HISTORY AND PHYSICAL Flashcards
H&P: what questions should be asked for general ROS?
Previous VS problems, previous measurements, fever, fatigue, unintentional wt gain or loss, night sweats or chills, appetite, sleep. Children-specific assessment tests.
H&P: what questions should be asked for ENT ROS.
Usual condition, headache, dizziness, syncope, trauma, LOC, concussion, ROM.
H&P: what questions should be asked for ENT ROS?
Usual condition, tinnitus, vertigo, infections, surgeries, epistaxis, post-nasal drip, polyps, hearing loss, congestion, sore throat, voice changes, allergies, sores, gum/mucosa lesions, dental abscess, or issues (mouth and teeth condition).
H&P: what questions should be asked for eyes ROS?
Usual condition, discharge, redness, visual changes (blurred vision, diplopia, photophobia) eye pain, cataracts, glaucoma, surgeries, corrective lens use.
H&P: what questions should be asked for Chest and lungs ROS?
Usual condition, cough, sputum, blood, colored sputum, asthma, COPD/emphysema, SOB, SOBOE, wheezing, chest wall pain, infections, last x-ray or pulmonary function tests.
H&P: what questions should be asked for Heart and blood vessels ROS?
Usual condition, previous problems, edema, loss of sensation in legs, CP, palpitations, orthopnea, dyspnea, last ECG, stress test or cardiac BW.
H&P: what questions should be asked for breast and axillae ROS?
Usual condition, previous problems, tenderness redness, nipple discharge, skin changes, new lump or nodule, last mammogram.
H&P: what questions should be asked for GI ROS?
Usual condition, previous problems, abd pain, dyspepsia, N/V/D, constipation, blood in stool, painful defecation, normal bowel habits.
H&P: what questions should be asked for GU ROS?
Usual condition, previous problems, dysuria, frequency, urgency, retention, incontinence, hematuria, flank pain.
H&P: what questions should be asked for reproductive: Male ROS?
Usual condition, previous problems, dysuria, testicular pain, genital lesions, masses, hernias, discharge, sexual history, sexual risks/health, erectile dysfunction.
H&P: what questions should be asked for reproductive: Female ROS?
Usual condition, previous problems, menstruation, irregular or painful menses, heavy bleeding, genital lesions, dyspareunia, sexual health, sexual history, childbearing history.
H&P: what questions should be asked for anus, rectum, prostate ROS?
Usual condition, previous problems, rectal bleeding, pain, hemorrhoids, fissures, discharge, incontinence.
H&P: what questions should be asked for MKS ROS?
Usual condition, previous problems (#, back pains), gait, joint or muscle pain, changes in ROM, MSK trauma, deformities, limitations, use of mobility devices (cane, walker, braces).
H&P: what questions should be asked for CNS ROS?
Usual condition, previous problems, paresthesia, head pain, visual changes, dizziness, tremors, gait disturbances, weakness, memory loss, confusion, trauma, seizure activity.
H&P: what questions should be asked for MH ROS?
Usual condition, previous problems/psych history, depression, memory difficulties, concentrations, mood, hallucinations, SI or HI thoughts.
H&P: what questions should be asked for cross-system data ROS?
Endocrine and thyroid problems –> polydipsia, polyphagia, polyuria, heat or cold intolerance.
H&P: what questions should be asked for lymphatic system ROS?
Usual condition, previous problems, edema, lumps or nodules to neck, groin, axillae.
H&P: what questions should be asked for skin hair and nails ROS?
Usual condition, previous problems, bruising, lesions, masses, odors, pruritus, hair loss, rashes, moles, sores (poor healing).
H&P: what questions should be asked for nutritional status ROS?
Usual diet, appetite trends, and cravings, usual preparation, food choices, intake questions (chewing, choking, denture, plates, braces).
H&P: what kind of identifying information should be noted?
Cultural backgrounds, family structure, education, economic and environmental data, client reliability.
H&P: What data should be included during the HPI?
Location, Onset, Type, Alleviating or Aggravating, Radiation, Timing, Severity, Associated Symptoms, affect on the client, client perception, health pre-illness.
H&P: What information should be listed under medical history?
Surgeries, injuries, and disabilities, major childhood illnesses, major adult illnesses, blood transfusions, obstetrical history, mental health history (dates for all).
H&P: What information should be listed under Previous health care?
Recent health exams (physical, pap smear, x-rays, BW, TB test, dental, vision, hearing, mammogram), immunizations, skin tests, obstetric care, screening tests.
H&P: What information should be listed under current health/risk factors?
Exercise, nutrition, sleep, smoking, alcohol, drug use.
H&P: What information should be listed under medications and allergies?
OTC drugs, vitamins, supplements, Rx medications, allergies with Rxn.
H&P: What information should be listed under family history?
Status of family members (family tree), major health conditions in the family (HTN, CA, cardiopulmonary problems, psych, hepatitis( Genetic disorders (sickle cell, alcoholism), family death of unknown etiology.
H&P: What information should be listed under social history?
Cultural backgrounds, family structure, education, economic and environmental data, stress factors, “typical day”, interpersonal violence, diet, exercise, rec drug use, ETOH, safety measures.
What are the main components of an H&P?
Identifying demographics, Cheif complaint, History of Presenting Illness (HPI), Past Medical History (PMH) and surgical history, Medications and Allergies, Social History, Family History, ROS.
