Write-Up Flashcards
(15 cards)
What should be contained in the HPI?
age, +/- race, +/- social descriptor, +/- pertinent diagnoses, +/- diagnoses that are too significant to ignore.
What disease should you always ask about for family history?
cancer, heart disease, cardiac risk factors, stroke, diabetes, HTN
What should be included for each piece of past medical history?
date of diagnosis, key findings, treatment, level of control
what is the time frame for ROS?
last few weeks/months
Who should be included in the family history?
1st degree relatives
NKDA = ?
no known drug allergies
What order should the Past Medical History be in?
enumerate by priority
What should be included about each medication?
-GENERIC name, dose, timing, adherence
ROS is presented in the appropriate section of the HISTORY or physical exam?
The HISTORY! ROS is subjective! The physical exam is objective/measured!
Should the ROS contain diagnoses?
No! These should go in Past Medical History
Pertinent parts of the ROS should go in the ______.
History of present illness (HPI)
The first part of the interview should be purely ________ , with minimal interruptions.
patient-centered!!
The formulation is a listing of the _________, ________, ________, and ____ presented in that order.
history, physical, labs, and data.
The differential diagnosis is explored in the
Assessment
In what order should the HPI be told?
chronologically, beginning with the first sign or symptom
