Week 1 objectives Ch 1 Flashcards
Differentiate and explain what information is subjective vs objective
• Subjective Data
o What the patient tells you
o The history, from chief complaint through Review of Systems
Chief Complaint; Allergies reported by patient; Social History; Medication List reported by patient; History of Present Illness; Family History; Past Medical History; Review of Systems
• Objective Data
o What you detect during the examination
o All Physical Examination Findings
X-ray; Blood Pressure; Allergies from test results; Pulse; Lab bloodwork
- Know the components of a comprehensive adult history and be able to illicit the appropriate information for each component. In addition, be able to correctly document all of the information using this model
Identifying Data and Source of the History Reliability Chief Complaint Present Illness Past History Family History Personal and Social History Review of Systems
Identifying data and source of history
o Identifying data
Such as age, gender, occupation, marital status
o Source of the History
Usually the patient, but can be a family member or friend, letter of referral, or the medical record
Reliability
Varies according to the patient’s memory, trust, and mood
Chief complaint
the one or more symptoms or concerns causing a patient to seek care
Present illness
o Amplifies the chief complaint, describes how each symptom develops
o Includes patient’s thoughts and feelings about the illness
o Pulls in relevant portions of Review of Systems, called pertinent positives and pertinent negatives
o May include medications, allergies, and habits of smoking and consuming alcohol, which are frequently pertinent to present illness
Past history
o List of childhood illnesses
o Lists adult illnesses with dates for at least four categories
Medical: illnesses such as diabetes, HTN, hepatitis, etc.
Surgical: Dates, indications and types of operations
Obstetric/gynecologic: Menstrual history, methods of contraception, and sexual function
Psychiatric: Illness and time frame, diagnoses, hospitalizations, and treatments
Family History
o Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents
o Documents presence or absence of specific illnesses in family, such as HTN or CAD
Personal and Social History
o Describes educational level, family of origin, current household, personal interests, and lifestyle
Review of systems
o Documents presence or absence of common symptoms related to each major body system
o Should be long series of yes or no questions, prepare patient by letting them know there will be many questions asked
Think of questions from head to toe
Elicit in an interview and document the 7 attributes of a symptom
- Location
- Quality
- Quantity or Severity
- Timing, including onset, duration, and frequency
- The sitting in which it occurs
- Factors that aggravated or relieve symptoms
- Associated manifestations
General review of systems questions
usual weight, recent weight changes, clothing that fits differently, weakness, fatigue, or fever
Skin review of systems questions
Rashes, lumps, sores, itching, dryness, change in color, changes in hair or nails, changes in size or color of moles
Head review of systems questions
headache, head injury, dizziness, lightheadedness
Eyes review of systems questions
Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts
Ears review of systems questions
Hearing, tinnitus, vertigo, earaches, infection, discharge, decrease in hearing, use of hearing aids
Nose review of systems questions
Frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble
Throat review of systems questions
Condition of teeth and gums, bleeding gums, dentures (if any and how they fit), last dental exam, sore tongue, dry mouth, frequent sore throats, hoarseness
Neck review of systems questions
Swollen glands, goiter, lumps, pain, or stiffness
Breasts review of systems questions
Lumps, pain or discomfort, nipple discharge, self-examination practices
Respiratory review of systems questions
Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray; may include asthma, bronchitis, emphysema, pneumonia, and tuberculosis
Cardiovascular review of systems questions
Heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, results of past EKG or other cardiovascular tests
Gastrointestinal review of systems questions
Trouble swallowing, heartburn, appetite, nausea, Bowel movements, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black and tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing of gas; jaundice, liver or gallbladder trouble, hepatitis
Peripheral vascular review of systems questions
: intermittent claudication; leg cramps; varicose veins; past clots in the veins; swelling in calves, legs or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness
Urinary review of systems questions
Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, hematuria, urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of urinary stream, hesitancy, dribbling
Male genital review of systems questions
Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments; sexual habits, interest, function, satisfaction, birth control methods, and problems
