Subjective Interview Flashcards
HPI, social, PMHX, family hx
OLDCARTS
General
Denies weakness, fatigue, fever, or night sweats white changes
Nutrition
Patient reports healthy diet and denies changes in weight, diet overall appetite,
Skin hair, nails
Denies rash, eruptions, itching, pigmentation, texture changes, excessive sweating, or unusual nail or hair growth that I change the nail appearance and health
Head and neck
Denies frequent or unusual HA, dizziness, syncope, brain injuries, concussions, LOC
Breast
Developing appropriate for age nice pain tenderness discharge galactorrhea
Respiratory
Denied pain relayed to inhalation, exhalation, shortness of breath, cyanosis, wheezing, cough, sputum, production, optics, or night sweats
Cardiac
Denies cardiac issues, palpitations, chest pain to compete, edema, art, and exercise tolerance
G.I.
Abdominal pain stoop changes, constipation diarrhea, any blood in stool, indigestion
GU
Denies avoiding issues, dysuria, flank, or superpubic pain urgency frequency, bacteria hematuria polyurea has since seen dribbling loss of force stream, stone passage, edema face dress incontinence, hernias or STDs
Psych
Denies history of psychiatric disorders, depression, mania, mood changes, difficulty concentrating, nervousness, tension, SI, irritability, sleep issues
Neuro
I think a P seizure’s weakness or paralysis sensation or coordination issues, trimmers concentration issues, or memory issues
Lymph, heme, endocrine
Denies limp and enlargement, tenderness, separation anemia. Blood disorders are enlargement, tenderness, heat, or exercise tolerance, unexplained, weight changes, polydipsia, polyurea, changes and facial or body hair increases in hand or size or skin ray denies previous blood transfusion denies recent travel or recent communicable disease exposure.
Confirm name, date of birth reason for visit introduced self hand hygiene
Eyes
Denies vision issues, blurring, double vision, light sensitivity, pain, use of glasses or contacts
Ears
Denies hearing loss, pain, discharge, ringing, vertigo
Nose
Denies loss of smell, frequency of colds, obstruction, nosebleeds, post nasal discharge, sinus pain
Throat and mouth
Denies hoarseness, but r changes in voice, frequent sore throats, bleeding or swollen gums, dental caries, tooth abscess, extraction, denture, implants or devices, tongue soreness, changes in taste
Ending
Is there anything else that you think would be impotent for me to know
