Vol. 3 Chapter 4 : History Taking Flashcards
Obtaining a Patient History Procedure
- Establishes patient rapport and trust
- Performs proper introductions
- Asks appropriate open-ended and closed-ended questions
- Demonstrates active listening skills
- Obtains preliminary data
- Obtains chief complaint
- Obtains history of present illness or injury
- Obtains information on pertinent past history
- Obtains information on current health status
- Performs a review of body systems
- Handles special challenges appropriately
The patient’s age, sex, race, birthplace, and occupation are included in which element of the comprehensive patient history? A. Past history B.Preliminary data C.Current health status D.None of the above
B.Preliminary data
The mnemonic OPQRST-ASPN is a tool used during which element of the comprehensive patient history? A. Chief complaint B. Past history C. Present illness/injury D. Current health status
C. Present illness/injury
Which of the following is true regarding the patient’s chief complaint?
A. The chief complaint is asked as a closed-ended question.
B. The chief complaint is the reason EMS was called.
C. An accurate chief complaint can always be determined from dispatch information.
D. The chief complaint is the same as the primary problem.
B. The chief complaint is the reason EMS was called.
In the OPQRST mnemonic, the “P” stands for: A. Pertinent negatives C. Prescription medications B. Past medical history D. Provocative/palliative factors
D. Provocative/palliative factors
The term referred pain means pain that:
A. Is not really there, as in an amputated limb
B. Is felt at a location away from its source
C.Has been relieved or is not as severe as it previously was
D. Is elicited through palpation
B. Is felt at a location away from its source
Which of the following statements about obtaining a patient’s past medical history is true?
A. Asking about surgeries may help you correctly assess your patient’s current problem.
B. Asking about past medical history is a formality only and has little bearing on your care of the patient.
C. Asking about childhood diseases is always relevant.
D. Use the mnemonic OPQRST-ASPN when questioning about past history.
A. Asking about surgeries may help you correctly assess your patient’s current problem.
The patient’s family/social history should include questions regarding: A. Surgeries and hospitalizations B. The onset of the chief complaint C. Tobacco, alcohol, and drug use D. Childhood diseases
C. Tobacco, alcohol, and drug use
The CAGE questionnaire should be employed when investigating
A. The patient’s chief complaint
B. Alcohol use
C. The history of the present illness/injury
D. Tobacco (cigarette, cigar, smokeless) use
B. Alcohol use
The patient’s home situation, daily life, and religious beliefs are among the elements that may be determined when investigating the patient’s: A. Current health status B. Past medical history C. Present illness D. Preliminary data
A. Current health status
Which of the following statements is true regarding the review of systems?
A. Your history taking should begin with questions regarding the systems.
B. The questions you ask will be determined by the patient’s chief complaint, condition, and clinical status.
C. It is important to ask all questions in the review of systems of each patient.
D. The questions asked in the review of systems include sleep patterns and family history.
B. The questions you ask will be determined by the patient’s chief complaint, condition, and clinical status.
A sudden onset of shortness of breath at night is called: A. Nocturia B. Hemoptysis C. Paroxysmal nocturnal dyspnea D. Chronic obstructive pulmonary
C. Paroxysmal nocturnal dyspnea
The term gravida refers to the number of: A. Times a woman has been pregnant B. Viable births a woman has had C. Abortions a woman has had D. Living children the woman has
A. Times a woman has been pregnant
A preliminary list of possible causes for your patient’s problem is called a: A. Preliminary diagnosis B. Clinical reasoning C. Presumptive diagnosis D. Differential diagnosis
D. Differential diagnosis
The list of possible causes for your patient’s symptoms is known as
the ________________________________________________.
Differential field diagnosis
The reason the ambulance was called to respond is known as the
________________________________________________.
Chief Complaint
Asking if anything makes the pain any better or worse is a way to
determine________________ and _________________.
Provocation and palliation
A practical template for exploring chief complaints is the mnemonic
__________________________________________________________ -
________________________________________.
OPQRST - ASPN
The pain that is felt at a location away from its source is called
________________________________________ pain.
Referred
The absence of any likely associated symptom is known as a(n)
____________________________________________________________.
Pertinent negative
Your patient has a chief complaint of chest pain and also complains
of shortness of breath, nausea, and vomiting. These latter are known as
____________________________________________________________.
Associated symptoms
The acronym HEENT refers to the
Head, Eyes, Ears, Nose, and Throat
The CAGE questionnaire is asked regarding the use of
________________________________________ or
________________________________________.
Alcohol or drugs
The list of questions categorized by body system is known as the
___________________________________________________________.
Review of Systems
Difficulty breathing while lying supine is called
________________________________________.
Orthopnea
Coughing up blood is called ________________________________________.
Hemoptysis
Menstrual difficulties are called ________________________________________.
Dysmenorrhea
Polyuria is the name given to excessive ________________________________________.
urination
deterioration of mental status that is usually associated with
structural neurological disease is called
__________________________________________________________.
Dementia
Match the patient response to the appropriate OPQRST_ASPN
“The pain goes into my jaw.”
Region/Radiation
Match the patient response to the appropriate OPQRST_ASPN
“It feels like an elephant sitting on my chest”
Quality
Match the patient response to the appropriate OPQRST_ASPN
“All of a sudden I couldn’t breathe.”
Onset
Match the patient response to the appropriate OPQRST_ASPN
“I have been nauseated ever since the pain began”
Associated Symptoms
Match the patient response to the appropriate OPQRST_ASPN
“Lying down makes the pain worse.”
Provocation/Palliation
Match the patient response to the appropriate OPQRST_ASPN
“This pain is the worst pain I have ever felt.”
Severity
Match the patient response to the appropriate OPQRST_ASPN
“No, I didn’t break out into a sweat.”
Pertinent Negatives
Match the patient response to the appropriate OPQRST_ASPN
“The pain began 4 hours ago.”
Time
