History and Physical Flashcards
1
Q
What are the parts of the HPI?
A
- Location
- Radiation
- Quality
- Severity/Intensity
- Timing (onset, duration)
- Frequency/Pattern
- Setting
- Aggravating Factors
- Alleviating Factors
- Associated Manifestations
- Associated Active Problems
- Past Experience With Symptoms (Prior Treatment, Response)
- Significant +/-
- Psychosocial Context
- PPI
2
Q
What are the parts of the Medical History?
A
- Adult Illnesses
- Immunizations
- Screenings
- Ob/Gyn History
- Psychiatric Illnesses
- Childhood Illnesses
- Injuries/Accidents
- Hospitalizations
- Operations/Procedures
3
Q
What are the parts of the Ob/Gyn History?
A
- # of pregnancies
- Outcome of pregnancies
- Vaginal/Caesarean
- Last menstrual period
- Regularity of menses
- Fertility concerns
- Pap smear
4
Q
What are the parts of the Therapies/Allergies?
A
- Medications
- Complementary/Alternative Medicine
- Allergies
- Drug Reactions
5
Q
What are the parts of the Psychosocial History?
A
- Marital status/relationships
- Living arrangements/family structure/safety at home
- Employment history/job satisfaction/military service
- Significant life events and stressors
- Spiritual history/source of support
- Diet, sleep, exercise
- Tobacco, alcohol, drugs
- Sexual history
6
Q
What are the parts of the Family History?
A
- Current health of first degree relatives
- History of significant illnesses
- Deaths
7
Q
What are the parts of the ROS?
A
- Constitutional
- Integumentary
- Eyes
- Ears/Nose/Mouth/Throat
- Breasts
- Respiratory
- Cardiovascular
- GI
- GU
- Musculoskeletal
- Neurologic
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
8
Q
What are the parts of the Constitutional ROS?
A
- Changes in appetite
- Changes in weight
- Fevers or night sweats
- Fatigue
9
Q
What are the parts of the Integumentary ROS?
A
- Rashes
2. Change in color/size of a mole
10
Q
What are the parts of the Eye ROS?
A
- Eye pain or discomfort
2. Changes in vision
11
Q
What are the parts of the Ears/Nose/Mouth/Throat ROS?
A
- Hearing loss
- Dizziness/spinning
- Drainage from ears
- Congestion/stuffiness
- Drainage from nose
- Changes in voice/hoarseness
- Pain/ulcers in mouth
12
Q
What are the parts of the Breast ROS?
A
- Lumps
- Pain
- Nipple discharge
- Rashes/skin changes
13
Q
What are the parts of the Respiratory ROS?
A
- Cough
- Coughing up blood
- Wheezing
- Snoring/daytime tiredness
14
Q
What are the parts of the Cardiovascular ROS?
A
- Shortness of breath (at rest, exercise, lying flat)
- Chest pain
- Palpitations
- Lightheadedness/fainting
- Leg/ankle swelling
15
Q
What are the parts of the GI ROS?
A
- Abdominal pain/discomfort
- Change in bowel habits
- Trouble swallowing
- Vomiting blood
- Rectal bleeding/black stools
- Yellowing of the skin/eyes