Medical History and Physical Exam Flashcards
PP
presenting picture
an introductory statement
CC
chief complaint
reason the patient sought medical attention
stated in patient’s own words
HPI
history of present illness narrative story of what is wrong with the patient now, told in medical terms info relevant to problem goes here Chronology is King MOST IMPORTANT PART
PH
past history
divided into 8 subheadings
anything having to do with current illness go in HPI instead of here
Medical
previous medical illness
only goes here if occurred in the past and IS a diagnosis
isolated symptoms go in Review of Systems
surgical
all past surgical procedures with information on where, when, and by whom they were done
allergies
drugs and food
find out what happens
menstrual, obstetrical, sexual
age of onset, interval duration and amount, date of onset of last menstrual period
include how many times pregnant
Include sexual orientation, sexual activity
include menopause symptoms, erectile dysfunction, dyspareunia
Habits
include alcohol and tobacco
ask about recreational drugs
medications
list and dose
occupation
emphasis of health hazards. (social history)
military
relates to eligibility or VA benefits but also be important in terms of exposures immunizations
FH
Family history
record age and state of health of parents, siblings, children, and marital partners/ domestic partners
If they are living are not, record cause of death and age at death
include presence or absence of: hypertension, liver disease, heart disease, diabetes, allergies, obesity, mental illness
SH
social history
living situation, emotional and financial adjustments to illness
CAN BE VERY IMPORTANT
ROS
review of systems
review of all major body systems for symptoms
Diagnosis goes in PH
ISOLATED SYMPTOMS go here
