Medical History Flashcards
1
Q
HPI
A
Onset: date/time/duration Provocative Palliative Quality Quantified Regionality Radiation Symptoms (associated)
2
Q
PMH
A
General Health Chronic Illness Surgical Procedures Hospitalizations Injuries/major illnesses Medications Allergies & reaction Immunizations
3
Q
FH
A
Cancer Hypertension Heart Disease Diabetes Stroke Seizures Bleeding Disorders Age/Health (parents/grand)
4
Q
Social History
A
Occupation Education Living Situation Safe at Home Diet Physical activity Caffeine/alcohol/tobacco use Prescription/illicit drug use Military History Travel Sexually active Number of Partners
5
Q
ROS: General
A
Weight changes Fatigue Malaise Weakness Fever/Chills Sweats/Night sweats
6
Q
ROS: Skin
A
Rashes./sores/lesions Lumps/masses Pruritus (itching) Dryness/moistures Hair/Nail changes
7
Q
ROS: Head
A
Headaches
Head trauma
Dizziness/vertigo
Syncope/LOC/Concussion
8
Q
ROS: Ears
A
General Hearing Status Otalgia (earaches) Past Infections Drainage/Discharge Tinnitis
9
Q
ROS: Eyes
A
General Vision Status Glasses/Contacts Last Eye Exam Pain/Redness/Tearing Diplopia/blurriness H/O trauma/foreign body
10
Q
ROS: Nose/Sinuses
A
Sinus pain Epistaxis Nasal Congestion Nasal Drainage Frequent colds Sneezing
11
Q
ROS: Mouth/Throat
A
Dental Hygeine Last Dental Exam Tootaches Pain/Soreness Hoarseness
12
Q
ROS: Neck/Lymph nodes
A
Pain
Stiffness/limited ROM
Masses/Swelling
Tenderness/enlargement (lymph nodes)
13
Q
ROS: Breasts
A
Pain
Lumps/masses
Nipple changes/discharge
Self-exams
14
Q
ROS: Respiratory
A
Pleuritic chest pain Cough/Sputum Hemoptysis Wheezing or H/O Asthma H/O Bronchitis TB or past exposure Last PPD or CSR
15
Q
ROS: Cardiovascular
A
Pain Palpitations Diaphoresis SOB/dyspnea Orthopnea/PND Edema H/O HTN, murmurs, heart problems EKG/other dx testing
16
Q
ROS: Gastrointestinal
A
Appetite Food intolerances Dysphagia (Solid/liquid) Dyspepsia (heartburn) N/V Change in bowel habits Constipation/diarrhea Rectal bleeding/melena Hemorrhoids H/O PUD, Jaundice, Appendix, GB disease
17
Q
ROS: Genitourinary
A
Change in frequency, force of stream, color Hesitancy/difficulty initiating Pain/dysuria Dribbling/incontinence H/O infections, hematuria Penile/vaginal discharge H/O STD's/Treatment Libido WOMEN- Dyspareunia MEN- Scrotal pain/mass/edema Erectile problems Self-testicular exams
18
Q
ROS: OB/GYN
A
Menarche Last menstrual period Gravida (# pregnancies) Para (# deliveries) Delivery complications Abortions/miscarriages Last pap (Results) Menopause (Symptoms)
19
Q
ROS: Musculoskeletal
A
Intermittent claudication Varicosities Decrease strength Decreased ROM Joint swelling, redness, stiffness, pain H/O bone/joint infections, fractures/dislocations, back pain/disc disease, sciatica
20
Q
ROS: Neurologic
A
H/O convulsions/seizures, infections/meningitis Memory loss Trouble Concentrating Tremors Numbness/sensory loss Paresthesia (pins/needles)
21
Q
ROS: Hematologic
A
Easy bruising
Bleeding (gums/skin)
H/O transfusions, anemia, blood diseases
22
Q
ROS: Endocrine
A
Intolerance to heat/cold Nervousness Sleeplessness Polyphagia/-uria/-dipsia Nocturia Tested for diabetes H/O thyroid disease
23
Q
ROS: Psychiatric
A
Depression, mood changes Anxiety, agitation Tension, irritability Suicidal thoughts Sleep disturbances Difficulty getting up