Medical History Checklist Flashcards
1
Q
Categories/headings in order
26
A
Introductions/Personal Information Chief Complaint HPI PMH FH Social History REVIEW OF SYSTEMS General Skin Head Ears Eyes Nose/Sinuses Mouth/Throat Neck Lymph Nodes Breasts Respiratory Cardiovascular Gastrointestinal Genitourinary OB/GYN Extremities-musculoskeletal Neurologic Hematologic Endocrine Psychiatric
2
Q
Checklist for History of Present Illness
8
A
Onset: date/time/duration Provocative Palliative Quality Quantified Regionality Radiation Associated symptoms
3
Q
Checklist for Past Medical History
8
A
General Health Chronic illnesses Surgical procedures Hospitalizations Injuries/major illnesses Medications Allergies and reaction Immunizations
4
Q
Checklist for Family history?
8
A
Cancer Hypertension Heart disease Diabetes Stroke Seizures Bleeding disorders Age/health of parents and grandparents
5
Q
Checklist of Social History?
15
A
Occupation Education Living situation Diet Physical activity Caffeine use Alcohol use Tobacco use Sexually active Monogamous/# of partners Prescription drug abuse Illicit drug abuse Military history Safe at home Travel
6
Q
General Review of Systems
6
A
Weight changes Fatigue Malaise Fever/Chills Sweats/Night sweats Weakness
7
Q
Skin
5
A
Rashes/sores/lesions Lumps/masses Pruritis/itching Dryness/moisture Hair/nail changes
8
Q
Head
4
A
Headaches
Head Trauma
Dizziness/vertigo
Syncope/LOC/concussion
9
Q
Ears
5
A
General hearing status Otalgia (earaches) Past infections Drainage/discharge Tinnitis
10
Q
Eyes
6
A
General vision status Glasses/contacts Last eye exam Pain/redness/tearing Diplopia/blurriness H/O trauma/foreign bodies
11
Q
Nose/Sinuses
6
A
Sinus pain Epistaxis Nasal congestion Nasal drainage Frequent colds Sneezing
12
Q
Mouth/Throat
5
A
Dental hygiene Toothaches Last dental exam Pain/soreness Hoarseness
13
Q
Neck
3
A
Pain
Stiffness/limited ROM
14
Q
Lymph Nodes
2
A
Tenderness
Enlargements
15
Q
Breasts
4
A
Pain
Lumps/masses
Nipple changes/discharge
Self-exam
16
Q
Respiratory
7
A
Pleuritic chest pain Cough/sputum Hemoptysis Wheezing or H/O asthma H/O bronchitis TB or past exposure Last PPD or CXR
17
Q
Cardiovascular
10
A
Pain Palpitations Diaphoresis SOB/dyspnea Orthopnea/PND Edema H/O HTN H/O murmurs H/O heart problems EKG/other diagnostic testing
18
Q
Gastrointestinal
12
A
Appetite Food intolerances Dysphagia Dyspepsia Nausea/vomiting Change in bowel habits Diarrhea/constipation Rectal bleeding/melena Hemorrhoids H/O PUD H/O Jaundice H/O appendix/gall bladder disease
19
Q
Genitourinary
11
women-1
men-3
A
Change of frequency Change in force of stream Normal color/Change in color Hesitancy/difficulty initiating Pain/Dysuria Dribbling/ incontinence H/O infections H/O hematuria Penile/Vaginal discharge H/O STDs/Treatment Libido/Sex drive
Women: Dyspareunia Men: Scrotal pain/mass/edema Erectile problems Self-testicular exams
20
Q
OB/GYN
8
A
Menarche Last menstrual period Gravida (# of pregnancies) Para (# of deliveries) Delivery complications Abortions/miscarriages Last pap (results?) Menopause (symptoms?)
21
Q
Extremities-Musculoskelatal
10
A
Intermittent claudication Varicosities Decreased strength Decreased ROM Joint swelling/redness Joint stiffness/pain H/O bone/joint infections H/O fractures/dislocations H/O back pain/disc disease H/O sciatica
22
Q
Neurologic
7
A
H/O convulsions/seizures H/O infections/meningitis Memory loss Tremors Numbness/sensory loss Paresthesia (pins/needles) Trouble concentrating
23
Q
Hematologic
5
A
Easy bruising Bleeding (gums, skin) H/O transfusions H/O anemia H/O blood diseases
24
Q
Endocrine
7
A
Intolerance to heat/cold Nervousness Sleeplessness Polyphagia, uria, dipsia Nocturia Tested for diabetes H/O thyroid disease
25
Q
Psychiatric
6
A
Depression, mood changes Anxiety, agitation Tension, irritability Suicidal thoughts Sleep disturbances Difficulty getting up
