History & Physical Flashcards
Subjective Data
What the pt tells you
chief complaint to ROS
Objective Data
What you detect during exam
all physical exam findings
7 Attributes of Symptoms in HPI
ChLORIDE CHaracter/quality of symptom Location of symptom Onset of symptom Radiation of symptom Intensity of symptom Duration/timing of symptom Exacerbation (or alleviation) of symptom
Medications
Name, Dose, Route, Frequency
Date & Time
Always document/note date and time all evaluations
Identifying Data
Age, gender, marital status, occupation
Source of history or referral
(who &/or what is the reason for H&P and referral)
Source of history
Should be documented if source other than pt
Document reliability of source (mental status, trustworthiness, and mood)
Chief Complaint
Reason the pt is here
use the pt’s own words
History of Present Illness (HPI)
Complete account of why the pt is seeking care (CHLORIDE)
Past Medical History (PMH)
General health/strength of pt Adult illnesses Childhood illnesses PSH, hospitalizations, serious injuries Screening tests (EKG, MRI, etc.) Immunizations Emotional status, disabilities
Allergies
Note specific reaction
Family History
Looking for specific conditions in family members
Blood relatives with illnesses and symptoms similar to pt’s
Personal & Social History
To capture pt’s personality, interests, support, stress, coping style, strengths, fears
Review of Systems (ROS)
Gain an understanding of overall health of pt and prevent missing any important history that might have been missed in HPI
Cardinal Techniques of Physical Examination
Inspection
Palpation
Percussion
Auscultation
