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Patient Assessment > Patient Assessment Questions > Flashcards

Patient Assessment Questions Flashcards

1
Q

What is the first thing to check when taking patient history?

A

Patient identifcation

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2
Q

What are the 4 things to check to confirm patient identity?

A

Name, DOB/age, biological sex, gender identity (plus any other relevant factors)

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3
Q

What is the 2nd thing to check when taking patient history?

A

Historian and reliability

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4
Q

How do you document historian and reliability?

A

Historian - document who is providing the medical history
Reliability - document the perceived level of reliability of the historian

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5
Q

What is the 3rd thing to collect when taking patient assessment?

A

Chief complaint (CC)

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6
Q

What is the CC?

A

The patient’s reason for their visit, stated in their own words

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7
Q

What is the 4th thing to collect when taking patient assessment?

A

History of present illness (HPI)

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8
Q

What is HPI?

A

Descriptive aspect of the patient’s current illness (describes a chronological narrative of the problem)

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9
Q

What are the 2 mnemonics used for taking HPI?

A

OLDCARTs and OPQQRST

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10
Q

What does OLDCARTs stand for?

A

Onset
Location
Duration
Character
Aggravating/alleviating factors
Radiation
Timing
Severity

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11
Q

What does OPQQRST stand for?

A

Onset and chronology
Position and radiation
Quality
Quantification
Related symptoms
Setting
Transforming factors

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12
Q

What is the 5th thing to collect when taking patient history?

A

Past medical history (PMH)

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13
Q

What is included in a patient’s PMH?

A

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.

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14
Q

What is the 6th thing to collect when taking patient assessment?

A

Family history (FH)

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15
Q

How many generations do you include when taking FH?

A

3 generations of blood relatives (ex: grandparents, parents, siblings, offspring depending on age)

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16
Q

What info do you need when taking FH?

A

Disease, age (current and age at diagnosis), age at death/COD if applicable

17
Q

What is the pedigree to include when looking at FH?

A

Maternal and paternal grandparents, parents, siblings, offspring

18
Q

What is the 7th thing to obtain when looking at patient assessment?

A

Social history (SH)

19
Q

What is included in SH?

A

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.

20
Q

What is the 8th thing to obtain when taking patient assessment?

A

Sexual history

21
Q

What is included in sexual history?

A

Sexually active
# of partners
Any past STDs?
Any hx of pregnancy/plans of pregnancy?
Protection against STDs (condoms, birth control, etc.)?

22
Q

What is the 9th thing to collect when taking patient assessment?

A

Review of systems (ROS)

23
Q

ROS: General

A

Fever
Chills
Night sweats
Appetite
Weight change
Fatigue

24
Q

ROS: Skin

A

Itching
Rashes
Easy bruising
Change in hair pattern
Change in nails

25
Q

ROS: Eyes

A

Use of glasses
Change in vision
Double vision (diplopia)
Pain
Redness
Discharge

26
Q

ROS: Ears

A

Use of hearing aid
Hearing change/loss
Discharge
Pain
Ringing (tinnitus)

27
Q

ROS: Nose

A

Nosebleeds (epistaxis)
Discharge
Obstruction
Loss of smell (anosmia)

28
Q

ROS: Mouth/throat

A

Bleeding gums
Painful swallowing (odynophagia)
Difficulty swallowing (dysphagia)
Hoarseness
Tongue swelling/burning

29
Q

ROS: Chest

A

Cough
Pain with cough/breathing
Shortness of breath (dyspnea)
Sputum production
Coughing blood (hemoptysis)
Wheezing

30
Q

ROS: Breast

A

Lumps
Bloody discharge
Milky discharge (galactorrhea)
Pain

31
Q

ROS: Cardiac

A

Chest pain
Palpitations
SOB (dyspnea) - on exertion, lying flat (orthopnea), awakening from sleep (paroxysmal nocturnal dyspnea)

32
Q

ROS: Vascular

A

Pain in lower extremities when walking (claudication)
Leg swelling (edema)
Blood clots
Ulcers

33
Q

ROS: GI

A

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

34
Q

ROS: GU

A

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

35
Q

ROS: Neuropsychiatric

A

Headaches
Lightheaded/fainting
Memory loss
Poor balance (ataxia)
Numbness/tingling
Tremors
Paralysis
Mood changes
Sleep
Nervousness
Speech disorders
Hallucinations
Seizures

36
Q

ROS: MSK

A

Weakness
Pain
Stiffness
Swelling

37
Q

ROS: Endocrine

A

Excessive thirst
Excessive urination
Weight gain/loss
Hair loss
Loss of skin pigment
Dry skin
Blurry vision
Palpitations
Heat/cold intolerance

Patient Assessment (5 decks)

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