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Flashcards in Medical History Deck (23)
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1
Q

HPI

A
Onset: date/time/duration
Provocative
Palliative
Quality
Quantified
Regionality
Radiation
Symptoms (associated)
2
Q

PMH

A
General Health
Chronic Illness
Surgical Procedures
Hospitalizations
Injuries/major illnesses
Medications
Allergies & reaction
Immunizations
3
Q

FH

A
Cancer
Hypertension
Heart Disease
Diabetes
Stroke
Seizures
Bleeding Disorders
Age/Health (parents/grand)
4
Q

Social History

A
Occupation
Education
Living Situation
Safe at Home
Diet 
Physical activity
Caffeine/alcohol/tobacco use
Prescription/illicit drug use
Military History
Travel
Sexually active
Number of Partners
5
Q

ROS: General

A
Weight changes
Fatigue
Malaise
Weakness
Fever/Chills
Sweats/Night sweats
6
Q

ROS: Skin

A
Rashes./sores/lesions
Lumps/masses
Pruritus (itching)
Dryness/moistures
Hair/Nail changes
7
Q

ROS: Head

A

Headaches
Head trauma
Dizziness/vertigo
Syncope/LOC/Concussion

8
Q

ROS: Ears

A
General Hearing Status
Otalgia (earaches)
Past Infections
Drainage/Discharge
Tinnitis
9
Q

ROS: Eyes

A
General Vision Status
Glasses/Contacts
Last Eye Exam
Pain/Redness/Tearing
Diplopia/blurriness
H/O trauma/foreign body
10
Q

ROS: Nose/Sinuses

A
Sinus pain
Epistaxis
Nasal Congestion
Nasal Drainage
Frequent colds
Sneezing
11
Q

ROS: Mouth/Throat

A
Dental Hygeine
Last Dental Exam
Tootaches
Pain/Soreness
Hoarseness
12
Q

ROS: Neck/Lymph nodes

A

Pain
Stiffness/limited ROM
Masses/Swelling
Tenderness/enlargement (lymph nodes)

13
Q

ROS: Breasts

A

Pain
Lumps/masses
Nipple changes/discharge
Self-exams

14
Q

ROS: Respiratory

A
Pleuritic chest pain
Cough/Sputum
Hemoptysis
Wheezing or H/O Asthma
H/O Bronchitis
TB or past exposure
Last PPD or CSR
15
Q

ROS: Cardiovascular

A
Pain
Palpitations
Diaphoresis
SOB/dyspnea
Orthopnea/PND
Edema
H/O HTN, murmurs, heart problems
EKG/other dx testing
16
Q

ROS: Gastrointestinal

A
Appetite
Food intolerances
Dysphagia (Solid/liquid)
Dyspepsia (heartburn)
N/V
Change in bowel habits
Constipation/diarrhea
Rectal bleeding/melena
Hemorrhoids
H/O PUD, Jaundice, Appendix, GB disease
17
Q

ROS: Genitourinary

A
Change in frequency, force of stream, color
Hesitancy/difficulty initiating
Pain/dysuria
Dribbling/incontinence
H/O infections, hematuria
Penile/vaginal discharge
H/O STD's/Treatment
Libido
WOMEN- Dyspareunia
MEN- Scrotal pain/mass/edema
           Erectile problems
           Self-testicular exams
18
Q

ROS: OB/GYN

A
Menarche
Last menstrual period
Gravida (# pregnancies)
Para (# deliveries)
Delivery complications
Abortions/miscarriages
Last pap (Results)
Menopause (Symptoms)
19
Q

ROS: Musculoskeletal

A
Intermittent claudication
Varicosities
Decrease strength
Decreased ROM
Joint swelling, redness, stiffness, pain
H/O bone/joint infections, fractures/dislocations, back pain/disc disease, sciatica
20
Q

ROS: Neurologic

A
H/O convulsions/seizures, infections/meningitis
Memory loss
Trouble Concentrating
Tremors
Numbness/sensory loss
Paresthesia (pins/needles)
21
Q

ROS: Hematologic

A

Easy bruising
Bleeding (gums/skin)
H/O transfusions, anemia, blood diseases

22
Q

ROS: Endocrine

A
Intolerance to heat/cold
Nervousness
Sleeplessness
Polyphagia/-uria/-dipsia
Nocturia
Tested for diabetes
H/O thyroid disease
23
Q

ROS: Psychiatric

A
Depression, mood changes
Anxiety, agitation
Tension, irritability
Suicidal thoughts
Sleep disturbances
Difficulty getting up