Medical history checklist Flashcards
(26 cards)
What are the 20 categories for Review of Systems?
General Skin Head Ears Eyes Nose/Sinuses Mouth/Throat Neck Lymph Nodes Breasts Respiratory Cardiovascular Gastrointestinal Genitourinary OB/GYN Extremities/Musculoskeletal Neurologic Hematologic Endocrine Psychiatric
What are the first 5 items on the medical history list?
Chief Complaint HPI PMH FH Social History
What are the subcategories for HPI? (8)
Onset: date/time/duration Provocative Palliative Quality Quantified Regionality Radiation Symptoms (associated)
What are the subcategories for PMH? (8)
General health Chronic illnesses Surgical Procedures Hospitalizations Injuries/major illnesses Medications Allergies & reaction Immunizations
What are the subcategories for FH? (8)
Cancer Hypertension Heart disease Diabetes Stroke Seizures Bleeding disorders Age/health parents/grandparents
What are the subcategories for Social History? (15)
Occupation Education Living situation Diet Physical activity Caffeine use Alcohol use Tobacco Use Sexually active Monogamous/#partners Prescription drug abuse Illicit drug use Military history Safe at home Travel
What are the subcategories for General? (6)
Weight changes Fatigue Malaise Fever/chills Sweats/night sweats Weakness
What are the subcategories for Skin? (5)
Rashes/sores/lesions lumps/masses Pruritus (itching) Dryness/moisture Hair/nail changes
What are the subcategories for Head? (4)
Headaches
Head trauma
Dizziness/vertigo
Syncope/LOC/concussion
What are the subcategories for Ears? (5)
General hearing status Otalgia (earaches) Past infections Drainage/discharge Tinnitus
What are the subcategories for Eyes? (6)
General vision status Glasses/contacts Last eye exam Pain/redness/tearing Diplopia/blurriness Hx trama/foreign bodies
What are the subcategories for Nose/Sinus? (6)
Sinus pain epistaxis (nosebleeds) Nasal congestion Nasal drainage Frequent colds Sneezing
What are the subcategories for Mouth/throat? (5)
Dental Hygeine Toothaches Last dental exam Pain/soreness Hoarseness
What are the subcategories for Neck? (3)
Pain
Stiffness/Limited ROM
Masses/swelling
Subcategories for Lymph nodes? (1)
Tenderness/enlargements
Subcategories for Breasts? (4)
Pain
Lumps/Masses
Nipple changes/discharge
Self exams
Subcategories for Respiratory? (7)
Pleuritic chest pain Cough/sputum Hemoptysis (coughing up blood) Wheezing or Hx asthma Hx bronchitis TB or past exposure Last PPD (TB test?) or CXR
What are the subcategories for Cardiovascular? (10)
Pain Palpitations Diaphoresis SOB/dyspnea Orthopnea/PND Edema Hx hypertension Hx murmurs Hx heart problems EKG/other dx testing
What are the subcategories for GI? (12)
Appetite Food intolerances Dysphagia (solid/liquid) Dyspepsia (heartburn) Nausea/vomiting Change in bowel habits Diarrhea/constipation Rectal bleeding/melena (tarry stools from upper GI bleed) Hemorrhoids Hx PUD (peptic ulcer disease) Hx Jaundice Hx Appendix/GB disease
Subcategories for Genitourinary? (15)
Change in frequency Change in force of stream Normal color/change in color Hesitancy/difficulty initiate Pain/dysuria Dribbling/incontinence Hx infections Hx hematuria Penile/vaginal discharge Hx STDs/treatment Libido
Women: Dyspareunia (painful sex)
Men: Scrotal pain/mass/edema
Erectile problems
Self testicular exams
Subcategories for OB/GYN (8)
Menarche LMP Gravida (# pregnancies) Para (# of deliveries) Delivery complications Abortions/miscarriages Last pap (results?) Menopause (symptoms?)
Subcategories for Extremities/Musculoskeletal)? (10)
Intermittent claudication (pain and cramping on exercise) Varicosities Decreased strength Decreased ROM Joint swelling/redness Joint stiffness/pain Hx bone/joint infections Hx fractures/dislocations Hx back pain/disc disease Hx sciatica
Subcategories for Neurologic (7)
Hx convulsions/seizures Hx infection/meningitis Memory loss Tremors Numbness/sensory loss Paresthesia (pins/needles) Trouble concentrating
Subcategories for Hematologic? (5)
Easy bruising Bleeding from gums/skin Hx transfusions Hx anemia Hx blood disease
