Patient Assessment Questions Flashcards
What is the first thing to check when taking patient history?
Patient identifcation
What are the 4 things to check to confirm patient identity?
Name, DOB/age, biological sex, gender identity (plus any other relevant factors)
What is the 2nd thing to check when taking patient history?
Historian and reliability
How do you document historian and reliability?
Historian - document who is providing the medical history
Reliability - document the perceived level of reliability of the historian
What is the 3rd thing to collect when taking patient assessment?
Chief complaint (CC)
What is the CC?
The patient’s reason for their visit, stated in their own words
What is the 4th thing to collect when taking patient assessment?
History of present illness (HPI)
What is HPI?
Descriptive aspect of the patient’s current illness (describes a chronological narrative of the problem)
What are the 2 mnemonics used for taking HPI?
OLDCARTs and OPQQRST
What does OLDCARTs stand for?
Onset
Location
Duration
Character
Aggravating/alleviating factors
Radiation
Timing
Severity
What does OPQQRST stand for?
Onset and chronology
Position and radiation
Quality
Quantification
Related symptoms
Setting
Transforming factors
What is the 5th thing to collect when taking patient history?
Past medical history (PMH)
What is included in a patient’s PMH?
Medication allergies (reaction + associated allergies)
OTC medications (current) - reason taken, dose, route, frequency
Herbal remedies, vitamins, supplements (current) - reason taken, dose, route, frequency
Adult illnesses and chronic medical conditions (ex: HTN, CKD, CAD, history of MI or stroke, TB, asthma, etc.)
Surgeries - reason for surgery, type of surgery, date, outcome
Hospitalizations - reason (disease/illness/accident), date, treatment, outcome
Psychiatric admissions - diagnosis, date, treatment, outcome
OBGYN history - age at menarche, LMP, usual cycle length/flow, pregnancies, deliveries or C-section, pregnancy losses (including abortions/miscarriages), age of menopause
Health maintenance examinations - immunization history as well as most recent mammogram, colonoscopy, etc.
What is the 6th thing to collect when taking patient assessment?
Family history (FH)
How many generations do you include when taking FH?
3 generations of blood relatives (ex: grandparents, parents, siblings, offspring depending on age)
What info do you need when taking FH?
Disease, age (current and age at diagnosis), age at death/COD if applicable
What is the pedigree to include when looking at FH?
Maternal and paternal grandparents, parents, siblings, offspring
What is the 7th thing to obtain when looking at patient assessment?
Social history (SH)
What is included in SH?
Habits - tobacco, alcohol, drug use/abuse, caffeine use
Health promotion - diet, physical activity/exercise, safety practices
Personal life - job (description, hours per week, hazards/exposures, use of PPE), education (current or highest level), military service, personal relationships and support system (spouse/partner, children, caretakers), abuse concerns, home/living situation, sources of stress (home/work/financial), leisure/hobbies, spiritual/religious affiliation/beliefs
Exposures - recent travel, pets, etc.
What is the 8th thing to obtain when taking patient assessment?
Sexual history
What is included in sexual history?
Sexually active
# of partners
Any past STDs?
Any hx of pregnancy/plans of pregnancy?
Protection against STDs (condoms, birth control, etc.)?
What is the 9th thing to collect when taking patient assessment?
Review of systems (ROS)
ROS: General
Fever
Chills
Night sweats
Appetite
Weight change
Fatigue
ROS: Skin
Itching
Rashes
Easy bruising
Change in hair pattern
Change in nails
ROS: Eyes
Use of glasses
Change in vision
Double vision (diplopia)
Pain
Redness
Discharge
ROS: Ears
Use of hearing aid
Hearing change/loss
Discharge
Pain
Ringing (tinnitus)
ROS: Nose
Nosebleeds (epistaxis)
Discharge
Obstruction
Loss of smell (anosmia)
ROS: Mouth/throat
Bleeding gums
Painful swallowing (odynophagia)
Difficulty swallowing (dysphagia)
Hoarseness
Tongue swelling/burning
ROS: Chest
Cough
Pain with cough/breathing
Shortness of breath (dyspnea)
Sputum production
Coughing blood (hemoptysis)
Wheezing
ROS: Breast
Lumps
Bloody discharge
Milky discharge (galactorrhea)
Pain
ROS: Cardiac
Chest pain
Palpitations
SOB (dyspnea) - on exertion, lying flat (orthopnea), awakening from sleep (paroxysmal nocturnal dyspnea)
ROS: Vascular
Pain in lower extremities when walking (claudication)
Leg swelling (edema)
Blood clots
Ulcers
ROS: GI
Appetite
Nausea
Vomiting (emesis)
Vomiting blood (hematemesis)
Swallowing difficulty/pain
Heartburn (dyspepsia)
Abdominal pain
Constipation
Diarrhea
Change in stool color/caliber
Black, tarry stools (melena)
Rectal bleeding
ROS: GU
Frequent urination
Urgency to urinate
Painful urination (dysuria)
Blood in urine (hematuria)
Urinary incontinence
Difficulty starting stream
Genital lesions/discharge/itching
Painful intercourse (dyspareunia)
Libido
Amount of menstrual flow
Testicular pain/swelling
Hernias
ROS: Neuropsychiatric
Headaches
Lightheaded/fainting
Memory loss
Poor balance (ataxia)
Numbness/tingling
Tremors
Paralysis
Mood changes
Sleep
Nervousness
Speech disorders
Hallucinations
Seizures
ROS: MSK
Weakness
Pain
Stiffness
Swelling
ROS: Endocrine
Excessive thirst
Excessive urination
Weight gain/loss
Hair loss
Loss of skin pigment
Dry skin
Blurry vision
Palpitations
Heat/cold intolerance
