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Flashcards in Medical History Checklist Deck (25)
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1
Q

Categories/headings in order

26

A
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
Q

Checklist for History of Present Illness

8

A
Onset: date/time/duration
Provocative
Palliative
Quality
Quantified
Regionality
Radiation
Associated symptoms
3
Q

Checklist for Past Medical History

8

A
General Health
Chronic illnesses
Surgical procedures
Hospitalizations
Injuries/major illnesses
Medications
Allergies and reaction
Immunizations
4
Q

Checklist for Family history?

8

A
Cancer
Hypertension
Heart disease
Diabetes
Stroke
Seizures
Bleeding disorders
Age/health of parents and grandparents
5
Q

Checklist of Social History?

15

A
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
Q

General Review of Systems

6

A
Weight changes
Fatigue
Malaise
Fever/Chills
Sweats/Night sweats
Weakness
7
Q

Skin

5

A
Rashes/sores/lesions
Lumps/masses
Pruritis/itching
Dryness/moisture
Hair/nail changes
8
Q

Head

4

A

Headaches
Head Trauma
Dizziness/vertigo
Syncope/LOC/concussion

9
Q

Ears

5

A
General hearing status
Otalgia (earaches)
Past infections
Drainage/discharge
Tinnitis
10
Q

Eyes

6

A
General vision status
Glasses/contacts
Last eye exam
Pain/redness/tearing
Diplopia/blurriness
H/O trauma/foreign bodies
11
Q

Nose/Sinuses

6

A
Sinus pain
Epistaxis
Nasal congestion
Nasal drainage
Frequent colds
Sneezing
12
Q

Mouth/Throat

5

A
Dental hygiene
Toothaches
Last dental exam
Pain/soreness
Hoarseness
13
Q

Neck

3

A

Pain

Stiffness/limited ROM

14
Q

Lymph Nodes

2

A

Tenderness

Enlargements

15
Q

Breasts

4

A

Pain
Lumps/masses
Nipple changes/discharge
Self-exam

16
Q

Respiratory

7

A
Pleuritic chest pain
Cough/sputum
Hemoptysis
Wheezing or H/O asthma
H/O bronchitis
TB or past exposure
Last PPD or CXR
17
Q

Cardiovascular

10

A
Pain
Palpitations
Diaphoresis
SOB/dyspnea
Orthopnea/PND
Edema
H/O HTN
H/O murmurs
H/O heart problems
EKG/other diagnostic testing
18
Q

Gastrointestinal

12

A
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
Q

Genitourinary
11
women-1
men-3

A
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
Q

OB/GYN

8

A
Menarche
Last menstrual period
Gravida (# of pregnancies)
Para (# of deliveries)
Delivery complications
Abortions/miscarriages
Last pap (results?)
Menopause (symptoms?)
21
Q

Extremities-Musculoskelatal

10

A
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
Q

Neurologic

7

A
H/O convulsions/seizures
H/O infections/meningitis
Memory loss
Tremors
Numbness/sensory loss
Paresthesia (pins/needles)
Trouble concentrating
23
Q

Hematologic

5

A
Easy bruising
Bleeding (gums, skin)
H/O transfusions
H/O anemia
H/O blood diseases
24
Q

Endocrine

7

A
Intolerance to heat/cold
Nervousness
Sleeplessness
Polyphagia, uria, dipsia
Nocturia
Tested for diabetes
H/O thyroid disease
25
Q

Psychiatric

6

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