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Flashcards in Medical History Deck (23)
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1

HPI

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

2

PMH

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

3

FH

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

4

Social History

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

ROS: General

Weight changes
Fatigue
Malaise
Weakness
Fever/Chills
Sweats/Night sweats

6

ROS: Skin

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

7

ROS: Head

Headaches
Head trauma
Dizziness/vertigo
Syncope/LOC/Concussion

8

ROS: Ears

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

9

ROS: Eyes

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

10

ROS: Nose/Sinuses

Sinus pain
Epistaxis
Nasal Congestion
Nasal Drainage
Frequent colds
Sneezing

11

ROS: Mouth/Throat

Dental Hygeine
Last Dental Exam
Tootaches
Pain/Soreness
Hoarseness

12

ROS: Neck/Lymph nodes

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

13

ROS: Breasts

Pain
Lumps/masses
Nipple changes/discharge
Self-exams

14

ROS: Respiratory

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

15

ROS: Cardiovascular

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

16

ROS: Gastrointestinal

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

ROS: Genitourinary

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

ROS: OB/GYN

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

19

ROS: Musculoskeletal

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

ROS: Neurologic

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

21

ROS: Hematologic

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

22

ROS: Endocrine

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

23

ROS: Psychiatric

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