Health History and General Survey Flashcards
1
Q
Components of General Survey (4)
A
appearance
body structure
mobility
behavior
2
Q
Physical appearance markers (general survey)
A
age sexual development level of consciousness skin color (looking for erythema, jaundice, lesions) facial features any apparent distress
3
Q
body structure and development (general survey)
A
stature nutrition symmetry posture position body build/contour obvious physical deformities
4
Q
mobility (general survey)
A
range of motion
gait
5
Q
behavior (general survey)
A
mood and affect facial expressions dress speech personal hygiene
6
Q
Reasons for seeking care
A
chief complaint, symptoms, illness
7
Q
perception of health
A
definition of health
expectations
hopes/plans for health
8
Q
OLD CARTS
A
Onset Location (point, changes/movement over time) Duration Characteristics Aggravating or alleviating Related symptoms Treatment Severity
9
Q
Review of Systems - broad strokes
A
subjective
10
Q
Head to toe body systems
A
- overall
- HEENT
- Skin
- Respiratory
- Cardiovascular
- Peripheral vascular
- GI
- Urinary
- Genital/reproductive
- Musculoskeletal
- Neurological
- Hematologic
- Endocrine
11
Q
BATHE assessment for anxiety, depression, situational stress
A
background affect trouble handle empathy
12
Q
HITS assessment for intimate partner violence
A
How often does your partner... hurt you physically insult or talk down to threaten you scream at you
13
Q
CAGE assessment for alcohol and drug use
A
cut down (you feel)
annoyed by criticism
guilt about drinking or drug use
eye opener – use drugs/alcohol to get going in the morning
