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History and Physical Exam > Health and History Part 1 > Flashcards

Health and History Part 1 Flashcards

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1
Q

for new patients in offices or hospitals you will complete a _________ exam

A

comprehensive exam

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2
Q

for established patients during routine or urgent care visits you will complete a ________ exam

A

focused exam

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3
Q

What type of exam includes past history, medications, extensive physical exam, and allows the patient to develope repor with you (their opinion)

A

comprehensive exam

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4
Q

an assessment that is specific to one or two concerns/problems

A

focused exam

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5
Q

a patient is complaining of ear pain. you then examine the patients head, ears, eyes nose and throat. What type of exam is this

A

focused exam

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6
Q

A ________ exam should be performed annually and are a review of previous exams.

A

A routine exam should be performed annually and are a review of previous exams.

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7
Q

what exam is primarily to prevent illness or catch illness in early stages

A

routine exam

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8
Q

The _____________ information is the information the patient tells you during the history.

A

The Subjective information is the information the patient tells you during the history.

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9
Q

the _________ information is what you identify in the physical exam, and diagnostic testing

A

the objective information is what you identify in the physical exam, and diagnostic testing

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10
Q

the objective information is what you identify in the _________, and _______________

A

the objective information is what you identify in the physical exam, and diagnostic testing

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11
Q

What information should NOT be included in the history

A

the objective findings.

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12
Q

aqcuiring the ______________ is one of the most important skills in medicine

A

health history

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13
Q

A good health history allows you to ____________, gain ______ and ______, and formulate a good _____________.

A

A good health history allows you to get to know the patient, gain trust and respect, and formulate a good differential diagnosis.

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14
Q

what is a differential diagnosis.

A

An analysis of exam findings and pt history that gives a hypothesized diagnosis for further testing

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15
Q

patients name, age, gender, sex, medical record number and DOB is known as ______________

A

identifying data/demographics

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16
Q

where the history of the patient comes from is known as

A

the source of history

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17
Q

Where is the patients story told

A

HPI

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18
Q

Documentation of the HPI is taken in ___________ form and using __________________. If a number is used you must ___________ if the number is less than _______

A

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

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19
Q

What part of the HPI is always in quotes

A

the chief complaint

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20
Q

Other than the chief complaints what else could be documented in quoatations

A

anything that is difficult to describe such as “i have bugs crawling under my skin.”

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21
Q

If the patient does not have a chief complaint what goes in quotes

A

the reason the patient is there, “I am here for lab work. “ “ i am here for a routine checkup”

22
Q

Do not put any _______________ in the HPI

A

Physical Exam Findings

23
Q

Only use medical abbreviations in the HPI that you know have been_________

A

approved

24
Q

The first sentence of the HPI should include _____________ and _____________if someone is giving history other than the patient.

A

The first sentence of the HPI should include patient identifiers and historian if someone is giving history other than the patient.

25
Q

what does the pneumonic LOCATES stand for

A

Location
Onset
Character
Aggravating and Alleviating factors and associated symptoms (Factors/Symptoms)
Timing
environment
severity

26
Q

Location includes ____________ and whether it __________.

A

Location includes where is it and whether it radiates

27
Q

Onset includes ___________________, do NOT put _______________________________ because this is not ___________________________.

A

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.

28
Q

Character includes ____________________/___________________You may need to give examples

A

Character includes How the illness feels, descriptions of the symptom. You may need to give examples

29
Q

Aggravating and alleviating factors includes anything that makes the symptoms ______________________. you may need to give the patient examples

A

Aggravating and alleviating factors includes anything that makes the symptoms better or worse. you may need to give the patient examples

30
Q

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?”

A

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?”

31
Q

Timing includes whether the illness is _____________, _____________, ______________and _________________

A

Timing includes whether the illness is constant, waxing and waning, intermittent and how long it lasts

32
Q

Environment includes _________________________________________Sometimes the patient does not remember, this is okay, just document it as such

A

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

33
Q

Severity includes a ______________________________. non pain related symptoms can be assessed by determining _______________________________________

A

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

34
Q

what are pertinent positives and negatives

A

symptoms the pt admits to having or not having that are related to the differential diagnosis

35
Q

What is the order of the HPI
1. _________________
2. _____________________
3. _____________________
4. ______________________

A

What is the order of the HPI
1. Cheif complaint
2. 7 attributes
3. pertinent negatives
4. History/risk factors.

36
Q

Past medical histroy includes ________________, ______________, _____________, and past _________________

A

Past medical histroy includes adult/childhood illnesses, OBGYN, Psych hx, and past hospitalizations

37
Q

Surgical history includes ________________ and ________________

A

surgical histroy includes date of surgery and type of surgery

38
Q

Health maintenance history includes _______________ and ______________that have been completed.

A

Health maintenance history includes immunizations and screenings that have been completed.

39
Q

Medication history (prescriptions, OTC, and herbal) should be known in ____________, _____________, ________________, and _______________

A

Medication history (prescriptions, OTC, and herbal) should be known in dosage, route, frequency, and compliance

40
Q

Allergic history should includes ______________ and how _____________. If ____________is not known then “__________unknown” is documented

A

Allergic history should includes allergies if any and how they react to them. If reaction is not known then “reaction unknown” is documented

41
Q

Family hx should at least include _______, ______, __________ and ________. You can also include______________ but not required

A

Family hx should at least include mom, dad, brothers and sisters. You can also include extended family but not required

42
Q

personal and social history includes ______________, _____________________ and _____________ use MANDATORY. Every other personal/social is not required but may be necessary.

A

personal and social history includes alcohol, smoking/tobacco and illicit drug use MANDATORY. Every other personal/social is not required but may be necessary.

43
Q

review of systems is a brief review of ___________in a _______________ fashion. questions are asked on organs systems related to the ________________

A

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

44
Q

You should at least ask and document about____________ symptoms for each organ system.

A

2

45
Q

Pertinent positives and negatives are documented in both the _______ and the _______

A

HPI and ROS

46
Q

Pertinent systems are documented ________ first and _______second

A

positive first negative second

47
Q

Aside from the HPI what other portion is wirtten in paragraph form

A

social histroy

48
Q

If you go over at least two systems from the organ system in the __________you may put __________ under that organ system in the ROS

A

“in HPI”

49
Q

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.

A

okay cool

50
Q

_______________________ includes anything that makes the symptoms better or worse. you may need to give the patient examples

A

Aggravating and alleviating factors includes anything that makes the symptoms better or worse. you may need to give the patient examples

51
Q

___________________________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?”

A

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?”

History and Physical Exam (5 decks)

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