, polydipsia, polyuria)
Abnormal weight loss/gain
Goiter (secondary: tremors)
abnormal periods? (secondary: age at menarche/menopause, cycle/duration/amount, date of LMP, menstrual pain/debility/swelling)
27
ROS Musculoskeletal
Pain/swelling/stiffness of joints
limitations of range of motion joints
secondary:
fractures/serious sprains
28
ROS Neuro
```
Dizziness
Paralysis
weakness on one side
numbness or tingling/change in sensation
bowel or bladder incontinence
secondary:
muscle atrophy
gait abnormalities
tremors
involuntary movements
```
29
ROS Psych
```
mood?
depression
anxiety/fears
sleep problems
memory loss
```
30
SH alcohol
-how much do you drink?
-type of alcohol
-pattern (when was the last time you had 5(m)/4(f) drinks in a day?'
-CAGE:
tried to Cut down?
been Annoyed?
felt Guilty?
had an Eye opener?
31
SH tobacco
Do you smoke cigarettes? Have you ever?
| previous attempts to quit
32
SH partner violence
- do you feel safe at home?
| - have you ever been hit, punched, or hurt by someone in your home
33
SH sexual hx
- Do you have a partner?
| - Sexually active? men women or both?
34
SH drugs
- Have you used any non-medical drugs?
| - -> whether yes or no --> cocaine? heroin? etc
35
Depression screening
Start with: Do you feel sad or depressed? Or Over the past two weeks have you felt down, depressed, hopeless?" and "over the past two weeks have you felt little interest or pleasure in doing things?"
