H&P

Question 1

Often overlooked component needed on H&P

Answer 1

Date and Time it was completed. Pt could be seen multiple times throughout the day

Question 2

10 components of H&P

Answer 2

date & time, identifying data, source of history, chief complaint, history of previous illness, past history, medications, allergies, family history, personal & social history, review of systems.

Question 3

Subjective data

Answer 3

what the patient tells you “Mr Joe is a 28 year old student reports laziness and apathy toward studying “I’d rather shoot myself in the face than study this stuff” which has been going on for weeks. :(

Question 4

Objective data

Answer 4

physical exam findings “the patient is an overworked white male who is pleasant and cooperative, BP 120/80, HR 70, and regular respiratory rate. Jittery from his addiction to coffee and smells like whiskey

Question 5

Chief Complaint

Answer 5

The reason patient is here to see you “my brain feels like Oprahs toilet seat with her on it.” usually in quotes.

Question 6

History of present illness

Answer 6

details about the chief complaint CHLORIDE

Question 7

CHLORIDE acronym

Answer 7

Character, location, onset, radiation, intensity, duration, exacerbating or alieviating factors.