New patient history

Question 1

assessment is also known as what?

Answer 1

differential diagnosis or the diagnosis

Question 2

What is a differential diagnosis?

Answer 2

multiple alternative diagnoses are possible

Question 3

During the review of cardiovascular system, what are some questions to ask?

Answer 3

chest pain, palpitations, edema, claudication

Question 4

During the review of respiratory system, what are some questions to ask?

Answer 4

shortness of breath, wheezing, cough, hemoptysis

Question 5

During the review of gastrointestinal system, what are some questions to ask?

Answer 5

change in appetite, bowel habits, weight loss, heartburn

Question 6

During the review of endocrine system, what are some questions to ask?

Answer 6

dry skin, cold or heat intolerance, frequency of urination

Question 7

During the review of musculoskeletal system, what are some questions to ask?

Answer 7

joint pain and stiffness, loss of strength, atrophy

Question 8

During the review of hematologic system what are some questions to ask?

Answer 8

bleeding problems, anemia, blood clots

Question 9

During the review of neurological system what are some questions to ask?

Answer 9

numbness, tingling, tremors

Question 10

During the review of head and neck (ROS), what are some questions to ask?

Answer 10

vertigo, syncope, memory loss, soreness

Question 11

How many ROS should be done?

Answer 11

about 4 or 5

Question 12

During the lower extremity portion of the physical exam, what are some things to be done regarding the vascular system?

Answer 12

lower extremity pulses, capillary fill time, edema, pallor on elevation rubor with dependency

Question 13

During the lower extremity portion of the physical exam, what are some things to be done regarding the dermatological system?

Answer 13

texture, turgor, temperature, hair growth, lesions or irregularities

Question 14

During the lower extremity portion of the physical exam, what are some things to be done regarding the neurological system?

Answer 14

deep tendon reflexes, vibratory, two point discrimination, proprioception, sharp/dull, Semmes-Weinstein monofilament, balance, Tinel’s sign

Question 15

During the lower extremity portion of the physical exam, what are some things to be done regarding the musculoskeletal system?

Answer 15

muscle strength, range of motion, deformities, gait

Question 16

What are some special studies that can be done?

Answer 16

x-rays, blood work, microscopic tests

Question 17

What do you put in the plan section?

Answer 17

what was done, what will be done, when the patient is to return to the office