Test 1 Flashcards
Brief subjective statement for reason of
visit or what brought patient to seek
medical help (what is this called?)
Chief Complaint
true or false
the chief complaint usually describes most serious/severe
symptoms
true
how should you document a persons chief complaint
in patient’s own words
what does HPI stand for
history of present illness
what should you identify first with HPI
-Age
• Sex/Race
• Review C/C
• Length of problem or onset of symptoms
what type of questions should be followed up with for HPI
OPQRST questions
what does OPQRST stand for
onset, provocation, quality, region, severity, time
what does PMH stand for
Past medical history
true or false
you should ask about family history with PMH
true
what are some question to ask about personal/ social history
- Smoking, Alcohol, Drug Use
- Marital issue
- Sexual habits
- Employment situation
- Level of education
what does ROS stand for
review of systems
what are the types of questions that you want to ask about with ROS
- Chest and lungs, Cardiovascular
- Hematology
- Genital/Urinary
- Musculoskeletal
- Mental Status
what does OTC stand for
Over the counter
what are the three types of things that can cause allergies
food, drugs, enivronment
what does PE stand for
Physical exam
what does the PE info consis of
General Statement regarding of how
you perceive the patient
what is the normal for body temp
98.6F or 37C
what is the range for pulse and how long should you check their pulse for
60-80bpm and for 1 min
what is the range for respirations and how long should you check for
12-20 bpm and 1 min
what units should height and weight be measured in
height in cm
weight in kg
if you are checking BP how much should you pump the cuff and how much should you release each second
pump upto 200mmHg and release 5mmHg each second
what does RTC stand for
return to clinic
what does F/U stand for
Follow up
specific injury, illness,
disease, or condition determined by the exam (is this diagnosis, Differental diagnosis, or coexisting/comorbid condtions)
diagnosis
