Complete Medical Hx Flashcards
CC
reason for patients visit
HPI
paragraph form;
OLDCARTS: onset, location, duration, character, aggravating/alleviating, radiation, timing, setting
PMH
allergies, meds, medical illnesses, surg/hosp, accid/injury, ob/gyn, immunizations
FH
first degree relatives; ask about ht dis, DM, HTN, CA, infections
SH
occupation, relationship status, IVDU/rec drugs, smoker, ETOH, exercise/hobbies/education
ROS-General
fever/chills, weight change(amount over time/intended), fatigue/malaise, sweats, sleep:insomnia/interrupted
ROS-Skin
rash/eruption, itching, pigmentation/texture change
ROS-HEENT-Head
HA, syncope/LOC, trauma/injury, dizziness
ROS-HEENT-Eyes
acuity decreased, blurring, diplopia, pain, glaucoma, trauma, discharge, scotoma (field loss), photophobia, eye drop use, family eye disorder?
ROS-HEENT-Ears
hearing acuity, discharge, pain, tinnitus, vertigo
ROS-HEENT-Nose
freq of colds, congestion, discharge, epistaxis, postnasal drip, sinus pain
ROS-HEENT-Throat and Mouth
sore throat/tongue, hoarseness, diff. swallowing, bleeding gums, abscess, dental problems
ROS-Neck
swollen glands, stiffness/pain, thyroid problems, limited ROM
ROS-Breasts
pain/tenderness, lumps, mammograms, discharge, self exam
ROS-Respiratory
cough(freq,type), sputum(amount/appearance), hemoptysis, dyspnea, hx pulm infections(pneumonia, TB, bronchitis), wheezing, chest pain (pleuritic), hx asthma, last CXR
ROS-Cardiac
pain, dyspnea(exertional, DOE?), orthopnea, palpitations, edema, claudication, hx MI, last EKG, stress test, HTN, HLD, other heart problems
ROS-GI
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
ROS-GU
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
ROS-gynecologic
age at menarche, LMP, last PAP, menses schedule/flow, dysmennorhea, vaginal discharge/itching, libido, sexual difficulties, age at menopause, hot flashes, freq of intercourse
ROS-Extremities
joint pain/stiffness, reduced ROM, warmth, hx fracture/trauma/DVT, swelling, redness, deformity, pror xrays/procedures
ROS-Neuro
memory change, seizures, numbness, syncope/dizziness, reduced coordination, HA, paresthesias, tremors, paralysis/weakness, falls
ROS-Psych
anxiety/nervousness, mood change, suicidal thoughts/actions, insomnia/early wakening, sadness/depression, anhedonia, memory change, psych meds/care
ROS-Hematologic
anemia, swollen lymph nodes, transfusions, easy bruising, excessive bleeding, other blodd abnormalities
ROS-Endocrine-Thyroid
hot/cold sensitivity, tremor, weight change, excessive sweating, palpitations, skin/hair change
ROS-Endocrine-Pancreas
polyuria, polydyspsia, polyphagia, hx DM, pancreatitis
ROS-Endocrine-Adrenal
skin pigment change, skin striae, orthostatic hypotension sx’s, weakness/fatigue
ROS-Endocrine-Gonadal
libido change, erectile dysfunction, infertility
