Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Clinical Assessment > Attributes of HPI to ROS > Flashcards

Attributes of HPI to ROS Flashcards

1
Q

History of Present Illness (HPI) includes:

A
  • Opening sentence
  • Attributes for CC (Chronology, Location, etc.)
  • Relevant ROS (positive & negative responses)
  • Relevant Past Medical History (PMH)
  • Relevant Social/Spiritual/Sexual/Family Hx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What information is included in the Opening sentence for the HPI?

A

Age, Race, Gender, Chief Complaint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Attributes for Chief Complaint

A
  • Chronology
  • Location & Radiation
  • Quality
  • Quantity/Severity
  • Aggravating/Alleviating
  • Any Additional Concurrent Symptom(s)
  • Setting
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is included in Chronology

A

Chronology (aka Timing) of symptom development

  • Onset
  • Duration
  • Periodicity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is included in Location & Radiation

A

Anatomical location

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is included in Quality

A

Description (eg. dull, sharp, etc.)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is included in Quantity/Severity

A
  • Pain Scale (1-10)
  • How bad is it?
  • How does it affect daily activities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is included in Aggravating/Alleviating

A
  • What makes it worse (exacerbating)
  • What makes it better (remitting)
  • Self Treatment?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is included in Setting

A

Environmental factors
Emotional factors
Personal factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Past Medical History (PMH) includes…

A

General Health:

  • Childhood illnesses (date, type, outcome, complications)
  • Adult illness, accidents, injuries, hospitalizations not already listed
  • Immunizations (eg. DPT, MMR, Polio)
  • Screening Tests (eg. CBC or H&H, UA, pap smear, mammogram)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Attributes of Past Surgical History includes…

A
  • Date of surgery
  • Type of surgery
  • Reason
  • Outcome
  • Transfusions
  • Complications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Family members to include in Family Hx

A
  • Parents
  • Siblings
  • Spouse
  • Children
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Attributes to include for each relative in FHx

A
  • Age

- Health status/Cause of death

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Diseases to include in Family Hx

A

Asthma, TB, HTN, Heart Disease, DM, Stroke, Seizure disorders, Mental illness or Addiction issues, Cancer, Bleeding disorders, Arthritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Attributes of Social History includes…

A
  • Birthplace
  • Education
  • Employment
  • Religion/spirituality
  • Relationship status
  • Living accommodations
  • Hobbies
  • Exercise & Diet
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Attributes of Medications

A
  • Current medication names with dose
  • Frequency
  • Duration of use
  • Reason for taking
  • How compliant with taking medication or write none if not taking anything
17
Q

Attributes of Allergies

A
  • Name of medication/substance-

- Description of reaction

18
Q

Tobacco, Alcohol, Drugs

A
  • Current and Past Usage / Never Used

- If addiction Hx give summary of overdose/treatment/rehab

19
Q

What is included in ROS: General

A
  • Recent weight change
  • Weakness
  • Fatigue
  • Fever/chills
  • Night sweats
20
Q

What is included in ROS: Skin

A
  • Changes in hair, skin or nails
  • Rashes
  • Sores
  • Pruritis
  • Change in size or color of moles
21
Q

What is included in ROS: Head

A

New or uncharacteristic Headache, Trauma

-If yes: Location, Nausea/Vomiting, Frequency, Visual changes

22
Q

What is included in ROS: Eyes:

A
  • General state of vision (use of corrective lenses
  • Date of last eye examination & results of exam)
  • Excessive tearing
  • Diplopia or blurred vision
  • Acute vision loss (glaucoma, cataracts)
23
Q

What is included in ROS: Ears

A
  • Change in hearing
  • Earache
  • Vertigo
  • Tinnitus
  • Discharge
24
Q

What is included in ROS: Nose/Sinuses

A
  • Rhinorrhea
  • Epistaxis
  • Nasal congestion
  • Discharge or sneezing
25
Q

What is included in ROS: Oral cavity/Throat/Neck

A
  • Last dental exam
  • Bleeding gums
  • Sore throat
  • Hoarseness
  • Swollen glands
26
Q

What is included in ROS: Breasts

A
  • Self-exam practice
  • Lumps/masses
  • Pain
  • Nipple discharge or changes in skin
27
Q

What is included in ROS: Cardiac

A
  • HTN
  • Murmurs
  • Chest pain or angina
  • Dyspnea on exertion (DOE)
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Palpitations
  • Last ECG
28
Q

What is included in ROS: Respiratory

A
  • Cough
  • Sputum (if “yes” - quantity/color)
  • Hemoptysis
  • Wheezing
  • Shortness of breath (SOB)
  • TB or exposure to TB
  • COPD or emphysema
  • Asthma
  • Pneumonia
  • Bronchitis
  • Last CXR
29
Q

What is included in ROS: GI

A
  • Appetite,
  • Nausea
  • Vomiting
  • Dysphagia
  • Indigestion
  • Bowel habits (frequency, stool color & consistency)
  • Diarrhea
  • Constipation
  • Bleeding (hemorrhoids, hematemesis, melena, hematechezia)
  • Abdominal pain
  • Jaundice
  • Hepatitis
  • Date/results of any GI studies
30
Q

What is included in ROS: Urinary

A
  • Frequency
  • Polyuria
  • Hesitancy
  • Urgency
  • Dysuria
  • Hematuria
  • Nocturia
  • Stones
  • Incontinence
  • UTI
31
Q

What is included in ROS: Genital (Male)

A
  • Hernias
  • Penile lesions or discharge
  • Testicular pain or masses
32
Q

What is included in ROS: Genital (Female GYN)

A
  • Menarche
  • Frequency & duration of menses
  • LMP
  • Vaginal pruritis
  • Discharge or lesions
  • Pregnancies & complications
  • Miscarriages/terminations
  • BCM
  • Menopausal symptoms
33
Q

What is included in ROS: Genital (General)

A

STI hx & treatments

  • Interest (change in libido or satisfaction with sex)
  • Problems (safety in relationship, hx assault, # lifetime partners, length of relationships, issues w/gender of partners or types of intercourse)
34
Q

What is included in ROS: Vascular

A
  • Claudication
  • Leg edema
  • Varicose veins
  • Thromboses/emboli
35
Q

What is included in ROS: Musculoskeletal

A
  • Muscle weakness or pain
  • Joint stiffness
  • Range of motion
  • Instability
  • Erythema
  • Edema
  • Arthritis
  • Gout
36
Q

What is included in ROS: Neurologic

A
  • Fainting or blackouts
  • Seizures
  • Weakness or paralysis
  • Numbness
  • Tingling
  • Tremors
37
Q

What is included in ROS: Hematologic

A
  • Anemia
  • Easy bruising or bleeding
  • Past transfusions (if YES reason for transfusion & any transfusion reactions)
38
Q

What is included in ROS: Endocrine

A
  • Thyroid trouble
  • DM
  • Heat or cold intolerance
  • Excessive sweating
  • Increased thirst (polydipsia)
  • Hunger (polyphagia)
  • Urination (polyuria)
39
Q

What is included in ROS: Psychiatric

A
  • Change in mood or memory
  • Anxiety
  • Tension
  • Depression; if positive depression - inquire about suicidal ideation or attempts (Are you thinking about killing yourself or putting yourself in a dangerous situation in the hope that you are killed? If there were no ramifications – would you kill yourself? Do you have a plan to kill yourself?)

Clinical Assessment (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions