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26 Cards in this Set
- Front
- Back
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what questions should be asked about a woman's menstrual and obstetric history?
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onset of menses duration
cycle length number of pads daily birth control pills and other hormonal preparations pregnancies abortions (spontaneous) abortions (induced) deliveries of living children other deliveries complications of pregnancy menopause |
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what questions should be asked about a patient's diet?
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what they ate the day before including meals and snacks
salt intake fiber intake caffeine intake sugar intake (diabetics) |
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what questions should be asked about a person's family unit?
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spouse
partner children parents siblings quality of relationships |
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what questions should be asked about a person's social support?
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friends
community organizations pets spiritual beliefs or community |
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what questions should be asked about a person's personal background?
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education
occupational history military travel religion dwelling |
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what prevention questions should a patient be asked?
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alcohol
drugs tobacco diet exercise hobbies periodic health examinations sleep stress seatbelts smoke detectors sexual risks/exposures |
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what questions should be asked of a patient about their family medical history?
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Family members with similar symptoms and signs
Presence of infectious and/or chronic diseases in family members summary of ages and states of mental/physical health or causes of death of immediate family Note family interaction patterns and gestalt (happy, successful, competitive, distant, dysfunctional, love, anger, alcoholism) |
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what questions should be asked about a patient's general/constitutional health?
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change in appetite (poor or excessive)
change in weight fever chills sweats anhedonia (no enjoyment in life) pain fatigue |
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what questions should be asked about a patient's skin/integument?
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sores and skin ulcers
itching rash change in size or color of moles abnormal hair growth changes in nails |
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what questions should be asked about a patient's hematopoietic system?
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enlarged glands
lumps anywhere urge to eat dirt abnormal bleeding or excessive bruising frequent or unusual infections |
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what questions should be asked about a patient's endocrine system?
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heat or cold intolerance
decreased sexual drive salt craving enlarging glove and hat size excessive thirst |
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what questions should be asked about a patient's musculoskeletal system?
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frequent fractures
muscular weakness painful muscles joint pain and swelling low back pain paralysis movement difficulty claudication (pain in calf with walking) swollen leg |
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what questions should be asked about a patient's vision/eyes?
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change in vision
bright flashes of light image of light with jagged, shimmering appearance spots in visual field double vision |
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what questions should be asked about a patient's ears, nose, and throat?
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loss of hearing
ringing in the ears drainage from nose decreased/altered sense of smell bloody nose sore throat impaired speech painful tooth hoarseness |
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what questions should be asked about a patient's head and neck?
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headache
dizziness lightheadedness loss of consciousness stiff neck |
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what questions should be asked about a patient's breasts?
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lump or mass
discharge tenderness |
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what questions should be asked about a patient's cardiovascular system?
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chest pain
shortness of breath shortness of breath when lying down needs to sit to breath wakening at night with dyspnea pounding sensation in the chest peripheral arterial and venous insufficiency |
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what questions should be asked about a patient's respiratory system?
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wheezing
cough yellow or green sputum clear sputum bloody sputum |
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what questions should be asked about a patient's GI tract?
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appetite
sticking sensation in throat difficulty swallowing heartburn upper abdominal pain mid-lower abdominal pain nausea nonbloody vomiting bloody emesis (vomiting) black stools bloody stools difficult or infrequent bowel movements loose or frequent bowel movements yellow discoloration of sclera and skin dark urine that is the color of tea or a cola drink excessive upper or lower bowel gas rectal pain rectal discharge rectal itching lump in groin or scrotum |
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what questions should be asked about a patient's urinary tract?
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increased urinary frequency
burning with urination nocturia need to urinate suddenly and urgently loss of urinary control bloody urine particulate matter in urine slow to get urinary stream started |
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what questions should be asked about a man's genitals?
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urethral discharge
penile sores or growths painful or swollen testicle impotence blood ejaculation retrograde ejaculation into bladder premature ejaculation decreased libido |
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what questions should be asked about a woman's genitals?
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vaginal discharge
sores or lumps on genitals painful menses absence of menses irregular or heavy menses hot flashes decreased libido painful intercourse nonorgasmic |
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what questions should be asked about a patient's neurologic health?
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cranial nerves
motor nerves numbness tingling sensation in extremities decreased or absent sensation tremor loss of balance difficulty walking seizures |
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what questions should be asked about a patient's psychiatric health?
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bizarre, unrealistic thoughts
depression mania poor judgment orientation memory attention concentration inability to get to sleep or to stay asleep hypersomnolence (sleeping too much) nightmares anhedonia (finding no joy in life) suicidal thoughts anxiety nervousness symptoms without an explanation |
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what does the acronym CLOSER mean?
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important things to take note of for the history of present illness
C – Characteristics (quality, severity) L – Location and radiation O – Onset and duration (gradual, sudden, continuous, progressive, intermittent) S – Symptoms associated with the concern E – Exacerbating factors R – Relieving factors (include what the patient has tried as therapeutic maneuvers) |
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in what order should a ROS be performed?
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general/constitutional
neurologic eyes ENT head/neck endocrine hematopoietic musculoskeletal integument breasts cardiovascular respiratory GI urinary genital psychiatric |
