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Flashcards in HPI ROS Deck (8)
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1
Q

subjective vs. objective data

A
Subjective Data:
◼ What the patient tells you
◼ The History, from Chief Complaint, Chief Concern through Review of Systems
Objective Data:
◼ What you detect on the examination
◼ All physical examination findings
◼ Includes Lab data and Imaging
2
Q

differential diagnosis

A

list of the disease hypotheses to be tested.Each disease or condition is more or less probable based upon how well it explains the full range of the patient’s problems

3
Q

Steps of history and physical

A

review these

  1. take history
  2. develop hypothesis
  3. perform physical exam
  4. make problem list
  5. generate differential diagnosis
  6. test hypothesis
  7. modify differential diagnosis
  8. repeat 1-7
  9. make diagnosis/diagnoses
4
Q

Chief complaint

A

patient’ reason for presenting to the clinician in the pts own words; use open ended questions initially

5
Q

chief complaint is used as a springboard for what?

A

additional questioning to help identify the HPI.

6
Q

The big eight of HPI

A
body location
quality
quantity (severity)
chronology (duration and timing)
setting
aggravating factors
alleviating factors 
associated symptoms
7
Q

ROS

A

list of questions, arranged by organ system, designed to uncover dysfunction and disease

8
Q

General ROS

A

fever, chills, night sweats, fatigue, weakness, weight change