History Of Present Illness Question

Front 1

Cardiac

Back 1

I need to know what the PT was doing when the symptoms began;

…what if anything makes it feel better or worse;

…the patient’s description of the symptoms;

…if there is radiating or referred pain;

…a rating on a scale of 1-10;

… when the symptoms begin and how long they continued;

…whether or not the patient has done anything to correct the problem.
(7)

Front 2

Respiratory

I need to know…

Back 2

…what the PT was doing when the symptoms began;

… if anything makes it feel better or worse;

…the patient’s description of the symptoms;

…if there is radiating or referred pain;

…a rating on a scale of 1-10;

… when the symptoms begin and how long they continued;

…whether or not the patient has done anything to correct the problem.
(7)

Front 3

AMS

I need to know…

Back 3

… how the PT was behaving;

…what the patient was doing when the episode began;

…how long it continued or how it has been going on;

…whether anything else is bothering the patient;

…if the patient has injured his or herself;

…if the patient had a seizure;

…if the pt has a fever;

… what if anything has been done to correct the problem.

Front 4

Allergic Reaction

I need to know...

Back 4

...about allergies;

…what the PT was exposed to;

…how the PT was exposed;

…the symptoms;

…how fast the symptoms came on;

… what if any has been done to correct the problem.
(6)

Front 5

Poisoning/Overdose

I need to know...

Back 5

... what the pt ingested or he was exposed to;

…when the ingestion /exposure occurred;

… how much was ingested or the extent of exposure;

…over what period;

…the weight of the pt;

… what if anything has been done to correct the problem.
(6)

Front 6

Environmental Emergency

I need to know...

Back 6

the source of the pt’s exposure;

…identify the type of environmental exposure;

… the duration of exposure;

… did the pt lose consciousness;

…whether the injury is systemic or local.
(5)

Front 7

OBY

I need to...

Back 7

...confirm pregnancy;

…the length of the pregnancy;

… if there is pain or contractions;

…if there is bleeding or discharge;

…if her water has broken;

… if she has the need to push/ or to have a bowel movement;

…when she had her last menstrual period.
(7)

Front 8

Behavioral

I need to know ...

Back 8

...how the pt “feels;”

…if the pt has ideations of suicide;

…if the pt is a threat to himself or others;

…is there an underlying medical problem;

… what if anything has been done to correct the problem.
(3)