Complete Medical Hx Flashcards
1
Q
Chief Complaint
A
patient’s own words x duration
2
Q
History of Present Illness
A
Onset Location Duration (constant/intermittent) Character (quality, severity) Aggravating and Alleviating factors Associated signs/sxs Radiation Timing (relative to time of day, recurring circumstances) Setting where it occured
3
Q
Past Medical Hx
A
Allergies Medications Medical Illness Surgeries/Hospitalizations Accidents/Injuries OB/Gyn (pregnancies, children, LMP) Immunizations
4
Q
Family Hx
A
Parents, Siblings, Children
Hx of HTN, DM, CVD
Age, major illnesses
5
Q
Social Hx
A
Occupation Relationship status Tobacco ETOH Drug use Exercise Education
6
Q
General
A
fever/chills fatigue excessive sweating sleep quality weight change
7
Q
GI
A
DJ AFGHAN CHIPS • Diarrhea • Jaundice, dark urine • Abdominal pain • Food Intolerance • Gas and flatus • Hernia, Hemorrhoid • Appetite change • Nausea/vomiting – How much? • Constipation • Hematemesis (vomiting blood) • Indigestion, heartburn, reflux • Pruritis- Severe itching • Stool Changes (type, color) & Hematochezia (blood in poo) or Melena (black)
8
Q
Urogenital Urinary
A
HHUDDLFIN • Hematuria (Blood in Urine) • Hesitancy- Go to restroom but have trouble urinating • Urgency • Dysuria • Dark Urine • Low Back Pain • Frequency- going often • Incontinence- do you ever lose urine when coughing or sneezing? • Nocturia (Urination at night)
9
Q
Urogenital Genital
A
DRUBS • Discharge • Rash • Ulcers • Blisters • . sexual activity
10
Q
Gyn
A
MADD FLASH
- Menses Schedule, flow, bleeding btwn menses
- Age at menarche
- Dysmenorrhea (painful periods or cramps)
- Discharge (Vaginal) or itching
- Frequency of intercourse
- Libido
- LMP
- Age at Menopause- any spotting?
- Sexual Difficulties
- Hot Flashes
