UNIT 2 MED HX

Question 1

FEMALE; PREGNANCIES

Answer 1

NUMBER; LIVING CHILDREN; MULTIPLE BIRTHS; MISCARRIAGES; ABORTIONS; DURATION OF PREGNANCY; EACH TYPE OF DELIVERY; ANY COMPLICATIONS DURING ANY EACH PREGNANCY OR POSTPARTUM PERIOD

Question 2

FEMALE: MENSES

Answer 2

AGE AT MENARCHE, REGULARITY; DURATION AND AMOUNT OF FLOW; DYSMENORRHEA; LAST MENSTRAL PERIOD (LMP)

Question 3

FEMALE: IRRIGULARITIES

Answer 3

ABNORMAL BLEEDING OR DISCHARGE; ITCHING; DATE OF LAST PAP SMEAR; PAIN DURING INTERCOURSE; DATE OF MENOPAUSE

Question 4

MALE SPECIFIC

Answer 4

DIFFICULTY W/ ERECTIONS; PENILE DISCHARGE; TESTICULAR PAIN, SCROTAL MASSES

Question 5

PSYCHIATRIC (5)

Answer 5

DEPRESSION; MOOD CHANGES; DIFFICULTY CONCENTRATING; ANXIETY; AGITATION; TENSION; SUICIDAL THOUGHTS; IRRITABILITY; SLEEP DISTURBANCES

Question 6

NEUROLOGICAL

Answer 6

SYNCOPE; SEIZURES; WEAKNESS OR PARALYSIS; ABNORMALITIES OF SENSATION OR COORDINATION; TREMORS; LOSS OF MEMORY; ABILITY TO CONCENTRATE

Question 7

MUSCULOSKELETAL

Answer 7

JOINT STIFFNESS; PAIN; RESTRICTION OF MOTION; SWELLING; REDNESS; HEAT; BONY DEFORMITY

Question 8

GENITOURINARY

Answer 8

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

Question 9

ENDOCRINE

Answer 9

THYROID ENLARGEMENT OR TENDERNESS; HEAT OR COLD INTOLERENCE; UNEXPLAINED WEIGHT CHANGES; DIABETES; POLYDIPSIA; POLYURIA; DISTRIBUTION AND CHANGES IN FACIAL OR BODY HAIR

Question 10

GASTROINTESTINAL

Answer 10

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

Question 11

HEMATOLOGIC

Answer 11

ANEMIA; ANY KNOWN ABNORMAL OF BLOOD CELLS; TRANSFUSION

Question 12

PERIPHERAL VASCULATURE

Answer 12

CLAUDICATION; TENDANCY TO BRUISE OR BLEED; THROMBOSES; THROMBOPHLEBITIS

Question 13

HEART AND BLOOD VESSELS

Answer 13

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

Question 14

BREASTS

Answer 14

PAIN; TENDERNESS; DISCHARGE; LUMPS; GALATORRHEA, PAST MAMMOGRAMS; FREQUENCY OF BREAST SELF EXAMINATION

Question 15

CHEST AND LUNGS

Answer 15

PAIN RELATED TO RESPIRATION; DYSPNEA; CYANOSIS; WHEEZING; COUCH; SPUTUM; HEMOPTYSIS; EXPOSURE TO TUBERCULOSIS; PAST CHEST X-RAY

Question 16

LYMPHNODES

Answer 16

ENLARGEMENT; TENDERNESS; SUPPURATION

Question 17

THROAT AND MOUTH

Answer 17

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

Question 18

NOSE

Answer 18

SNESE OF SMELL; FREQUENCY OF COLDS; OBSTRUCTION; EPISTAXIS; POSTNASAL DISCHARGE; SINUS PAIN

Question 19

EARS

Answer 19

HEARING LOSS; PAIN; DISCHARGE; TINNITUS; VERTIGO

Question 20

HEAD

Answer 20

HEADACHES; DIZZINESS; SYNCOPE; SEVERE HEAD INJURIES; PERIODS OF LOSS OF COSNSCIOUSNESS

Question 21

SKIN, HAIR, NAILS (2)

Answer 21

RASH OR ERUPTION;ITCHING; PIGMENTATION OR TEXTURE CHANGES; ABNORMAL NAIL OR HAIR GROWTH

Question 22

GENERAL CONSTITUTIONAL STMPTOMS (7)

Answer 22

PAIN
FEVER
CHILLS
WEIGHT CHANGE
MALAISE
NIGHT SWEATS
FATIGUE

Question 23

TRAVEL HISTORY

Answer 23

• RECENT TRAVEL HISTORY
• DEPLOYMENT
• GEOGRAPHIC LOCATION
• PDHA/PDHRA

Question 24

PERSONAL AND SOCIAL HISTORY

Answer 24

PERSONAL STATUS
HABITS
SELFCARE
SEXUAL HISTORY
OCCUPATION
TRAVEL

Question 25

OCCUPATION

Answer 25

DISCRIPTION OF WORK
EXPOSURE TO HEAT/COLD/TOXINS
PPE REQUIRED

Question 26

SEXUAL HISTORY

Answer 26

CONCERNS W/ FEELING AND PERFORMANCE
MODES OF BIRTH CONTROL OR PROTECTION
PAST STD’S

Question 27

SELF-CARE

Answer 27

BREAST/ TESTICLE EXAM SELF EXAM
HOME/ NATURAL/ ALTERNATIVE THERAPY
EXERCISE

Question 28

HABITS

Answer 28

DIET AND NUTRITION
CAFFINE
SMOKE
ALCOHOL
SLEEPING PATERN

Question 29

PERSONAL STATUS

Answer 29

BIRTH PLACE
EDUCATION
MARITAL STATUS
LIFE SATISFACTION
STRESSORS

Question 30

FAMILY HISTORY

Answer 30

MATERNAL/PATERNAL
MAJOR HEALTH DISORDERS
GENETIC DISORDERS
AGE AND OUTCOME OF EVERY ILLNESS

Question 31

PAST MEDICAL HISTORY

Answer 31

GENERAL HEALTH
HOSPITALIZATIONS OR SURGERIES
ILLNESSES
INJURIES
IMMUNIZATIONS
MEDICATIONS
ALLERGIES
PHA/ PHYSICAL EXAM
LABS

Question 32

MEDICATIONS

Answer 32

PRESCRIOTION OR OTC
NAME
DOSE
ROUTE
SCHEDULE
LAST DOSE

Question 33

ALLERGIES

Answer 33

MEDS/FOODS/ENVIRONMENT
REACTION
ALLERGY ALERT TAG

Question 34

HISTORY OF PRESENT ILLNESS

Answer 34

ONSET
LOCATION
DURATION
CHARACTERISTICS
AGGRAVATING
ASSOCIATED FACTORS
RELIEVING FACTORS
TEMPORAL
SEVERITY

Question 35

CHIEF COMPLAINT

Answer 35

WHAT BRINGS YOU IN TODAY?
WHAT HAPPENED?
ARE YOU CURRENTLY IN PAIN?

Question 36

DYSMENORRHEA

Answer 36

PAINFUL MENSTRATION, TYPICALLY ABD. CRAMPS