Pt Encounter Script Flashcards
What are the 6 elements of a general health survey?
1) Health
2) Awareness/ LOC
3) Distress
4) Grooming/ hygiene
5) Face
6) Posture/ motor
HAD GFP
General health survey for an average/ well patient
1) Pt is a well-appearing man/ woman who is awake and oriented with no signs of distress.
2) Pt has appropriate grooming and hygiene for this visit and their mood and affect/ facial expression is flat/ cheerful
4) And their posture is upright with appropriate motor activity
ROS: head
Hair loss, scalp pain, and jaw pain (with chewing)
ROS: eyes
Redness, double vision, and blurry vision
ROS: ears
Loss of hearing, ringing in ears, and ear pain.
ROS: nose/ sinuses
Runny nose, stuffy nose, and bloody nose.
ROS: throat
Sore throat, hoarseness, and trouble swallowing
ROS: neck
Stiff neck, changes in ROM of neck, and lumps or bumps in neck.
ROS: cardiovascular
Chest pain, feeling of heart skipping a beat, and heart racing
ROS: respiratory
Shortness of breath, wheezing, and cough.
ROS: GI
Nausea, vomiting, and constipation
ROS: urinary
Difficulty urinating, pain during urination, and change in color or smell of urine.
ROS: genital
Itching, swelling, and pain of genitals
ROS: musculoskeletal
Acute back pain, joint pain, and changes in range of motion of joints.
ROS skin
Rashes, dryness, and itchiness.
ROS: endocrine
Cold or heat sensitivity, excessive thirst, and excessive hunger
ROS: peripheral vascular
Numbness, coldness, and swelling in hands or feet.
ROS: hematologic
Bruising or bleeding, history of anemia, or blood transfusions.
ROS neurologic
Pt denies dizziness, headaches, and changes in memory
ROS: psychiatric
Anxiety, depression, and suicidal thoughts.
Psych exam
-Pt’s fluency and rate of speech are appropriate. She displays logical and organized thoughts.
-Her higher cognitive functioning is intact.
2 depression questions
1) Over the past 2 weeks have you felt down, depressed, or hopeless?
2) Over the past 2 weeks, have you felt little pleasure in doing things?
3 anxiety questions
1) Over the past 2 weeks, have you felt nervous, anxious, or on edge?
2) Over the past 2 weeks, have you been unable to stop or control worrying?
3) Over the past 4 weeks, have you had an anxiety attack; suddenly feeling fear or panic?
What are the social Hx questions?
1) Tobacco
2) Illicit drugs + Rx misuse
3) Alcohol
4) Sexual history
○ Partners (marital status)
○ Protection
○ Preference
5) Home life / abuse
6) Occupation/ military history /travel
7) Exercise and diet + caffeine