OP 1: Patient History (HPI) Flashcards
High Blood Pressure
Hypertension (HTN)
High Cholesterol
Hyperlipidemia (HLD)
Diabetes
Diabetes Mellitus (DM)
“I only take pills for my diabetes”
Non-Insulin-Dependent Diabetes Mellitus (NIDDM)
- Type II
“I take shots or insulin for my diabetes”
Insulin Dependent Diabetes Mellitus (IDDM)
- Type I or Type II
Heart Disease
Coronary Artery Disease (CAD)
Heart Attack
Myocardial Infarction (MI) and CAD
Heart Failure
Congestive Heart Failure (CHF)
Irregular Heartbeat
Arrhythmia
Emphysema/Chronic Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
Blood clot in lung
Pulmonary Embolism (PE)
Pneumonia/lung infection
Pneumonia (PNA)
Reflux
Gastroesophageal Reflux Disease (GERD)
Ulcers
Gastric Ulcer or Peptic Ulcer Disease (PUD)
Irritable Bowel
Irritable Bowel Syndrome (IBS)
Bladder Infection
Urinary Tract Infection (UTI)
Kidney Infection
Pyelonephritis
“On dialysis”
Chronic Kidney Disease (CKD) on dialysis
Enlarged prostate
Benign Prostatic Hyperplasia (BPH)
Stroke
Cerebrovascular Accident (CVA)
“Blood clot in brain”
Ischemic CVA
“Brain bleed”
Hemorrhagic CVA
“Mini Stroke”
Transient Ischemic Attack (TIA)
“Blood clot in my leg”
Deep Vein Thrombosis (DVT)
“Bulge in my aorta”
Aortic Aneurysm
“Bad blood flow in my legs”
Peripheral Vascular Disease (PVD)
Cancer
Cancer or Carcinoma (CA)
“Cancer spread to my…”
“With metastasis to the…”
Chemo
Chemotherapy
“They cut it out…”
Status-post Surgical Resection
Radiation
Radiation Therapy
“It’s gone.”
In remission
True Allergy
- Rash
- Itching
- Swelling
- Difficulty Breathing
Tonsils removed
Tonsillectomy
Adenoids removed
Adenoidectomy
“Neck arteries were cleaned”
Carotid endarterectomy
Leg Amputation
Above Knee Amputation (AKA)
Below Knee Amputation (BKA)
Joint Repair
Arthroplasty
“Balloon in my heart”
Angioplasty
“Stents in my heart”
Coronary Stents
Heart bypass
Coronary Artery Bypass Graft (CABG)
Breast removal
Mastectomy
Part of my lung removed
Partial lobectomy
Appendix removed
Appendectomy (RLQ)
Gallbladder removed
Cholecystectomy (RUQ)
Part of colon removed
Partial cholectomy (LUQ)
Spleen removed
Splenectomy
Kidney removed
Nephrectomy
Uterus removed
Hysterectomy
Ovar(y)/(ies) removed
Oophorectomy
Family History FHx
Includes any medical condition present in the patient’s blood relatives
- Age of onset <55 -> higher genetic risk
Social History (SHx)
- Alcohol Use
- Tobacco Use/Vaping
- Drug Use
- Occupation
- Living Circumstance