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POM > Lecture 2 > Flashcards

Lecture 2 Flashcards

1
Q

What are the eight parts of the history?

A 
CC- Chief complaint
HPI - History of Present Illness
PMH - Past Medical History
PSH - Past Surgical History
Allergies
Medications
SH - Personal and Social History
FH - Family History
ROS - Review of Systems (ROS)
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2
Q

Past Medical History:

How do you transition?

How is the past medical history recorded?

A
  • “Next, I am going to ask you questions about your medical history/ overall health”
  • Recorded as a list, with recent events first.
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3
Q

What are the six parts of the PMH?

** Start open ended, if they say no, ask a couple more pointed questions**

A
  1. Medical Illnesss
  2. Hospitalizations
  3. Accidents
  4. Obstetric and GYN History
  5. Immunizations
  6. Health maintenance (Disease prevention)
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4
Q

What are three examples of major adult illnesses?

A

Hypertension, Diabetes, Ulcers

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5
Q

What are three examples of major childhood illnesses? (primarily those that impact upon adult health)

A

Mumps, polio, meningitis

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6
Q

How do you ask about hospitalizations?

A

“Have you ever been in the hospital overnight for a medical illness?” i.e. pneumonia, heart attack, bowel problem

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7
Q

What 5 categories of significant accidents or injuries?

A
  1. Serious motor vehicle accidents
  2. Major work-related injuries or sport-related injuries
  3. Any functional limitations, and do they affect ADLs (Activities of Daily Living)?
  4. Required a blood transfusion?
  5. Any hardware/ devices in place?
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8
Q

What needs to be covered in obstetric and GYN history?

A
  • Depends on the age of your patient
  • Age of menarche, cycle length, last menstrual period (and age at menopause if relevant)
  • Number of pregnancies (Gravida), and births (Para) Florida Power and Light (Full term, Premature, Abortions, Live births)
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9
Q

What is a questions to ask about immunizations?
What do you ask for:
-Adults
-Children

A

Have you had any reactions to immunizations?

Adults: Have you received immunizations as an adult? AND Did you receive childhood immunizations?

Children: Is he/she up to date on his/her immunizations?

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10
Q

What do you ask about preventative services/health maintenance?

A

Do you go to check-ups regularly?

Do you get your blood pressure, fasting lipid profile, mammography, pap smear, colonoscopy, eye/dental exams regularly?

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11
Q

What do you ask about past surgical history?

A

have you had any surgeries, operations, or minor surgical procedures? (i.e. getting your gallbladder, appendix removed, pacemaker)

make sure to include indication for surgery and when surgery was

Did you have any complications?

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12
Q

What do you need to record about allergies?

A 
List allergen (medication and non-medication)
List reaction - allergic reaction v/ adverse reaction

(When you take XYZ and get a reaction, what happens?)

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13
Q

What do you record about medication?’

What do you ask in addition to medication?

A

Name, dose, route, frequency:
Lipitor 10mg orally, daily

Do you take any home remedies, vitamins, or nonprescription drugs (OTC drugs)
i.e. Melatonin, advil, centrum silver

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14
Q

How do you transition into social history?

A

“I’d like to ask you a few questions about your personal/social habits.”

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15
Q

What are 12 topics for social history?

A 
Tobacco use
Alcohol use
Drug use
Exercise and diet habits
Marital status & social support at home
Sexual history
Family violence
Occupation
Travel History
Living Situation
Hobbies
Functional capacity/ADLs
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16
Q

How do you ask about tobacco use and what are points to cover?

A

PPD (packs per day) X # years = Pack Year History

Have you ever used any tobacco products? When did you quit?

Present and past tobacco use

Experience with quitting?

17
Q

What are questions to ask about alcohol use?

A

Type, quantity and frequency

CAGE questions (any two is a potential sign for abuse):
Concern or "tried to cut down?"
Annoyed by criticism
Guilty
Eye-opener
18
Q

What are questions to ask about drug use?

A
  • Prescription abuse?
  • Recreational? Have you ever used…IV drug use…“Shared needles”…
  • Any experience with rehabilitation?
19
Q

What are questions to ask about exercise and diet habits?

A
  • Do you follow a special diet?
  • Have you tried to lose weight?
  • Do you have any regular exercise?
20
Q

What are questions to ask about sexual history?

A

“Are you sexually active?”
“Are your partners male female or both?”
“Do you have any concerns about your sexuality?”

21
Q

What are questions to ask about family violence?

A

S: Do you feel safe in your relationship?
A: Are you ever afraid? Have you or your children ever been physically abused?
F: Are your friends or family aware?
E: What would you do in an emergency? Do You have an escape plan?

POM (2 decks)

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