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Patient Assessment > Comprehensive Health History > Flashcards

Comprehensive Health History Flashcards

1
Q

Comprehensive Pt Assessment

A

New Pts or Hospital admission
-whole knowledge about the pt
-rule out physical causes related to the concern
-baseline

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2
Q

Focused Pt assestment

A

established pts or urgent care
-focuses on specific concerns
-ROS over only pertinent systems

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3
Q

subjective

A

“symptoms” “spoken”
what the patient tells you
CC, ROS

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4
Q

Objective

A

“signs”
physical examination findings
Diagnostic testing results
Personal observations (odor, language, gait, etc)

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5
Q

Subjective data

A

Initial info
CC
HPI
PMH
FH
Personal/social HX
ROS

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6
Q

Initial information

A

Date and time
Pt initials, age, gender
Source of Info and Pt reliability

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7
Q

CC

A

always in “x”
select one CC that predominates

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8
Q

HPI

A

the story
OLDCARTSS
(include an intro sentence w Pt initials, age and gender and PMH)
-pertinent + and - symptoms

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9
Q

Onset

A

When did it start? What setting did it start in

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10
Q

Location

A

Where on the body is the problem, symptom or pain at?

(point)

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11
Q

Duration

A

How long has it been present?
How long does it last?

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12
Q

Character

A

Adjective describing the problem, symptom or pain
-dull, sharp, burning, tingling etc

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13
Q

Alleviating and Aggravating factors

A

what makes it better or worse?

any meds?

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14
Q

Radiation

A

Does the pain move to other areas?

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15
Q

Timing

A

How often does it occur?
Constant or Intermittent

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16
Q

Severity

A

pain scale (1-10), comparison to other experiences

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17
Q

Symptoms associated

A

(+) or (-) symptoms

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18
Q

Allergies

A

Drug, food, environmental

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19
Q

true allergy

A

anaphylaxis
hives
immune response

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20
Q

Side effect

A

stomach pain
rash
(known Rx of a drug)

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21
Q

Current Medicaitons

A

Rx, OTC, herbal supplements, vitamins

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22
Q

Order for recording a medicine

A

Name, dose, route, frequency, (as needed?)

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23
Q

PO

A

oral

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24
Q

PR

A

per rectal

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25
Q

SQ

A

subcutaneous

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26
Q

OS

A

left eye

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27
Q

OD

A

right eye

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28
Q

OU

A

both eyes

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29
Q

AS

A

left ear

30
Q

AD

A

right ear

31
Q

AU

A

both ears

32
Q

childhood illness

A

acute illlness (measles, mumps, rubella, whooping cough, chickenpox, rheumatic fever, scarlet fever, polio)
Chronic illness

33
Q

Adult medical HX

A

Acute or chronic
hospitalizations

34
Q

Surgical HX

A

name of surgery, date, indication
-problems with anesthesia
-complications?

35
Q

OB/GYN

A

age at menarche
current period (duration, frequency, regularity of meneses)
Age at menopause?
G#PTPAL
Contraception?
Pap smear? Results?
Mammogram? Results?

36
Q

G#PTPAL

A

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

37
Q

Psychiatric history

A

Diagnoses (date and age), Treatment, or hospitalization

38
Q

Health maintenance

A

Immunizations
Screenings and other tests -Dental, Eye exam, low dose ct, ekg, colonoscopy

39
Q

Family history

A

3 generations
list age, health or age and cause of death
Specific disease: HTN, DM, Hyperlipidemia, thyroid, cancer, Heart disease, stroke, renal, mental illness

40
Q

SOGI

A

Sexual orientation
Gender identity
Sex on Birth certificate

41
Q

Social HX

A

Place of birth
occupation
education
household
significant relationships
exercise
diet
leisure/hobbies
safety
alcohol/tabacco/ caffeine, illicit drug use
ADLS
Spiritual history
sexual history

42
Q

CAGE

A

alcohol
cutting down? annoyance when criticized? guilty feelings? Eye openers?

43
Q

pack years

A

of packs smoked per day X
# of years person has smoked

44
Q

Basic ADLS

A

ambulating
feeding
dressing
toileting
bathing
transferring

45
Q

Instrumental ADLS

A

using the phone
shopping
preparing food
cleaning
doing laundry
driving
taking medicine
managing money

46
Q

FICA

A

Faith or beliefs
Importance and influence
Community
Address (how you would like it address)

47
Q

ROS

A

series of Yes or no questions
-go head to toe

48
Q

ROS skin

A

Rashes
lumps
sores
itching
dryness
changes in color
changes in hair or nails
changes in moles

49
Q

ROS Head

A

headache
head injury
dizziness
lightheadedness
facial pain
facial swelling

50
Q

ROS eyes

A

Vision
glasses/contact
eye pain
redness
excesssive tearing
double or blurred vision
spots/floaters
glaucoma
cataracts

51
Q

ROS ears

A

hearing aids?
tinnitus
vertigo
earaches/pain
HX ear infections
discharge/drainage

52
Q

ROS Nose and Sinuses

A

nasal stuffiness/congestion
discharge
hay fever/allergies
Sinus pain/pain
sinus infections

53
Q

ROS Throat

A

Teeth/gums
bleeding gums
Dentures
sore tongue
dry mouth
sore throat
hoarseness

54
Q

Neck

A

swollen glands
goiter
lumps
pain
stiffness

55
Q

ROS breasts

A

lumps
change in breasts
Change in the nipples
pain or discomfort
nipple discharge

56
Q

ROS Respiratory

A

cough
Sputum (color, quantity)
Hemoptysis
shortness of breath
wheezing
pleuritic pain
snoring

57
Q

ROS Cardiovascular

A

chest pain
angina pectoralis
SOB
Orthopnea (trouble breathing while laying down)
Paroxysmal Nocturnal Dsypnea
Edema
Hx of Heart murmurs

58
Q

ROS GI

A

Dysphasia
appetite
bowel habits
rectal bleeding
defecation pain
diarrhea
flatus or belching
heartburn
nausea and vomiting
melena
hemorrhoids
constipation
abdominal pain
jaundice

59
Q

ROS urinary

A

frequency
polyuria
nocturia
urgency
dysuria
hematuria
flank pain
suprapubic pain
incontinence

60
Q

ROS Urinary additional for males

A

reduced caliber or force of stream
hesitancy
dribbling

61
Q

ROS genital male

A

hernia
discharge
sores
testicular pain
scrotal pain or masses
sexual interest, satisfaction, function

62
Q

ROS Genital (female)

A

discharge
itching
sores, lumps
dyspareunia
bleeding between periods/after intercourse
dysmenorrhea
PMS
menopausal symptoms
sexual interest

63
Q

ROS peripheral vascular

A

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

64
Q

ROS Musculoskeletal

A

Muscle or joint pain (hx of trauma)
Joint swelling/redness
stiffness
arthritis
gout
back or neck pain

65
Q

ROS psychiatric

A

changers in mood
tension
anxiety
depression
memory change
Suicidal ideation
homicidal ideation
suicide plans

66
Q

ROS neurologic

A

weakness
paralysis
numbness
paresthesia
tremors
seizures
headaches
dizziness
syncope
change in memory, orientation, speech, judgment, insight

67
Q

ROS hematologic

A

anemia
easy bruising
abnormal bleeding
past transfusion
transfusion reaction

68
Q

ROS endocrine

A

heat or cold intolerance
excessive sweating
polydipsia
polyphagia
polyuria
change in glove or shoes size

69
Q

Q

A

every

70
Q

Fishbone documentation (4)

A

…….Hgb……
Wbc…….Plts
…….Hct…….

71
Q

Lab documentation with fishbone (7)

A

Na|Cl |BUN
K |CO2 |Cr ….Glucose

Patient Assessment (20 decks)

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