Complete health history with ROS

Question 1

Components of the complete health history

Answer 1

identifying information/patient profile, chief complaint, history of present illness, past medical history, family history, social history, review of systems

Question 2

identifying information/patient profile

Answer 2

include info such as name, age, sex, race, birthplace, marital status, occupation, religion, source of referral, and reliability of information

Question 3

chief complaint

Answer 3

the major reason for the encounter as expressed by the patient; includes duration. Best if in the patient’s own words. Not a diagnosis.

Question 4

Seven attributes of a symptom

Answer 4

location, quality, quantity, timing, setting, modifying factors, and associated manifestations

Question 5

present illness

Answer 5

clear, chronological narrative account of he problems for which the patient is seeking care. classify symptoms into 8 dimensions (lots of care says take all appropriate measures)

Question 6

Questions for location

Answer 6

point to spot; radiate?

Question 7

Questions for onset

Answer 7

Setting in which the symptom occurred. Where, doing what…

Question 8

Questions for character

Answer 8

dull, sharp, burning, stabbing, colicky?

Question 9

Questions for severity

Answer 9

grade on scale of 1-10; worse? better? same?

Question 10

Questions for timing/chronology

Answer 10

duration? frequency? pattern?

Question 11

What does “lots of care says take all appropriate measures” mean? (mnemonic)

Answer 11

Location, Onset, Character, Severity, Timing/chronology, Aggravating and alleviating factors, Associated symptoms, Meaning of symptom to patient

Question 12

Past medical history

Answer 12

general health (as the patient perceives it), childhood illnesses, adult illnesses, psychiatric illnesses, accidents/injuries, surgical procedures, hospitalizations, allergies, obstetrical history, immunizations, and current health status

Question 13

Current health status

Answer 13

current medications, allergies, immunizations, screening tests, habits (tobacco, coffee, alcohol, drugs), diet, sleep, exercise and leisure activities, environmental hazards, safety measures

Question 14

family history definition

Answer 14

usually a one or two generation analysis for significant diseases that tend to have a familial distribution

Question 15

family history components

Answer 15

age and cause of death of family members, health status of family members, known family diseases (diabetes, hypertension, cancer, heart disease, bleeding disorders, sickle cell anemia, stroke, long exposure to diseases such as tuberculosis) and include a description of the illness of family members that contain a psychological impact on the patient, a congenital influence, or a genetic factor or symptoms like those of the patient

Question 16

social history

Answer 16

an outline or narrative description capturing the most important things about the patient as a person. Includes home situation and significant others, habits (smoking, drug use, alcohol), occupation, sex life, religious beliefs, military service, overseas travel, and psychiatric status (emotional adjustment to work or friends)

Question 17

Review of systems definition

Answer 17

a specific review of each body system from head to toe. These are questions to be asked of all patients. Ask about common symptoms in each system to identify problems the patient has not mentioned.

Question 18

Integuement questions

Answer 18

any problems with skin, hair, or nails, rashes, sores (any changes in skin, hair, nails, any cracking, dryness, falling out, moistness, sweating, coloration, itching, or biting)

Question 19

Head questions

Answer 19

headache, dizziness, trauma (detailed nature of complaint)

Question 20

Eye questions

Answer 20

changes in vision, itching, redness, discharge (blurring, diplopia, scotoma, photophobia, amblyopia, tearing, pain)

Question 21

Ears

Answer 21

decrease hearing, pain, popping, discharge (tinnitus)

Question 22

Nose

Answer 22

any problems with nose (stuffy, runny, bleeding, colds, allergies, smell)

Question 23

Mouth and throat

Answer 23

sore throat, sores in mouth (dysphagia, sore tongue, swelling of tongue, changes in color or appearance of tongue, bleeding gums, voice, hoarseness, bad taste, teeth)

Question 24

Neck

Answer 24

any problems with neck (pain, swelling, decreased range of motion, lumps)

Question 25

Cardiovacular-Respiratory

Answer 25

difficulty breathing (dyspnea, SOB) chest pain, cough, tachycardia, palpitations, edema, syncope (orthopnea, PND, DOE, congestion, amount and color of sputum, hemoptysis, wheezing, cyanosis, HT, cold hands or feet, varicose veins, leg cramps)

Question 26

GI

Answer 26

normal appetite, nausea or vomiting, bowels regular, indigestion, food intolerance, abdominal pain (anorexia character and amount of vomitus, diarrhea or constipation, color changes of stool or urine, pyrosis, jaundice, flatulence, cramping, hemorrhoids, dysphagia)

Question 27

GU

Answer 27

any problems with bladder or kidneys, pain in abdomen/flanks/back, (CVA), [VD symptoms (sores in genitals, chancre, discharge) dysuria, stinging, burning, changes in urine flow (frequecy, polyuria, nocturia, oliguria, urgency, hesitancy, dribbling), pyuria, edema, incontinence, color change of urine]

Question 28

ob/GYN

Answer 28

Number of pregnancies (gravida), number of deliveries (parity), number of miscarriages (abortions), number of living children, any problems with pregnancies, problems with deliveries, menstrual (menarche, menses, cycle, duration, dysmenorrhea) irregularities of flow (IMS or metrorrheagea), heavy flow (how many pads soaked and passage of any clots), oligomenorrhea, amenorrhea, vaginal discharge , pelvic pain (cramps, when in cycle, duration, associated back pain), breasts (mastalgia, lumps, galactorrhea), contraception (current method), sexual life (dysparenunia)

Question 29

follow up questions to problems with pregnancies

Answer 29

hypertension, puerperal infection, septic abortion, pre-eclampsia or eclampsia, cephalopelvic disproportion (CPD), seizures, UTI, excessive weight gain, edema, jaundice, diabetes

Question 30

follow up questions to problems with deliveries

Answer 30

seizures, large babies, hypertension, infection, long labor, bleeding, fetal distress, CPD, c-section, thrombophlebitis, jaundice

Question 31

follow up questions to vaginal discharge

Answer 31

duration, amount, color, consisency, odor, itch, when in cycle

Question 32

Nervous system

Answer 32

nervousness (clarify), unusual sensations, (paresthesias, numbness, tingling, marching), motor problems (paralysis, paresis, ataxia), (convulsions, vertigo, dizziness, balance, moodiness, fainting, decreased memory, impaired judgement, behavioral changes)

Question 33

Musculoskeletal

Answer 33

joint trouble, lameness (decreased range of motion, arthralgias, arthritis, swelling, deformity, myalgias, back problem)

Question 34

Endocrine

Answer 34

weight stable, appetite, thirst, hunger, temperature intolerances, fever, chills, hair changes, polyuria, nocturia

Question 35

Blood and lymphatics

Answer 35

easy bruising, easy bleeding (how much, how often), slow healing, lumps, color of skin, weakness