Complete Medical Hx

Question 1

CC

Answer 1

reason for patients visit

Question 2

HPI

Answer 2

paragraph form;

OLDCARTS: onset, location, duration, character, aggravating/alleviating, radiation, timing, setting

Question 3

PMH

Answer 3

allergies, meds, medical illnesses, surg/hosp, accid/injury, ob/gyn, immunizations

Question 4

FH

Answer 4

first degree relatives; ask about ht dis, DM, HTN, CA, infections

Question 5

SH

Answer 5

occupation, relationship status, IVDU/rec drugs, smoker, ETOH, exercise/hobbies/education

Question 6

ROS-General

Answer 6

fever/chills, weight change(amount over time/intended), fatigue/malaise, sweats, sleep:insomnia/interrupted

Question 7

ROS-Skin

Answer 7

rash/eruption, itching, pigmentation/texture change

Question 8

ROS-HEENT-Head

Answer 8

HA, syncope/LOC, trauma/injury, dizziness

Question 9

ROS-HEENT-Eyes

Answer 9

acuity decreased, blurring, diplopia, pain, glaucoma, trauma, discharge, scotoma (field loss), photophobia, eye drop use, family eye disorder?

Question 10

ROS-HEENT-Ears

Answer 10

hearing acuity, discharge, pain, tinnitus, vertigo

Question 11

ROS-HEENT-Nose

Answer 11

freq of colds, congestion, discharge, epistaxis, postnasal drip, sinus pain

Question 12

ROS-HEENT-Throat and Mouth

Answer 12

sore throat/tongue, hoarseness, diff. swallowing, bleeding gums, abscess, dental problems

Question 13

ROS-Neck

Answer 13

swollen glands, stiffness/pain, thyroid problems, limited ROM

Question 14

ROS-Breasts

Answer 14

pain/tenderness, lumps, mammograms, discharge, self exam

Question 15

ROS-Respiratory

Answer 15

cough(freq,type), sputum(amount/appearance), hemoptysis, dyspnea, hx pulm infections(pneumonia, TB, bronchitis), wheezing, chest pain (pleuritic), hx asthma, last CXR

Question 16

ROS-Cardiac

Answer 16

pain, dyspnea(exertional, DOE?), orthopnea, palpitations, edema, claudication, hx MI, last EKG, stress test, HTN, HLD, other heart problems

Question 17

ROS-GI

Answer 17

abdom pain, appetitie change, food intolerance, N/V, constipation, diarrhea, hernia, hemmorhoids, gas, GI XRAY/Endoscopy, indigestion/heartburn, hematemesis, change in stool color or type, hematochezia, melena, jaundice/dark urine, pruritis, GI meds, hx hepatitis, gallstones, ulcers, polyps, tumors, diverticulitis

Question 18

ROS-GU

Answer 18

Urinary: freq, nocturia, hx cystitis, incontinence, urgency, hematuria, hx stones, low back pain, dysuria, hesistancy, hx kidney infections, dark urine
Venereal: discharge, blisters, rash, ulceration, hx herpes, HIV, etc

Question 19

ROS-gynecologic

Answer 19

age at menarche, LMP, last PAP, menses schedule/flow, dysmennorhea, vaginal discharge/itching, libido, sexual difficulties, age at menopause, hot flashes, freq of intercourse

Question 20

ROS-Extremities

Answer 20

joint pain/stiffness, reduced ROM, warmth, hx fracture/trauma/DVT, swelling, redness, deformity, pror xrays/procedures

Question 21

ROS-Neuro

Answer 21

memory change, seizures, numbness, syncope/dizziness, reduced coordination, HA, paresthesias, tremors, paralysis/weakness, falls

Question 22

ROS-Psych

Answer 22

anxiety/nervousness, mood change, suicidal thoughts/actions, insomnia/early wakening, sadness/depression, anhedonia, memory change, psych meds/care

Question 23

ROS-Hematologic

Answer 23

anemia, swollen lymph nodes, transfusions, easy bruising, excessive bleeding, other blodd abnormalities

Question 24

ROS-Endocrine-Thyroid

Answer 24

hot/cold sensitivity, tremor, weight change, excessive sweating, palpitations, skin/hair change

Question 25

ROS-Endocrine-Pancreas

Answer 25

polyuria, polydyspsia, polyphagia, hx DM, pancreatitis

Question 26

ROS-Endocrine-Adrenal

Answer 26

skin pigment change, skin striae, orthostatic hypotension sx’s, weakness/fatigue

Question 27

ROS-Endocrine-Gonadal

Answer 27

libido change, erectile dysfunction, infertility