Medical Interview Flashcards
(23 cards)
What are the main components of the medical interview?
1) Chief Complaint
2) History of Present Illness
3) Medical History
4) Surgical History
5) Therapies
6) Allergies
7) Psycosocial
8) Family History
9) Review of Systems
What are the main components of HPI?
1) Characteristics of symptoms
2) Associated active medical, surgical, or psychiatric problems
3) Past experience with symptoms
4) Significant positives and negatives
5) Psychosocial context of onset
6) Patient’s perspective of illness
OPQRST mnemonic
Onset Provocation/Palliation Quality of pain Region/Location Severity of pain Time of pain
SAMPLE mnemonic
Signs/symptoms Allergies Medications Past medical history Last meal/intake Events leading up to injury
What are the components of the medical history?
- Adult illnesses
- Health screenings
- Immunizations
- OB-GYN history
- Psychological illnesses/hospitalizations
- Childhood illnesses
- Injuries/Accidents
Psychosocial history mnemonic
SODAS
Smoking Occupation Drugs Alcohol Sex
What are the review of system components?
Neurologic Psychiatric Eyes Ears/Nose/Mouth/Throat Respiratory Cardiovascular Gastrointestinal Endocrine Hematologic/Lymphatic Urinary Genitoreproductive Breasts Integumentary (Skin) Musculoskeletal Constitutional
How should most ROS questions begin?
“Do you routinely have…?”
NOT “Have you ever?”
ROS: Neurological
Weakness/numbness in face, arm or leg
Problems speaking
Unsteadiness walking
Shaking
ROS: Psychiatric
Sadness/depressed mood
Feelings of harming one’s self or others
Feelings that other will harm you
ROS: Eyes
Eye pain or discomfort
Changes in vision
ROS: Ears, Nose, Mouth and Throat
Hearing loss Dizziness/spinning Drainage from the ear Congestion/stuffiness Drainage from nose Changes in voice/hoarseness Pain/ulcers in mouth
ROS: respiratory
Cough
Coughing up blood
Wheezing
Snoring/daytime tiredness
ROS: cardiac
Shortness of breath at rest/exercise/lying flat Chest pains Palpitations Lightheadedness/fainting Leg/ankle swelling
ROS: gastrointestinal
Abdominal pain/discomfort Change in bowel habits Trouble swallowing Vomiting blood Rectal bleeding/black stools Yellowing of skin/eyes
ROS: endocrine
Increased thirst or urination
Bone fractures
Heat/cold intolerance
ROS: hematologic/lymphatic
Prolonged or unusual bleeding
Increased bruising
New or tender lumps or glands
ROS: urinary
Problems passing urine
Problems holding urine
Blood in urine
ROS: genitourinary
Problems holding/passing urine
Male: discharge from/sores on penis; testicular lumps/pain
Female: abnormal menstruation, vaginal discharge, hot flashes, post-menopausal vaginal bleeding
ROS: breasts
Lumps
Pain
Nipple discharge
Rashes/skin changes
ROS: integumentary
Rashes
Changes in color/size of a mole
ROS: muskuloskeletal
Joint or muscle pain
Limitation of normal activities from pain
ROS: constitutional
Changes in appetite
Recent weight change
Fevers or night sweats
Fatigue
