Comprehensive Health History Flashcards
Comprehensive Pt Assessment
New Pts or Hospital admission
-whole knowledge about the pt
-rule out physical causes related to the concern
-baseline
Focused Pt assestment
established pts or urgent care
-focuses on specific concerns
-ROS over only pertinent systems
subjective
“symptoms” “spoken”
what the patient tells you
CC, ROS
Objective
“signs”
physical examination findings
Diagnostic testing results
Personal observations (odor, language, gait, etc)
Subjective data
Initial info
CC
HPI
PMH
FH
Personal/social HX
ROS
Initial information
Date and time
Pt initials, age, gender
Source of Info and Pt reliability
CC
always in “x”
select one CC that predominates
HPI
the story
OLDCARTSS
(include an intro sentence w Pt initials, age and gender and PMH)
-pertinent + and - symptoms
Onset
When did it start? What setting did it start in
Location
Where on the body is the problem, symptom or pain at?
(point)
Duration
How long has it been present?
How long does it last?
Character
Adjective describing the problem, symptom or pain
-dull, sharp, burning, tingling etc
Alleviating and Aggravating factors
what makes it better or worse?
any meds?
Radiation
Does the pain move to other areas?
Timing
How often does it occur?
Constant or Intermittent
Severity
pain scale (1-10), comparison to other experiences
Symptoms associated
(+) or (-) symptoms
Allergies
Drug, food, environmental
true allergy
anaphylaxis
hives
immune response
Side effect
stomach pain
rash
(known Rx of a drug)
Current Medicaitons
Rx, OTC, herbal supplements, vitamins
Order for recording a medicine
Name, dose, route, frequency, (as needed?)
PO
oral
PR
per rectal
SQ
subcutaneous
OS
left eye
OD
right eye
OU
both eyes
AS
left ear
AD
right ear
AU
both ears
childhood illness
acute illlness (measles, mumps, rubella, whooping cough, chickenpox, rheumatic fever, scarlet fever, polio)
Chronic illness
Adult medical HX
Acute or chronic
hospitalizations
Surgical HX
name of surgery, date, indication
-problems with anesthesia
-complications?
OB/GYN
age at menarche
current period (duration, frequency, regularity of meneses)
Age at menopause?
G#PTPAL
Contraception?
Pap smear? Results?
Mammogram? Results?
G#PTPAL
Gravida- number of pregnancies
Term- Number of term pregnancies
Preterm- number of preterm pregnancies (20w-36.6w)
Abortion- spontaneous or induced abortions (under 20w)
Living- Number of children living
Psychiatric history
Diagnoses (date and age), Treatment, or hospitalization
Health maintenance
Immunizations
Screenings and other tests -Dental, Eye exam, low dose ct, ekg, colonoscopy
Family history
3 generations
list age, health or age and cause of death
Specific disease: HTN, DM, Hyperlipidemia, thyroid, cancer, Heart disease, stroke, renal, mental illness
SOGI
Sexual orientation
Gender identity
Sex on Birth certificate
Social HX
Place of birth
occupation
education
household
significant relationships
exercise
diet
leisure/hobbies
safety
alcohol/tabacco/ caffeine, illicit drug use
ADLS
Spiritual history
sexual history
CAGE
alcohol
cutting down? annoyance when criticized? guilty feelings? Eye openers?
pack years
of packs smoked per day X
# of years person has smoked
Basic ADLS
ambulating
feeding
dressing
toileting
bathing
transferring
Instrumental ADLS
using the phone
shopping
preparing food
cleaning
doing laundry
driving
taking medicine
managing money
FICA
Faith or beliefs
Importance and influence
Community
Address (how you would like it address)
ROS
series of Yes or no questions
-go head to toe
ROS skin
Rashes
lumps
sores
itching
dryness
changes in color
changes in hair or nails
changes in moles
ROS Head
headache
head injury
dizziness
lightheadedness
facial pain
facial swelling
ROS eyes
Vision
glasses/contact
eye pain
redness
excesssive tearing
double or blurred vision
spots/floaters
glaucoma
cataracts
ROS ears
hearing aids?
tinnitus
vertigo
earaches/pain
HX ear infections
discharge/drainage
ROS Nose and Sinuses
nasal stuffiness/congestion
discharge
hay fever/allergies
Sinus pain/pain
sinus infections
ROS Throat
Teeth/gums
bleeding gums
Dentures
sore tongue
dry mouth
sore throat
hoarseness
Neck
swollen glands
goiter
lumps
pain
stiffness
ROS breasts
lumps
change in breasts
Change in the nipples
pain or discomfort
nipple discharge
ROS Respiratory
cough
Sputum (color, quantity)
Hemoptysis
shortness of breath
wheezing
pleuritic pain
snoring
ROS Cardiovascular
chest pain
angina pectoralis
SOB
Orthopnea (trouble breathing while laying down)
Paroxysmal Nocturnal Dsypnea
Edema
Hx of Heart murmurs
ROS GI
Dysphasia
appetite
bowel habits
rectal bleeding
defecation pain
diarrhea
flatus or belching
heartburn
nausea and vomiting
melena
hemorrhoids
constipation
abdominal pain
jaundice
ROS urinary
frequency
polyuria
nocturia
urgency
dysuria
hematuria
flank pain
suprapubic pain
incontinence
ROS Urinary additional for males
reduced caliber or force of stream
hesitancy
dribbling
ROS genital male
hernia
discharge
sores
testicular pain
scrotal pain or masses
sexual interest, satisfaction, function
ROS Genital (female)
discharge
itching
sores, lumps
dyspareunia
bleeding between periods/after intercourse
dysmenorrhea
PMS
menopausal symptoms
sexual interest
ROS peripheral vascular
claudication (leg pain with exertion)
leg cramps
varicose veins
past clots in the veins
swelling in calves, legs, or feet
Raynoids syndrome
hair loss on extremities
ROS Musculoskeletal
Muscle or joint pain (hx of trauma)
Joint swelling/redness
stiffness
arthritis
gout
back or neck pain
ROS psychiatric
changers in mood
tension
anxiety
depression
memory change
Suicidal ideation
homicidal ideation
suicide plans
ROS neurologic
weakness
paralysis
numbness
paresthesia
tremors
seizures
headaches
dizziness
syncope
change in memory, orientation, speech, judgment, insight
ROS hematologic
anemia
easy bruising
abnormal bleeding
past transfusion
transfusion reaction
ROS endocrine
heat or cold intolerance
excessive sweating
polydipsia
polyphagia
polyuria
change in glove or shoes size
Q
every
Fishbone documentation (4)
…….Hgb……
Wbc…….Plts
…….Hct…….
Lab documentation with fishbone (7)
Na|Cl |BUN
K |CO2 |Cr ….Glucose
