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27 Cards in this Set

  • Front
  • Back
Format of the history and physical 14 components
1 Source and reliabiliyt
2 Chief complaint
3 History of present Illness
4 Past medical History
5 Occupational and environmental History
6 Biographic Information (race, sex, ethnicity)
7 Family History
8 Psychosocial History (education, relationships, etc)
9 Sexual, reproductive, gynecologic history
10 review of symptoms
11 Physical Exam
12 Laboratory Data
13 Problem List
14 Assessment and plan
4 components to include in HPI
1 the patient's symptoms chronologically
2 Pertinent past history-previous medical evaluation
3 Pertinent positive and negatives
4 Affects of the illness on the patient's quality of life
9 components of Past Medical History
1 All past illnesses
2 All prior hospitalizations and Dates
3 All prior surgery and dates
4 Allergies--Type Reaction
5 Immunizations
6 All medications and dosages--DO NOT forget OTC and HERBAL
7 Substance Abuse
8 Transfusions
9 Smoking and Alcohol
Components of personal Profile, 7
1 Social History--Birthplace, education, religion, residencies
2 Family Relationships--Single, married, divorced
3 Average Day
4 Occupational History--All
5 Habits--Exercise, Diet
6 Stress and Support
7 Self Care
Review of systems--name the systems (20, inc general)
1 General
2 Skin
3 Head
4 Eyes
5 Ears
6 Nose
7 Mouth, throat
8 Neck
9 Chest
10 Heart
11 Breasts
12 Gastrointestinal
13 urinary
14 Genitalia
15 Extremities
16 Musculoskeletal
17 Neurological
18 Psychiatric
19 Endocrine
20 Hematologic
ROS General questions, 5
1 Appetite
2 Weight
3 Fever
4 Chills
5 Night Sweats
ROS Skin questions, 4
1 Rashes
2 Itching
3 Dryness
4 Changes
ROS head questions, 3
1 Headache
2 Dizziness
3 Fainting
ROS Eyes questions, 5
1 Glasses
2 Vision
3 Redness
4 Pain
5 Glaucoma
ROS ears questions, 3
1 Hearing
2 Infections
3 Discharge
ROS nose questions, 4
1 bleeding
2 congestion
3 pain
4 sense of smell
ROS mouth and throat questions, 4
1 Teeth
2 Bleeding gums
3 Sore throat
4 hoarseness
ROS neck questions, 3
1 Lumps
2 Swollen glands
3 Goiter
ROS chest (lungs) questions, 3
1 Cough
2 Shortness of Breath
3 Sputum
ROS heart questions, 4
1 Pain
2 Pressure
3 Palpitations
4 Swelling
ROS breasts, 3
1 Lumps
2 Pain
3 Discharge
ROS GI, 7
1 Nausea
2 Vomiting
3 pain
4 Jaundice
5 bloating
6 constipation
7 diarrhea
ROS urinary, 5
1 infection
2 pain
3 discharge
4 frequency
5 nocturia
ROS genitalia, 5
1 lesions
2 discharge
3 itching
4 hernias
5 menarche
ROS extremities, 4
1 joint pain
2 muscle pain
3 stiffness
4 cramps
ROS neurological, 5
1 fainting
2 dizziness
3 numbness
4 tingling
5 tremor
ROS psychiatric, 4
1 mood
2 anxiety
3 hallucinations
4 impulse control
ROS endocrine, 3
1 Excessive thirst
2 Poor wound healing
3 heat or cold intolerance
ROS hematologic, 3
1 easy bruising
2 bleeding
3 fatigue
four principles of physical exam
1 inspection
2 palpation
3 percussion
4 auscultation
Steps of the physical exam as described in notes, 11
1 Have patient dressed appropriately
2 Wash your hands
3 Perform exam in presence of a chaperone
4 begin with the vital signs
5 Respect patient's privacy
6 Speak to patient--good time to review history, remember missed questions
7 Do not comment on exam as it is performed
8 Review the precautions to take during exam swartz p 88
9 try to perform exam in least number positions
10 Keep the pt comfortable
11 Inform patient when exam completed
Recording data from physical exam, 3 steps
1 Record vital signs: BP, HR, T, R

2 Describe what you see, i.e. a well developed well nourished patient

3 Recod findings as they relate to each major organ system