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Medical history checklist Flashcards

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1
Q

What are the 20 categories for Review of Systems?

A 
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
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2
Q

What are the first 5 items on the medical history list?

A 
Chief Complaint
HPI
PMH
FH
Social History
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3
Q

What are the subcategories for HPI? (8)

A 
Onset: date/time/duration
Provocative
Palliative
Quality
Quantified
Regionality
Radiation
Symptoms (associated)
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4
Q

What are the subcategories for PMH? (8)

A 
General health
Chronic illnesses
Surgical Procedures
Hospitalizations
Injuries/major illnesses
Medications
Allergies & reaction
Immunizations
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5
Q

What are the subcategories for FH? (8)

A 
Cancer
Hypertension
Heart disease
Diabetes
Stroke
Seizures
Bleeding disorders
Age/health parents/grandparents
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6
Q

What are the subcategories for Social History? (15)

A 
Occupation
Education
Living situation
Diet
Physical activity
Caffeine use
Alcohol use
Tobacco Use
Sexually active
Monogamous/#partners
Prescription drug abuse
Illicit drug use
Military history
Safe at home
Travel
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7
Q

What are the subcategories for General? (6)

A 
Weight changes
Fatigue
Malaise
Fever/chills
Sweats/night sweats
Weakness
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8
Q

What are the subcategories for Skin? (5)

A 
Rashes/sores/lesions
lumps/masses
Pruritus (itching)
Dryness/moisture
Hair/nail changes
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9
Q

What are the subcategories for Head? (4)

A

Headaches
Head trauma
Dizziness/vertigo
Syncope/LOC/concussion

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10
Q

What are the subcategories for Ears? (5)

A 
General hearing status
Otalgia (earaches)
Past infections
Drainage/discharge
Tinnitus
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11
Q

What are the subcategories for Eyes? (6)

A 
General vision status
Glasses/contacts
Last eye exam
Pain/redness/tearing
Diplopia/blurriness
Hx trama/foreign bodies
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12
Q

What are the subcategories for Nose/Sinus? (6)

A 
Sinus pain
epistaxis (nosebleeds)
Nasal congestion
Nasal drainage
Frequent colds
Sneezing
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13
Q

What are the subcategories for Mouth/throat? (5)

A 
Dental Hygeine
Toothaches
Last dental exam
Pain/soreness
Hoarseness
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14
Q

What are the subcategories for Neck? (3)

A

Pain
Stiffness/Limited ROM
Masses/swelling

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15
Q

Subcategories for Lymph nodes? (1)

A

Tenderness/enlargements

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16
Q

Subcategories for Breasts? (4)

A

Pain
Lumps/Masses
Nipple changes/discharge
Self exams

17
Q

Subcategories for Respiratory? (7)

A 
Pleuritic chest pain
Cough/sputum
Hemoptysis (coughing up blood)
Wheezing or Hx asthma
Hx bronchitis
TB or past exposure
Last PPD (TB test?) or CXR
18
Q

What are the subcategories for Cardiovascular? (10)

A 
Pain
Palpitations
Diaphoresis
SOB/dyspnea
Orthopnea/PND
Edema
Hx hypertension
Hx murmurs
Hx heart problems
EKG/other dx testing
19
Q

What are the subcategories for GI? (12)

A 
Appetite
Food intolerances
Dysphagia (solid/liquid)
Dyspepsia (heartburn)
Nausea/vomiting
Change in bowel habits
Diarrhea/constipation
Rectal bleeding/melena (tarry stools from upper GI bleed)
Hemorrhoids
Hx PUD (peptic ulcer disease)
Hx Jaundice
Hx Appendix/GB disease
20
Q

Subcategories for Genitourinary? (15)

A 
Change in frequency
Change in force of stream
Normal color/change in color
Hesitancy/difficulty initiate
Pain/dysuria
Dribbling/incontinence
Hx infections
Hx hematuria
Penile/vaginal discharge
Hx STDs/treatment
Libido

Women: Dyspareunia (painful sex)

Men: Scrotal pain/mass/edema
Erectile problems
Self testicular exams

21
Q

Subcategories for OB/GYN (8)

A 
Menarche
LMP
Gravida (# pregnancies)
Para (# of deliveries)
Delivery complications
Abortions/miscarriages
Last pap (results?)
Menopause (symptoms?)
22
Q

Subcategories for Extremities/Musculoskeletal)? (10)

A 
Intermittent claudication (pain and cramping on exercise)
Varicosities
Decreased strength
Decreased ROM
Joint swelling/redness
Joint stiffness/pain
Hx bone/joint infections
Hx fractures/dislocations
Hx back pain/disc disease
Hx sciatica
23
Q

Subcategories for Neurologic (7)

A 
Hx convulsions/seizures
Hx infection/meningitis
Memory loss
Tremors
Numbness/sensory loss
Paresthesia (pins/needles)
Trouble concentrating
24
Q

Subcategories for Hematologic? (5)

A 
Easy bruising
Bleeding from gums/skin
Hx transfusions
Hx anemia
Hx blood disease
25
Q

Subcategories for Endocrine? (7)

A 
Intolerance to heat/cold?
Nervousness
Sleeplessness
Polyphagia/uria/dipsia
Nocturia
Tested for diabetes?
Hx thyroid disease
26
Q

Subcategories for Psychiatric? (6)

A 
Depression, mood changes
Anxiety, agitation
Tension, irritability
Suicidal thoughts
Sleep disturbances
Difficulty getting up

Medical history checklist (1 decks)

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