UNIT 2 MED HX Flashcards
FEMALE; PREGNANCIES
NUMBER; LIVING CHILDREN; MULTIPLE BIRTHS; MISCARRIAGES; ABORTIONS; DURATION OF PREGNANCY; EACH TYPE OF DELIVERY; ANY COMPLICATIONS DURING ANY EACH PREGNANCY OR POSTPARTUM PERIOD
FEMALE: MENSES
AGE AT MENARCHE, REGULARITY; DURATION AND AMOUNT OF FLOW; DYSMENORRHEA; LAST MENSTRAL PERIOD (LMP)
FEMALE: IRRIGULARITIES
ABNORMAL BLEEDING OR DISCHARGE; ITCHING; DATE OF LAST PAP SMEAR; PAIN DURING INTERCOURSE; DATE OF MENOPAUSE
MALE SPECIFIC
DIFFICULTY W/ ERECTIONS; PENILE DISCHARGE; TESTICULAR PAIN, SCROTAL MASSES
PSYCHIATRIC (5)
DEPRESSION; MOOD CHANGES; DIFFICULTY CONCENTRATING; ANXIETY; AGITATION; TENSION; SUICIDAL THOUGHTS; IRRITABILITY; SLEEP DISTURBANCES
NEUROLOGICAL
SYNCOPE; SEIZURES; WEAKNESS OR PARALYSIS; ABNORMALITIES OF SENSATION OR COORDINATION; TREMORS; LOSS OF MEMORY; ABILITY TO CONCENTRATE
MUSCULOSKELETAL
JOINT STIFFNESS; PAIN; RESTRICTION OF MOTION; SWELLING; REDNESS; HEAT; BONY DEFORMITY
GENITOURINARY
DYSURIA; FLANK OR SUPRAPUBIC PAIN; URGENCY AND FREQUENCY OF URINATION; NOCTURIA, HEMATURIA, POLYURIA; DARK OR MISCOLORED URINE, HESITANCY; DRIBBLING; LOSS IN FORCE OF STREAM; PASSAGE OF STONE; STRESS INCONTINENCE; HERNIAS; STD’S
ENDOCRINE
THYROID ENLARGEMENT OR TENDERNESS; HEAT OR COLD INTOLERENCE; UNEXPLAINED WEIGHT CHANGES; DIABETES; POLYDIPSIA; POLYURIA; DISTRIBUTION AND CHANGES IN FACIAL OR BODY HAIR
GASTROINTESTINAL
APPETITE; DIGESTION; INTOLERANCE FOR ANY CLASS OF FOOD; DYSPHAGIA; HEARTBURN; NAUSEA; VOMITTING; DIARRHEA; HEMATEMESIS, REGULARITY OF BOWELS; CONSTIPATION; CHANGE IN STOOL COLOR OR CONTENTS; FLATULENCE; HEMORRHOIDS; JAUNDICE; HISTORY OF ULCER; GALLSTONES; POLYP; TUMORS; PAST DIAGNOSTIC IMAGES OR TEST
HEMATOLOGIC
ANEMIA; ANY KNOWN ABNORMAL OF BLOOD CELLS; TRANSFUSION
PERIPHERAL VASCULATURE
CLAUDICATION; TENDANCY TO BRUISE OR BLEED; THROMBOSES; THROMBOPHLEBITIS
HEART AND BLOOD VESSELS
CHEST PAIN OR DISTRESS (precipitating causes, timing and duration, relieving factors) palpitations; orthopnea; edema; hypertension; previous myocardial infarction ; exercise tolerance; past electrocardiogram an other cell test
BREASTS
PAIN; TENDERNESS; DISCHARGE; LUMPS; GALATORRHEA, PAST MAMMOGRAMS; FREQUENCY OF BREAST SELF EXAMINATION
CHEST AND LUNGS
PAIN RELATED TO RESPIRATION; DYSPNEA; CYANOSIS; WHEEZING; COUCH; SPUTUM; HEMOPTYSIS; EXPOSURE TO TUBERCULOSIS; PAST CHEST X-RAY
LYMPHNODES
ENLARGEMENT; TENDERNESS; SUPPURATION
THROAT AND MOUTH
HOARSNESS OR CHANGE IN VOICE; FREQUENCY OF SORE THROATS; BLEEDING OR SWELLING OF GUMS; RECENT TOOTH ABSCESSES OR EXTRACTION; SORENESS OF TONGUE OR BUCCAL MUCOSA; ULCERS; DISTURBANCE OF TASTE
NOSE
SNESE OF SMELL; FREQUENCY OF COLDS; OBSTRUCTION; EPISTAXIS; POSTNASAL DISCHARGE; SINUS PAIN
EARS
HEARING LOSS; PAIN; DISCHARGE; TINNITUS; VERTIGO
HEAD
HEADACHES; DIZZINESS; SYNCOPE; SEVERE HEAD INJURIES; PERIODS OF LOSS OF COSNSCIOUSNESS
SKIN, HAIR, NAILS (2)
RASH OR ERUPTION;ITCHING; PIGMENTATION OR TEXTURE CHANGES; ABNORMAL NAIL OR HAIR GROWTH
GENERAL CONSTITUTIONAL STMPTOMS (7)
PAIN FEVER CHILLS WEIGHT CHANGE MALAISE NIGHT SWEATS FATIGUE
TRAVEL HISTORY
- RECENT TRAVEL HISTORY
- DEPLOYMENT
- GEOGRAPHIC LOCATION
- PDHA/PDHRA
PERSONAL AND SOCIAL HISTORY
PERSONAL STATUS HABITS SELFCARE SEXUAL HISTORY OCCUPATION TRAVEL
OCCUPATION
DISCRIPTION OF WORK
EXPOSURE TO HEAT/COLD/TOXINS
PPE REQUIRED
SEXUAL HISTORY
CONCERNS W/ FEELING AND PERFORMANCE
MODES OF BIRTH CONTROL OR PROTECTION
PAST STD’S
SELF-CARE
BREAST/ TESTICLE EXAM SELF EXAM
HOME/ NATURAL/ ALTERNATIVE THERAPY
EXERCISE
HABITS
DIET AND NUTRITION CAFFINE SMOKE ALCOHOL SLEEPING PATERN
PERSONAL STATUS
BIRTH PLACE EDUCATION MARITAL STATUS LIFE SATISFACTION STRESSORS
FAMILY HISTORY
MATERNAL/PATERNAL
MAJOR HEALTH DISORDERS
GENETIC DISORDERS
AGE AND OUTCOME OF EVERY ILLNESS
PAST MEDICAL HISTORY
GENERAL HEALTH HOSPITALIZATIONS OR SURGERIES ILLNESSES INJURIES IMMUNIZATIONS MEDICATIONS ALLERGIES PHA/ PHYSICAL EXAM LABS
MEDICATIONS
PRESCRIOTION OR OTC NAME DOSE ROUTE SCHEDULE LAST DOSE
ALLERGIES
MEDS/FOODS/ENVIRONMENT
REACTION
ALLERGY ALERT TAG
HISTORY OF PRESENT ILLNESS
ONSET LOCATION DURATION CHARACTERISTICS AGGRAVATING ASSOCIATED FACTORS RELIEVING FACTORS TEMPORAL SEVERITY
CHIEF COMPLAINT
WHAT BRINGS YOU IN TODAY?
WHAT HAPPENED?
ARE YOU CURRENTLY IN PAIN?
DYSMENORRHEA
PAINFUL MENSTRATION, TYPICALLY ABD. CRAMPS
