Complete history Flashcards
1 professionalism
wash hands
I’m brittany a student nurse practitioner
I am going to review your medical history
can you tell me your name and date of birth?
2 Chief complaint
before we begin is there anything you would like to make sure we address, any pains, discomforts or concerns?
HPI
History of the present illness
SLIDTA Severity Location Influencing factors Duration, onset, frequency Type Associated symptoms
UNDERSTAND: how is it affecting activities/what do you think is going on?
high risk questions for back pain
altered bowel or bladder function?
fever?
weight loss?
weakness to extremities?
PMH
Past Medical History
1. How has your health been?
recent hospitalizations?
any accidents or injuries?
2. medical
3. surgical
4.gyn: LMP, pregnancies and deliveries, vaginal pain or discharge
- allergies and reaction
- medications: prescription, OTC, vitamins, complementary
- health screening status: colonoscopy, opthalmology, gyn, mammogram, prostate exam etc.
Family History
PARENTS: age, health, cause of death and age of death
SIBLINGS: age, health, cause of death, age of death
Childrens health
SPECIFICALLY: any history of : HTN, HLD, Heart disease, CA, DM, addiction, Psychiatric illness?
relationships with immediate family
Social history
education level, and occupation
who do you live with/ SO?
any turmoil at home? emotional or physical abuse?
stressors
diet and exercise
smoking/vaping history? ready to quit?
ETOH use/ CAGE
recreational drug use
sexual history; how many partners over the last six months, male/female, any problems?
use of contraception
hx of sti'sROS
Review of Systems
General,wt loss chills etc skin HEENT Respiratory Cardio GI GU periph vasc hematological neurological endocrine psych
close encounter
summarize any abnormals
any final questions or concerns
