Medical History Checklist Flashcards Preview

Physical Assessment > Medical History Checklist > Flashcards

Flashcards in Medical History Checklist Deck (25)
Loading flashcards...
1

Categories/headings in order
26

Introductions/Personal Information
Chief Complaint
HPI
PMH
FH
Social History
REVIEW OF SYSTEMS
General
Skin
Head
Ears
Eyes
Nose/Sinuses
Mouth/Throat
Neck
Lymph Nodes
Breasts
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
OB/GYN
Extremities-musculoskeletal
Neurologic
Hematologic
Endocrine
Psychiatric

2

Checklist for History of Present Illness
8

Onset: date/time/duration
Provocative
Palliative
Quality
Quantified
Regionality
Radiation
Associated symptoms

3

Checklist for Past Medical History
8

General Health
Chronic illnesses
Surgical procedures
Hospitalizations
Injuries/major illnesses
Medications
Allergies and reaction
Immunizations

4

Checklist for Family history?
8

Cancer
Hypertension
Heart disease
Diabetes
Stroke
Seizures
Bleeding disorders
Age/health of parents and grandparents

5

Checklist of Social History?
15

Occupation
Education
Living situation
Diet
Physical activity
Caffeine use
Alcohol use
Tobacco use
Sexually active
Monogamous/# of partners
Prescription drug abuse
Illicit drug abuse
Military history
Safe at home
Travel

6

General Review of Systems
6

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

7

Skin
5

Rashes/sores/lesions
Lumps/masses
Pruritis/itching
Dryness/moisture
Hair/nail changes

8

Head
4

Headaches
Head Trauma
Dizziness/vertigo
Syncope/LOC/concussion

9

Ears
5

General hearing status
Otalgia (earaches)
Past infections
Drainage/discharge
Tinnitis

10

Eyes
6

General vision status
Glasses/contacts
Last eye exam
Pain/redness/tearing
Diplopia/blurriness
H/O trauma/foreign bodies

11

Nose/Sinuses
6

Sinus pain
Epistaxis
Nasal congestion
Nasal drainage
Frequent colds
Sneezing

12

Mouth/Throat
5

Dental hygiene
Toothaches
Last dental exam
Pain/soreness
Hoarseness

13

Neck
3

Pain
Stiffness/limited ROM

14

Lymph Nodes
2

Tenderness
Enlargements

15

Breasts
4

Pain
Lumps/masses
Nipple changes/discharge
Self-exam

16

Respiratory
7

Pleuritic chest pain
Cough/sputum
Hemoptysis
Wheezing or H/O asthma
H/O bronchitis
TB or past exposure
Last PPD or CXR

17

Cardiovascular
10

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

18

Gastrointestinal
12

Appetite
Food intolerances
Dysphagia
Dyspepsia
Nausea/vomiting
Change in bowel habits
Diarrhea/constipation
Rectal bleeding/melena
Hemorrhoids
H/O PUD
H/O Jaundice
H/O appendix/gall bladder disease

19

Genitourinary
11
women-1
men-3

Change of frequency
Change in force of stream
Normal color/Change in color
Hesitancy/difficulty initiating
Pain/Dysuria
Dribbling/ incontinence
H/O infections
H/O hematuria
Penile/Vaginal discharge
H/O STDs/Treatment
Libido/Sex drive

Women:
Dyspareunia
Men:
Scrotal pain/mass/edema
Erectile problems
Self-testicular exams

20

OB/GYN
8

Menarche
Last menstrual period
Gravida (# of pregnancies)
Para (# of deliveries)
Delivery complications
Abortions/miscarriages
Last pap (results?)
Menopause (symptoms?)

21

Extremities-Musculoskelatal
10

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

22

Neurologic
7

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

23

Hematologic
5

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

24

Endocrine
7

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

25

Psychiatric
6

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