HISTORY AND PHYSICAL

Question 1

H&P: what questions should be asked for general ROS?

Answer 1

Previous VS problems, previous measurements, fever, fatigue, unintentional wt gain or loss, night sweats or chills, appetite, sleep. Children-specific assessment tests.

Question 2

H&P: what questions should be asked for ENT ROS.

Answer 2

Usual condition, headache, dizziness, syncope, trauma, LOC, concussion, ROM.

Question 3

H&P: what questions should be asked for ENT ROS?

Answer 3

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).

Question 4

H&P: what questions should be asked for eyes ROS?

Answer 4

Usual condition, discharge, redness, visual changes (blurred vision, diplopia, photophobia) eye pain, cataracts, glaucoma, surgeries, corrective lens use.

Question 5

H&P: what questions should be asked for Chest and lungs ROS?

Answer 5

Usual condition, cough, sputum, blood, colored sputum, asthma, COPD/emphysema, SOB, SOBOE, wheezing, chest wall pain, infections, last x-ray or pulmonary function tests.

Question 6

H&P: what questions should be asked for Heart and blood vessels ROS?

Answer 6

Usual condition, previous problems, edema, loss of sensation in legs, CP, palpitations, orthopnea, dyspnea, last ECG, stress test or cardiac BW.

Question 7

H&P: what questions should be asked for breast and axillae ROS?

Answer 7

Usual condition, previous problems, tenderness redness, nipple discharge, skin changes, new lump or nodule, last mammogram.

Question 8

H&P: what questions should be asked for GI ROS?

Answer 8

Usual condition, previous problems, abd pain, dyspepsia, N/V/D, constipation, blood in stool, painful defecation, normal bowel habits.

Question 9

H&P: what questions should be asked for GU ROS?

Answer 9

Usual condition, previous problems, dysuria, frequency, urgency, retention, incontinence, hematuria, flank pain.

Question 10

H&P: what questions should be asked for reproductive: Male ROS?

Answer 10

Usual condition, previous problems, dysuria, testicular pain, genital lesions, masses, hernias, discharge, sexual history, sexual risks/health, erectile dysfunction.

Question 11

H&P: what questions should be asked for reproductive: Female ROS?

Answer 11

Usual condition, previous problems, menstruation, irregular or painful menses, heavy bleeding, genital lesions, dyspareunia, sexual health, sexual history, childbearing history.

Question 12

H&P: what questions should be asked for anus, rectum, prostate ROS?

Answer 12

Usual condition, previous problems, rectal bleeding, pain, hemorrhoids, fissures, discharge, incontinence.

Question 13

H&P: what questions should be asked for MKS ROS?

Answer 13

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).

Question 14

H&P: what questions should be asked for CNS ROS?

Answer 14

Usual condition, previous problems, paresthesia, head pain, visual changes, dizziness, tremors, gait disturbances, weakness, memory loss, confusion, trauma, seizure activity.

Question 15

H&P: what questions should be asked for MH ROS?

Answer 15

Usual condition, previous problems/psych history, depression, memory difficulties, concentrations, mood, hallucinations, SI or HI thoughts.

Question 16

H&P: what questions should be asked for cross-system data ROS?

Answer 16

Endocrine and thyroid problems –> polydipsia, polyphagia, polyuria, heat or cold intolerance.

Question 17

H&P: what questions should be asked for lymphatic system ROS?

Answer 17

Usual condition, previous problems, edema, lumps or nodules to neck, groin, axillae.

Question 18

H&P: what questions should be asked for skin hair and nails ROS?

Answer 18

Usual condition, previous problems, bruising, lesions, masses, odors, pruritus, hair loss, rashes, moles, sores (poor healing).

Question 19

H&P: what questions should be asked for nutritional status ROS?

Answer 19

Usual diet, appetite trends, and cravings, usual preparation, food choices, intake questions (chewing, choking, denture, plates, braces).

Question 20

H&P: what kind of identifying information should be noted?

Answer 20

Cultural backgrounds, family structure, education, economic and environmental data, client reliability.

Question 21

H&P: What data should be included during the HPI?

Answer 21

Location, Onset, Type, Alleviating or Aggravating, Radiation, Timing, Severity, Associated Symptoms, affect on the client, client perception, health pre-illness.

Question 22

H&P: What information should be listed under medical history?

Answer 22

Surgeries, injuries, and disabilities, major childhood illnesses, major adult illnesses, blood transfusions, obstetrical history, mental health history (dates for all).

Question 23

H&P: What information should be listed under Previous health care?

Answer 23

Recent health exams (physical, pap smear, x-rays, BW, TB test, dental, vision, hearing, mammogram), immunizations, skin tests, obstetric care, screening tests.

Question 24

H&P: What information should be listed under current health/risk factors?

Answer 24

Exercise, nutrition, sleep, smoking, alcohol, drug use.

Question 25

H&P: What information should be listed under medications and allergies?

Answer 25

OTC drugs, vitamins, supplements, Rx medications, allergies with Rxn.

Question 26

H&P: What information should be listed under family history?

Answer 26

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.

Question 27

H&P: What information should be listed under social history?

Answer 27

Cultural backgrounds, family structure, education, economic and environmental data, stress factors, “typical day”, interpersonal violence, diet, exercise, rec drug use, ETOH, safety measures.

Question 28

What are the main components of an H&P?

Answer 28

Identifying demographics, Cheif complaint, History of Presenting Illness (HPI), Past Medical History (PMH) and surgical history, Medications and Allergies, Social History, Family History, ROS.