H&P Flashcards
Comprehensive assessment
appropriate for a new patient encounter & serves as a baseline for follow-up epidosidic encounters
Episodic assessment
appropriate for established patients to focus on symptom-based complaints related to a particular system
Subjective
information directly from the patient. Chief complaint to review of systems
Objective
Information that the clinician gathers
Physical exam- inspection, palpation, auscultation, percussion
Vital signs, labs, other diagnostic data
Components of a comprehensive health history
Identifying information source of information reliability of information chiefs complaints history of present illness past medical hx family hx personal and social hx review of systems
Identifying information
date of encounter, patient initials, age, race, gender
Chief complaint
“symptom and duration” in the patients own words
HPI
8 variables related to the CC
ROS pertinent to the CC; positive and negatives
PMH pertinent to CC
FH pertinent to CC
8 variables of the CC
Onset- when did it start Location-where is it located Duration- How often and how long does it last? is it intermittent? Character- How does the patient? Aggravating/alleviating factors- does anything make it worse or better? Radiation- is there any radiation timing- when does it occur severity-what is the intensity
PMH
Childhood illnesses major adults illnesses health maintenance hospitalizations/surgeries injuries/accidents current medications with doses allergies and reactions
Family history
Inquires about a family history of DM, CAD, HTN, CA, Arthritis, mental disorders, or other hereditary conditions
Use a genogram
Personal and social history
family structure education level economic status home conditions/environments occupation history cultural considerations habits- tobacco, recreational drugs, ETOH, caffeine, Sleep, Seat belts, diet, exercise
Review of systems
General, skin hair nails, head and face, eyes, ears, nose/sinuses, mouth/throat, neck, CV/PV, respiratory, breast, GI, Urinary, Reproductive, musculoskeletal, neurologic, lymphatic, endocrine, hematopoietic, psychiatric
Physical exam
skin, head/face, eyes, ears, nose, mouth, neck, thorax/lungs, CV/PV, breasts, lymphatic, abdomen, Genitalia/rectum, musculoskeletal, neurologic
Assessment
Differential diagnoses- list of conditions that could have similar presenting symptoms
Presumptive diagnosis- the most likely cause of the patient’s symptoms after taking a history, performing a physical exam and interpreting tests/data
