Medical Hx Taking Reference Flashcards
Assessment/history taking verbal/written reports
C - chief complaint
H - history of chief complaint
A - assessment / on examination
T - treatment
Assessment and history taking baseline history
A - allergies/reaction
M - medications
P - past/present medical history
L - last oral intake / last bowel or urinary output
E - event leading up to this
Assessment and history taking baseline history; pain
O - onset
P - provocation
Q - quality
R - radiate
S - severity
T - time/trends
Assessment and history taking unconscious states
A - alcohol/acidosis
E - epilepsy/environment
I - insulin
O - overdose
U - uremia/underdose
T - trauma/toxin
I - infection
P - psychiatric/poison
S - shock/stroke/septic
Assessment and history taking difficulty breathing
D - diagnosis
Y - your patients position
S - sputum (productive cough)
P - progression of symptoms
N - normal breath sounds
E - exertion tolerance
A - associated chest pain/allergy
Assessment and history taking chest pain
Location, any associated shortness of breath, does the pain change with inspiration/movement/palpation, is the pain radiating, have you had this pain before, changes in diet/exercise/stress/medication, onset gradual or sudden
Assessment and history taking stroke
Last seen normal, seizure activity, any visual/auditory disturbances, facial droop/slurred speech/arm drift, headache, any period of unconsciousness/confusion
Assessment and history taking abdominal pain
Localized or diffuse, nausea or vomiting, rebound tenderness, recent ingestion, recent bowel or urinary output, referred pain, associated back pain, possible pregnancy/STI, last menses
Assessment and history taking obstetrics
Due date, prenatal care, number of pregnancies, number of deliveries, any miscarriages, contractions (duration/frequency), vaginal bleeding, need to push
