Consultation and History Taking Flashcards
Gather the necessary information to form a tentative diagnosis
Interviewing and health history
Main reason why the patient is seeking advice
Chief complaint
Amplifies the chief complaint by giving a full, clear, chronological account of each symptom and what events were related to them
History of present illness
Principal symptom: where the pain occurs
Location
Principal symptom: adjective describing the pain
Quality
Principal symptom: degree of the pain
Quantity/Severity
Principal symptom: onset, duration, frequency of the pain
Timing
Principal symptom: the ways that the patient employs that amplify the pain
Aggravating factors
Principal symptom: the ways that the patient employs that ease the pain
Relieving factors
Principal symptom: signs or symptoms that occur along with the pain
Associated symptoms or manifestations
Principal symptom: e.g. laboratory results
Relevant data
Principal symptom: what the patient doesn’t have or isn’t experiencing
Significant negatives
Patient’s prior illnesses, injuries, medical interventions
Past medical history
Patient’s present state of health, environmental conditions, personal habits, health related conditions
Current health status
Pattern of familial illness
Familial history
Family tree of diseases
Genogram
Patient as a person
Psychosocial history
To identify problems which the patient did not mention
Review of systems
AIL: Urinating too much in a day
Polyuria
AIL: can’t stop the urge to urinate
Urinary incontinence
T/F: Review charts before interviewing the patient
True
T/F: Environment doesn’t affect communication
False
T/F: There’s no need to consider privacy when interviewing the patient
False
T/F: The setting must be free from interruptions
True
T/F: Speak to the patient at eye level
True
T/F: Dress cleanly and appropriately
True
T/F: Don’t watch your demeanor
False
T/F: When asking the patient questions, don’t inquire several times
False
T/F: Allow the patient to recount their own stories
True
T/F: Incorporate passive listening
False
T/F: Don’t incorporate facilitative listening
False
T/F: Repeat words to encourage the patient to give more details
True (this technique is called reflection)
T/F: Ask the patient to clarify unclear and ambiguous words
True (this technique is called clarification)
T/F: Show understanding and acceptance by making the patient feel secure and encouraging them to continue
True (this technique is called emphatic response)
T/F: Observe the patient for clues of anger, anxiety, depression
True (this technique is called confrontation)
T/F: Don’t mind your posture
False
T/F: Show signs of panic and hurriedness
False
T/F: Take note of posture, gestures, eye contact
True
T/F: Ask the patient indirect questions
False
T/F: Ask the patient questions from general to specific
True
T/F: Avoid questions answerable by yes or no when taking HPI
True
T/F: Use language that is inappropriate and hard to understand
False
Gathering data: coffee, drugs, liquor, prescription drugs, marijuana, illicit use of drugs
Alcohol and drug history
T/F: Orient the patient with brief and transitional phrases
True
T/F: Ask the patient if there is anything else they want to talk about
True (this technique is called closing)
T/F: During note taking, it is okay to divert your attention from the patients
False (do not divert your attention from the patient)
T/F: During note taking, jot down long phrases and words that will guide you in making the final report
False (only use short phrases and words)
T/F: Take notes when the patient is talking about sensitive information
False (it is best not to take notes when the patient is talking about sensitive information)
T/F: Ask the patient about their weight changes
True
AIL: Increase in body fats or accumulation of fluid
Weight gain
AIL: Loss of energy, sense of weariness, withdrawal from activities
Fatigue
AIL: Caused by musculoskeletal or neurologic disorders
Weakness
AIL: Feelings of coldness, gooseflesh, shivering, rising temperature, hot feelings and sweats, defervescence, shaking, or chills
Fever
What should you investigate when a person has fever?
Travel and contact with a sick person
Change in hair distribution may be a sign that there is a problem with the patient’s _______
Skin
AIL: High level of urea in the blood
Uremia
AIL: Yellowish skin that may be caused by a problem in the liver or gall bladder
Obstructive jaundice
AIL: Parasitic insect that live on clothing and bedding used by an infected person
Body lice
AIL: Redness of the skin
Erythema
A type of headache that is felt only on one side of the head
One-sided headache
A type of headache that is felt on both sides of the head
Bilateral headache
A type of headache that has been occurring for a few hours or days
Acute headache
A type of headache that has been occurring for several months or years
Chronic headache
A type of headache that is recurrent
Tension headache or migraine
An acute and severe headache may suggest..
Subarachnoid hemorrhage
A headache that is progressively becoming severe may suggest..
Presence of tumor
A headache accompanied by nausea and vomiting may suggest..
Brain tumor
A type of headache that suggests problem in the eyes
Frontal headache
AIL: Blurring of vision
Error of refraction or refractive error
AIL: A sudden blurring of vision may suggest..
Retinal detachment
AIL: Blurring at near
Hyperopia
AIL: Blurring at far
Myopia
AIL: Visual disturbance when reading at near
Presbyopia
AIL: What causes a defect in the central visual field?
Development of cataract
AIL: Slow peripheral loss due to an increase in intraocular pressure
Glaucoma
AIL: One-sided visual field; loss of vision in one-half of the visual field
Hemianopsia
AIL: Loss of vision in one quadrant of the visual field
Quadrantanopia
AIL: Inflammation of the conjunctivita which causes redness of the eyes
Conjunctivitis (sore eyes)
Visible moving strands
Muscae volitantes or floaters
AIL: Fixed areas of blindness
Scotoma or lesion of visual pathways
AIL: Caused by the obstruction of the lacrimal canal
Excessive tearing
AIL: Double vision due to the weakness or paralysis of an extraocular muscle or tumor at the back of the eyeball
Diplopia
AIL: Change of color in the eye
Scleral icterus or conjunctival icterus
AIL: Which organs may be affected if the patient is icteric?
Liver or gall bladder
AIL: Another term for dizziness
Vertigo
AIL: Perceived sound without external stimuli or ringing of the ears
Tinnitus
AIL: Patient is complaining that people are mumbling
Sensorineural hearing loss
AIL: Hearing loss and vertigo may suggest..
Meniere’s disease
AIL: May be caused by an inflammation of the ear canal or perforation/rupture of the ear drum
Ear discharge
AIL: Inflammation of the middle ear
Otitis media
AIL: May be caused by pollen, contacts with the environment, allergic rhinitis
Nasal discharge
AIL: Pain in the sinus area
Sinusitis
AIL: Nasal stuffiness on one side
Nasal deviation
AIL: Another term for nosebleed
Epistaxis
AIL: Inflammation of the gums or bleeding gums
Gingivitis
AIL: Sore tongue
Apthous ulcers
AIL: Sore throat may suggest a problem with which body system ?
Respiratory
AIL: Over usage of voice
Hoarseness
AIL: Acute infection in the mouth may result to..
Laryngitis
AIL: Swollen glands in the neck may be due to..
Goiter, lymphadenitis, or lymphomas
AIL: Pain in the myocardium (heart attack)
Myocardial infarction
AIL: Pain in the myocardium (chest pain)
Angina pectoris
AIL: Pain in the aorta
Dissecting aneurysm
AIL: Pain in the trachea and large bronchi
Heartburn that may cause esophagus reflux esophagitis
AIL: Painful deep breathing due to an inflammation in the cartilage
Costochondritis
AIL: Chest heaviness may suggest..
Cardiac problems
AIL: Skipping, pounding, and occasional stopping of heartbeat; heartbeat is felt by the patient
Palpitation
AIL: Heart rate is over 100bmp
Tachycardia
AIL: Heart rate is below 60bmp
Bradycardia
AIL: Non-painful but uncomfortable awareness of breathing; shortness of breath
Dyspnea
AIL: Breathing quicky
Hyperventilation
AIL: Difficulty in breathing when lying down
Orthopnea
AIL: Difficulty in breathing at night
Paroxysmal nocturnal dyspnea
Sound produced that is caused by partial air obstruction
Wheezing
AIL: Accumulation of excessive fluid
Edema
AIL: Edema in lower extremities
Bipedal edema
AIL: Edema in the face
Facial edema
AIL: Edema in the abdomen causing enlarged wasitline
Ascites
AIL: Edema with puffy eyelids may suggest a severe problem in what organ?
Kidney
AIL: Edema with renal problems
Hypoalbuminemia
AIL: Edema all over the body
Anasarca
AIL: Cough with no phlegm
Dry cough
AIL: Cough with phlegm
Productive cough
AIL: A white colored phlegm may suggest..
Viral infection
AIL: A green colored phlegm may suggest..
Bacterial infection
AIL: Coughing with blood suggests that there is a problem in which organ?
Lungs
AIL: A build up of mucus in the lungs
Bronchiectasis
AIL: Coughing up or spitting out blood
Hemoptysis
AIL: Difficulty in swallowing
Dysphagia
AIL: Difficulty in swallowing liquid may suggest a disorder of what muscle?
Esophageal muscle
AIL: Feeling of burning or warmth that is felt retrosternal from the epigastric area to the neck
Heartburn that may cause reflux esophagitis
Causes abdominal bloating, distention, or flatus (farting)
Excessive gas
Medication used to prevent farting
Anti-flatulent medication
(Visceral/Parietal) Pain felt from hollow organs
Visceral pain
(Visceral/Parietal) Pain caused by inflammation
Parietal pain
(Visceral/Parietal) Pain that is more localized
Parietal pain
(Visceral/Parietal) Pain that is poorly localized
Visceral pain
(Visceral/Parietal) Pain that is aggravated by coughing or movement
Parietal pain
(Visceral/Parietal) Pain that is burning, cramping, aching
Visceral pain
(Visceral/Parietal) Pain that is associated with nausea and vomiting
Visceral pain
Pain that travels from an initial site; radiating pain
Referred pain
Colicky pain suggests a problem with what muscle contraction?
Peristalsis
AIL: Vomitus with blood
Hematemesis
AIL: loss or lack of appetite
Anorexia
AIL: Stomach is feeling sick
Nausea
AIL: Spasmodic movement of the chest and diaphragm that proceeds and culminate to vomiting
Retching
AIL: Forceful expulsion of gastric contents through the mouth
Vomiting
AIL: Raising of esophageal and gastric contents in the absence of nausea and vomiting
Regurgitation that may be caused by an incompetent gastroesophageal sphincter
AIL: May result to brownish or blackish vomitus
Duodenal and gastric ulcers
AIL: Presently grey stool
Acholic stool
AIL: Passage of hard or painful stools; incomplete defacation
Constipation
AIL: Passage of excessively frequent stools
Diarrhea
AIL: Greasy foul smelling stool
Steatorrhea
AIL: Inability to absorb enough nutrients
Malabsorption syndrome
A discoloration of the skin and eyes is caused by high levels of _____ in the blood
Bilirubin
A discoloration of the skin and eyes may suggest a problem in the _____
Liver, gallbladder, or bile duct
Jaundice may be caused by an obstruction of the _____ or obstruction of the _____
Common bile duct or pancreas
Dark urine suggests impaired excretion of _____
Bilirubin
Color of the stool of someone with obstructive jaundice
Acholic or light colored
Pain caused by a sudden distention of the renal capsule
Kidney pain
Pain in the ureter
Urethral pain
Pain in the ureter may be caused by stones in the _____
Urinary tract
AIL: Condition of having kidney stones
Nephrolithiasis
AIL: Condition of having gallstones
Cholelithiasis
Where is prostatic felt?
Perineum
Pain during urination may be caused by the presence of _____ or _____
Stones or tumors
AIL: Presence of blood in urine
Hematuria
Pain during urination with blood may be caused by the presence of…
Tumor
Urination with blood in the absence of pain may be caused by…
Cancer
AIL: Caused by an infection of the bladder that comes with a sudden urge to urinate
Urinary urgency
AIL: An urge to urinate but unable to
Urinary hesitancy
AIL: The need to strain in order to urinate
Straining to void
AIL: Urine does not flow smoothly
Dribble
AIL: Pain during urination without frequency is suggestive of…
Urethritis
AIL: Excessive thirst or excess drinking
Polydipsia
AIL: Group of diseases that injures the part of the kidney that filters blood
Glomerulonephritis
AIL: Intense urge to urinate with straining but little to no result
Vesical tenesmus
AIL: Intense urge to defecate but little to no result
Rectal tenesmus
AIL: Swelling of the limbs due to veins having trouble sending blood from the limbs back to the heart
Venous disease/Venous insufficiency
AIL: An inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs
Thrombophlebitis
AIL: Caused by weak vein walls and valves or an increase blood pressure in veins
Varicose veins
AIL: Inflammation of the tendons
Tendonitis
AIL: Inflammation of the bursa
Bursitis
AIL: Causes joint pain throughout the body
Rheumatoid arthritis
AIL: Joint pain
Arthralgia
AIL: Muscular pain
Myalgia
AIL: Butterfly rash is commonly associated with what condition
Systemic lupous erythematosus
AIL: Appears as the body’s reaction to allergy or drug reactions
Urticaria or hives
AIL: Low blood sugar level
Hypoglycemia
AIL: Low blood pressure caused by a sudden change in position
Postural hypotension
AIL: Paroxysmal disorder with or without loss of consciousness; change in brain’s electrical activity
Seizure
AIL: Sudden temporary loss of consciousness when blood flow to the brain is insufficient
Syncope (fainting)
AIL: Involuntary movement/shaking of one or more parts of the body
Tremors
AIL: Tingling sensation of the skin
Paresthesia
AIL: Occurs when your body does not produce enough hormones
Hypothyroidism
AIL: Hypothyroidism can result to _____ due to a deceleration of the body’s metabolism
Obesity
AIL: Occurs when your body produces too much hormones
Hyperthyroidism
AIL: Hyperthyroidism can result to _____ due to an acceleration of the body’s metabolism
Weight loss
Another term for black stool
Melena
