HPI ROS Flashcards
1
Q
subjective vs. objective data
A
Subjective Data: ◼ What the patient tells you ◼ The History, from Chief Complaint, Chief Concern through Review of Systems Objective Data: ◼ What you detect on the examination ◼ All physical examination findings ◼ Includes Lab data and Imaging
2
Q
differential diagnosis
A
list of the disease hypotheses to be tested.Each disease or condition is more or less probable based upon how well it explains the full range of the patient’s problems
3
Q
Steps of history and physical
A
review these
- take history
- develop hypothesis
- perform physical exam
- make problem list
- generate differential diagnosis
- test hypothesis
- modify differential diagnosis
- repeat 1-7
- make diagnosis/diagnoses
4
Q
Chief complaint
A
patient’ reason for presenting to the clinician in the pts own words; use open ended questions initially
5
Q
chief complaint is used as a springboard for what?
A
additional questioning to help identify the HPI.
6
Q
The big eight of HPI
A
body location quality quantity (severity) chronology (duration and timing) setting aggravating factors alleviating factors associated symptoms
7
Q
ROS
A
list of questions, arranged by organ system, designed to uncover dysfunction and disease
8
Q
General ROS
A
fever, chills, night sweats, fatigue, weakness, weight change
