Health and History Part 1 Flashcards
for new patients in offices or hospitals you will complete a _________ exam
comprehensive exam
for established patients during routine or urgent care visits you will complete a ________ exam
focused exam
What type of exam includes past history, medications, extensive physical exam, and allows the patient to develope repor with you (their opinion)
comprehensive exam
an assessment that is specific to one or two concerns/problems
focused exam
a patient is complaining of ear pain. you then examine the patients head, ears, eyes nose and throat. What type of exam is this
focused exam
A ________ exam should be performed annually and are a review of previous exams.
A routine exam should be performed annually and are a review of previous exams.
what exam is primarily to prevent illness or catch illness in early stages
routine exam
The _____________ information is the information the patient tells you during the history.
The Subjective information is the information the patient tells you during the history.
the _________ information is what you identify in the physical exam, and diagnostic testing
the objective information is what you identify in the physical exam, and diagnostic testing
the objective information is what you identify in the _________, and _______________
the objective information is what you identify in the physical exam, and diagnostic testing
What information should NOT be included in the history
the objective findings.
aqcuiring the ______________ is one of the most important skills in medicine
health history
A good health history allows you to ____________, gain ______ and ______, and formulate a good _____________.
A good health history allows you to get to know the patient, gain trust and respect, and formulate a good differential diagnosis.
what is a differential diagnosis.
An analysis of exam findings and pt history that gives a hypothesized diagnosis for further testing
patients name, age, gender, sex, medical record number and DOB is known as ______________
identifying data/demographics
where the history of the patient comes from is known as
the source of history
Where is the patients story told
HPI
Documentation of the HPI is taken in ___________ form and using __________________. If a number is used you must ___________ if the number is less than _______
HPI is taken in paragraph form and using correct English. If a number is used you must spell it out if the number is under 10
What part of the HPI is always in quotes
the chief complaint
Other than the chief complaints what else could be documented in quoatations
anything that is difficult to describe such as “i have bugs crawling under my skin.”
If the patient does not have a chief complaint what goes in quotes
the reason the patient is there, “I am here for lab work. “ “ i am here for a routine checkup”
Do not put any _______________ in the HPI
Physical Exam Findings
Only use medical abbreviations in the HPI that you know have been_________
approved
The first sentence of the HPI should include _____________ and _____________if someone is giving history other than the patient.
The first sentence of the HPI should include patient identifiers and historian if someone is giving history other than the patient.
what does the pneumonic LOCATES stand for
Location
Onset
Character
Aggravating and Alleviating factors and associated symptoms (Factors/Symptoms)
Timing
environment
severity
Location includes ____________ and whether it __________.
Location includes where is it and whether it radiates
Onset includes ___________________, do NOT put _______________________________ because this is not ___________________________.
Onset includes when did it start, do NOT put that this started “monday” or “December 24th” because this is not specific as to how long this has been happening.
Character includes ____________________/___________________You may need to give examples
Character includes How the illness feels, descriptions of the symptom. You may need to give examples
Aggravating and alleviating factors includes anything that makes the symptoms ______________________. you may need to give the patient examples
Aggravating and alleviating factors includes anything that makes the symptoms better or worse. you may need to give the patient examples
Associated symptoms include ___________________________________. These are usually based on questions provided by you as the provider.
ex. if patient is having runny nose you ask “are you having fever?”
Associated symptoms include anything that could be connected to the current illness. These are usually based on questions provided by you as the provider.
ex. if patient is having runny nose you ask “are you having fever?”
Timing includes whether the illness is _____________, _____________, ______________and _________________
Timing includes whether the illness is constant, waxing and waning, intermittent and how long it lasts
Environment includes _________________________________________Sometimes the patient does not remember, this is okay, just document it as such
Environment includes what the patient was doing when the illness began. Sometimes the patient does not remember, this is okay, just document it as such
Severity includes a ______________________________. non pain related symptoms can be assessed by determining _______________________________________
Severity includes a pain assessment on a scale of 1-10. non pain related symptoms can be assessed by how much the illness is effecting quality of life
what are pertinent positives and negatives
symptoms the pt admits to having or not having that are related to the differential diagnosis
What is the order of the HPI
1. _________________
2. _____________________
3. _____________________
4. ______________________
What is the order of the HPI
1. Cheif complaint
2. 7 attributes
3. pertinent negatives
4. History/risk factors.
Past medical histroy includes ________________, ______________, _____________, and past _________________
Past medical histroy includes adult/childhood illnesses, OBGYN, Psych hx, and past hospitalizations
Surgical history includes ________________ and ________________
surgical histroy includes date of surgery and type of surgery
Health maintenance history includes _______________ and ______________that have been completed.
Health maintenance history includes immunizations and screenings that have been completed.
Medication history (prescriptions, OTC, and herbal) should be known in ____________, _____________, ________________, and _______________
Medication history (prescriptions, OTC, and herbal) should be known in dosage, route, frequency, and compliance
Allergic history should includes ______________ and how _____________. If ____________is not known then “__________unknown” is documented
Allergic history should includes allergies if any and how they react to them. If reaction is not known then “reaction unknown” is documented
Family hx should at least include _______, ______, __________ and ________. You can also include______________ but not required
Family hx should at least include mom, dad, brothers and sisters. You can also include extended family but not required
personal and social history includes ______________, _____________________ and _____________ use MANDATORY. Every other personal/social is not required but may be necessary.
personal and social history includes alcohol, smoking/tobacco and illicit drug use MANDATORY. Every other personal/social is not required but may be necessary.
review of systems is a brief review of ___________in a _______________ fashion. questions are asked on organs systems related to the ________________
review of systems is a brief review of all organ systems in a head to toe fashion. questions are asked on organs systems related to the chief complaints
You should at least ask and document about____________ symptoms for each organ system.
2
Pertinent positives and negatives are documented in both the _______ and the _______
HPI and ROS
Pertinent systems are documented ________ first and _______second
positive first negative second
Aside from the HPI what other portion is wirtten in paragraph form
social histroy
If you go over at least two systems from the organ system in the __________you may put __________ under that organ system in the ROS
“in HPI”
must pull up rubric and make copy into google drive and then pul up the health histrory and review it to see if its correct or incorrect. then make note of it or highlight it for discussion next week and give it a grade. there are like three of them. we will discuss them next week during class.
okay cool
_______________________ includes anything that makes the symptoms better or worse. you may need to give the patient examples
Aggravating and alleviating factors includes anything that makes the symptoms better or worse. you may need to give the patient examples
___________________________include anything that could be connected to the current illness. These are usually based on questions provided by you as the provider.
ex. if patient is having runny nose you ask “are you having fever?”
Associated symptoms include anything that could be connected to the current illness. These are usually based on questions provided by you as the provider.
ex. if patient is having runny nose you ask “are you having fever?”
