2.22 Neuro Exam 2 Flashcards
CC
chief complaint
HPI
hx of present illness
PMH
past medical hx
PHI
pertinent health information
HF
family hx
SH
social hx
OH
occupational hx
ROS
review of systems
LOC
level of consciousness
AAO
alert and oriented
MME
mini mental exam
chief complaint: things to consider
- should have location/severity
- often gives you goals
- ask how it makes the patient feel
hx of present illness: things to consider
- if the person can give a chronological hx (could be insidious)
- agg/ease factors
- labs, tests, radiographs, MRI, etc
- avoid leading and suggesting (let them use their own words)
past medical hx: things to consider
- have to determine which diagnoses actually means something to you
- may have a laundry list, esp in acute care
- may have birth hx, childhood illnesses, gestation time, etc (peds)
pertinent health information: things to consider
- allergies
- immunizations (peds)
- habits
- drugs
- multiple partners
- smoking/drinking
- meds
- screening tests (BP, cholesterol, etc)
- sleep patterns
- diet
caveat to asking about medications
- should always ask which ones they are actually taking
- ask about supplements because they may interact with meds
If a patient is on blood thinners, what is something they shouldn’t eat?
leafy greens
important items for family hx
- Huntington’s
- stroke
social hx: things to consider
- relationships with family, caregiver
- level of education
- native to this country?
Why do we need to ask about relationships?
important for d/c plan
nonnative patients
- try not to use a family member to translate
- culturally competent questions related to care (Can destroy your relationship with that patient, may inadvertently disrespect)
occupational hx: things to consider-
- job requirements
- repetitive stress
- toxic material exposure
- Was it an accident at work?
- Magnifying or minimizing to get back or not get back to work
review of systems: things to consider
- hospital, will usu have a comprehensive ROS
- we typically don’t do an entire ROS
- HEENT
- RRR
- look it up if you don’t know it!
HEENT
Head Eyes Ears Nose Throat
