H&P Flashcards
What the patient tells you is ______ data.
What you detect during the exam is _____ data.
subjective
objective
Always document date and time of all patient evaluations. True or false.
true
Identifying data includes age, gender, marital status, occupation, source of history or referral. True or false?
true
If the source is other than the patient, then the source does not need to be documented. True or false?
false
The reliability of the source varies according to the patient’s mental status, trustworthiness, and mood. True or false.
true
The reason the patient is here to see you is the
chief complaint
Make every attempt to use the patient’s own words. True or false.
true
What is a complete, clear, and chronological account of the problems prompting the patient to seek care.
history of present illness
What should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments?
Narrative
Past medical history includes:
- general health and strength of the patient
- adult illnesses
- childhood diseases
- past surgeries
- recent screening tests
- immunizations
What are important aspects of the personal and social history?
- marital status
- stress
- occupation, job history
- level of schooling
- Activities of daily living
- personal habits such as alcohol, drug, and tobacco use
- diet and exercise
Series of questions from “head to toe” in a system based approach
review of systems (ROS)
Important neurological review of systems for neuro cases:
- fainting
- blackouts
- seizures
- weakness
- paralysis
- numbness
- tingling
- tremors
- involuntary movements
Thyroid, heat or cold intolerance, excessive sweating, thirst, or hunger, polyuria indicates ________ review of systems
endocrine
body mass index calculation
weight (kg)
____________
height (meters squared)
