Ch 14 Principles of Assessment

Question 1

Information gathered regarding the patient’s health problems in the past

Answer 1

Past medical history (PMH)

Question 2

A question requiring more than just a “yes” or “no” answer

Answer 2

Open-ended question

Question 3

A question requiring only a “yes” or “no” answer

Answer 3

Closed-ended question

Question 4

The patient’s statement that describes the symptom or concern associated with the primary problem the patient is having

Answer 4

Chief complaint

Question 5

The events and/or mechanism leading up to the patient’s current problem

Answer 5

History of present illness/injury (HPI or HOPI)

Question 6

A memory aid in which the letters stand for questions asked to get a description of the present illness

Answer 6

OPQRST: onset, provocation, quality, region/radiation, severity, time

Question 7

A memory aid in which the letters stand for elements of the past medical history

Answer 7

SAMPLE: signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness

Question 8

Bulging of the neck veins

Answer 8

Jugular vein distention (JVD)

Question 9

The grating sound or feeling of broken bones rubbing together

Answer 9

Crepitation

Question 10

A description or label for a patient’s condition that assists a clinician in further evaluation and treatment

Answer 10

Diagnosis

Question 11

A list of potential diagnoses compiled early in the assessment of the patient

Answer 11

Differential diagnosis