Health Status Eval Flashcards
do you need proper documentation/adequate notes for each patient?
Yes; if not, can get majorly sued
- Single most important source of information about this patient
- Depth of inquiry tailored to each patient, based on:
- Age
- Medical condition
- Extent of planned surgery
Medical history review
_____ information of soap method
-told to you by patient
Subjective
- Reason why the patient is in your office
- Must be in patient’s own words
- Usually within quotations
CHIEF COMPLAINT (CC)
- Delve deeper into patient’s symptoms: pain/swelling/foul smell/drainage
- Location and Radiation
- Onset (when first started)
- Duration (acute vs chronic)
- Change in symptoms (feels better, feels worse, feels same)
- Severity (scale 1-10, “1 is me throwing marshmallow at you, 10 you are engulfed in flames”)
- Character of pain (sharp, dull, throbbing, electric shock)
- Exacerbating factors
- Alleviating factors
- Can be brief
- Can be much more in depth
HISTORY OF PRESENT ILLNESS (HPI)
- “What has your physician/doctor diagnosed you with?”
- Heart, lung, liver, kidney, abdomen, blood, brain, bones, skin
- Questions tailored to quick view health history form answers
- Major illnesses and diseases
- When diagnosed, what treatment currently under
- Hospitalizations
- When, what for, follow up with PCP
- Operations
- What, when, any anesthetic complications
- H/O malignant hyperthermia (Important for IV sedation candidates)
Past medical history
PMH requiring ________
• Previous h/o IE
• Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
• Congenital heart disease (CHD):
• Unrepaired cyanotic CHD, including palliative shunts and conduits
• Completely repaired CHD with prosthetic material or device, whether placed by surgery or by catheter intervention,
during FIRST SIX MONTHS after procedure
• Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
• Cardiac transplant who develop cardiac valvulopathy
Relative indication
• Immunocompromised population
• Grafted shunts (dialysis shunts, hydrocephalus shunts)
• Total joint replacements (Continuing controversy)
- Uncontrolled diabetic
Antibiotic premedication
These herbal meds ______ drug affect (St. Johns Wort, garlic, fibers, laxatives)
Decrease
Herbal meds that _____ drug affect (Echinacea, ginger, cayenne, grapefruit juice, licorice, gingko (increase bleeding), kava, ginseng)
Increase
What are the 18 COMMON HEALTH CONDITIONS TO INQUIRE
ABOUT?
- Angina
- MI
- Heart murmurs (current or previous)
- Rheumatic fever
- Bleeding disorders
- Anticoagulant use
- Asthma
- Hepatitis
- Hypertension
- Kidney disease
- Diabetes
- Corticosteroid use (20 mg Prednisone equiv x 3 weeks)
- Seizure disorder
- Implanted prosthetic devices
- Pregnancy
- Breast feeding post-partum
- Lung diseases (TB, CA, OSA, COPD)
- Osteoporosis
• Behavior that can be detrimental to long term health and wound healing
• Tobacco
• Smoking or smokeless
• Measured in pack years (packs per day x years smoked) as well as when first started
• Alcohol
• What kind, how much (one cup to me is 8 oz, could be 72 oz for others)
• Alcohol Use Disorder Low Risk: MEN: ≤ 4 units per day for men or ≤ 14 units in one week
WOMEN: ≤ 3 units per day for women or ≤ 7 units in one week
• Illicit drug use
• Marijuana, meth (snort/smoke/IV), crack, cocaine, heroin, PCP, LSD, psillicybin, mescalin, bath salts, flakka
• How often, when quit, etc..
Social History
- Direct questioning of patient regarding all systems
- May reveal undiagnosed or hidden medical conditions
- Aids in assessing patients’ current physical status
- Tailor toward patients’ medical history
Review of systems
____ information in soap method
-your finding not told by patient
Objective
ASA ___
- normal healthy patient
ASA 1
ASA ___
Patient with mild systemic disease or significant health risk factor
-NIDDM, obesity, controlled HTN, controlled asthma,
controlled thyroid dx, smoker only, pregerrs
ASA 2
