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16 Cards in this Set

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  • Back
Principal symptoms well-characterized by seven attributes:
1 - location
2 - quality
3 - quantity or severity
4 - timing, including onset, duration, and frequency
5 - the setting in which they occur
6 - factors that aggravate or alleviate the symptoms
7 - associated manifestations
Illnesses can affect the patient's:
life
pertinent factors to the presenting illness:
medications, allergies, substance use
Observe the patient's:
general habitus/demeanor/eye contact/body language/manner of speaking
Identifying Data on an Adult Health History includes:
identification, i.e. age, gender, occupation, marital status

Source of the history - often the patient

Source of referral
Reliability varies according to:
patient's memory, trust, and mood
The Chief Complaint is defined as:
the one or more symptoms or concerns causing the patient to seek care
The Present Illness includes:
amplification of the CC
patient's thoughts and feelings
relevant portions of review of symptoms
pertinent medications, allergies, habits of smoking and alcohol
Broad question about pulmonary complaints:
Do you have any discomfort or unpleasant feelings in your chest?
Broad question about dyspnea:
Have you had any difficulty breathing?
What does the "O" in opqrst stand for?
Onset of the event
What the patient was doing when it started (active, inactive, stressed), whether the onset was sudden, gradual or part of an ongoing chronic problem.
What does the "P" in opqrst stand for?
Provocation or Palliation
Whether any movement, pressure (such as palpation or other external factor makes the problem better or worse. This can also include whether the symptoms relieve with rest
What does the "q" in opqrst stand for?
Quality of the pain
This is a description of the pain including whether it is sharp, dull, crushing or some other feeling, along with the pattern, such as intermittent, constant, only on movement etc.
What does the "r" in opqrst stand for?
Region and Radiation
Where the pain is on the body and whether it radiates to any other area. This can give indications for conditions such as a myocardial infarction, which can radiate through the jaw and arms.
What does the "s" in opqrst stand for?
Severity
The pain score (usually on a scale of 1 to 10). This can be comparative (such as 'compared to the worst pain you have ever experienced') or imaginative ('compared to having your arm ripped off by a bear'). The clinician must decide whether a score given is realistic within their experience - for instance, a pain score 10 for a stubbed toe is likely to be exaggerated. This may also be assessed for pain now, compared to pain at time of onset, or pain on movement. There are alternative assessment methods for pain, which can be used where a patient is unable to vocalise a score. One such method is the Wong-Baker faces pain scale.
What does the "T" in opqrst stand for?
Time (history)
How long the condition has been going on for, and how it has changed during it's development (better, worse, different symptoms). It may also be useful to know if it ever happened before.