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
ROS: Eyes
Use of glasses Change in vision Double vision (diplopia) Pain Redness Discharge
26
ROS: Ears
Use of hearing aid Hearing change/loss Discharge Pain Ringing (tinnitus)
27
ROS: Nose
Nosebleeds (epistaxis) Discharge Obstruction Loss of smell (anosmia)
28
ROS: Mouth/throat
Bleeding gums Painful swallowing (odynophagia) Difficulty swallowing (dysphagia) Hoarseness Tongue swelling/burning
29
ROS: Chest
Cough Pain with cough/breathing Shortness of breath (dyspnea) Sputum production Coughing blood (hemoptysis) Wheezing
30
ROS: Breast
Lumps Bloody discharge Milky discharge (galactorrhea) Pain
31
ROS: Cardiac
Chest pain Palpitations SOB (dyspnea) - on exertion, lying flat (orthopnea), awakening from sleep (paroxysmal nocturnal dyspnea)
32
ROS: Vascular
Pain in lower extremities when walking (claudication) Leg swelling (edema) Blood clots Ulcers
33
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
34
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
35
ROS: Neuropsychiatric
Headaches Lightheaded/fainting Memory loss Poor balance (ataxia) Numbness/tingling Tremors Paralysis Mood changes Sleep Nervousness Speech disorders Hallucinations Seizures
36
ROS: MSK
Weakness Pain Stiffness Swelling
37
ROS: Endocrine
Excessive thirst Excessive urination Weight gain/loss Hair loss Loss of skin pigment Dry skin Blurry vision Palpitations Heat/cold intolerance