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ECR > Medical History II > Flashcards

Medical History II Flashcards

1
Q

History overview components

A 
Title
Identifying Data
Source/Reliability
Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical History
Family History
Personal and Social HIstory
Review of Systems
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2
Q

What makes up Past Medical History (PMHx)

A 
childhood
general state of health
adult
obstretic/gynecologic
injuries or accidents
health maintenance
medications
allergies
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3
Q

PMHx: childhood illnesses

A

childhood specific illnesses
general health
hospitalizations
chronic illnesses

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4
Q

PMHx: adult illnesses

A 
general state of health
medical
hospitalizations
surgical
psychiatric
injuries or accidents
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5
Q

PMHx: OB/Gyn

A 
ob/gyn history
menstrual history
methods of contraception
TPAL
complications with pregnancy
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6
Q

PMHx: health maintenance

A

immunizations: childhood and adult

screening tests: were they performed, when, results

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7
Q

PMHx: medications

A 
name
route
dose
frequency
OTC
alternative remedies
vitamins/supplements
oral contraception pills/other
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8
Q

PMHx: allergies

A 
environmental
foods
medication
what happens with your "reaction"
side-effect or non-allergy adverse reaction
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9
Q

Family History components

A 
grandparents
parents
siblings
children
ask about age, health
if deceased, age and cause of death
screen for genetic and environmental illnesses
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10
Q

Social history (SocHx) components

A 
personal life/experiences
health promotion
relationships/sexuality/domestic abuse
substance use
spirituality
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11
Q

SocHx: personal life

A

occupation
home life
support/stress

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12
Q

SocHx: personal life - life experiences

A 
upbringing and family relationships
schooling / education
military service
financial situation
aging
retirement
life satisfaction
cultural/ethnic background
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13
Q

SocHx: Health Promotion

A 
diet
exercise/physical activity
functional status (ADLs)
safety
complementary/alternative health practices
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14
Q

SocHx: relationships/sexuality/domestic abuse

A

relationship(s)
sexual behavior determines risk for pregnancy, STDs, and AIDS
sexual partners
contraception
sexual function
domestic abuse/ physical / sexual/emotional

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15
Q

SocHx: substance use

A

tobacco
what form
calculate pack-years

alcohol
quantity
timing
CAGE questions (cut back, annoyed, guilty, eye-opener)

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16
Q

SocHx: spirituality/religious beliefs

A 
consider asking if appropriate
important in times of illness
FICA:
faith and belief
importance and influences
community
address in care
17
Q

Review of Symptoms

A

head to toe survey
complete the patient database
elucidate symptoms not related to the HPI
systematic review of all organ systems

18
Q

ROS

A 
General
Skin
HEENT
head, eyes, ears, nose, mouth and throat
Neck
Breasts
Respiratory
Cardiovascular
GI
Peripheral vascular
Urinary
genital male/female
Musculoskeletal
Psychiatric
Neurologic
Hematologic
Endocrine

ECR (1 decks)

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