Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/20

Click to flip

20 Cards in this Set

  • Front
  • Back
Whats in a Comprehensive H&P (History)?
-Date & Time
-Identifying Data
-Reliability
-Complaint
-History of Present Illness (HPI)
-Medications
-Allergies
-Past Medical History (PMHx)
-Family History (FamHx)
-Personal/Social Hx (socHx)
-Review of Systems (ROS)
Date & Time whats the deal?
-Always important to document the date & time of the patient encounter.
-Medico-legal issues especially important to document.
Identifying data?
-Gender
-Marital status
-Occupation
-Source of History
-Source of the referral
Reliability?
-Document only if relevant.
-Especially important in medico-legal cases, workman's comp, etc.
-Is the history obtained from a competent patient or are they incompetent mentally OR are they using falsehoods for gain?
Chief Complaint.
-Use the patients own words.
"I have a headache"
-If no CC, use the reason they are in the office.
"I am here for my sports exam.
Present Illness - History of Present Ilness - HPI
-Obtain a complete, clear & chronological account of the problems of the CC
What are the Seven attributes of a symptom
1. Location: Where is it and does it radiate?
2. Quality: What is it like? Compare to known quality.
3. Quanitity or severity? pain scale 1-10
4. Timing: when? How long? Frequency?
5. Setting: environment, activities, emotional reactions, other contributing info?
6. Remitting or exacerbating factors: better or worse?
7. Associated manifestations.
OLD CARTS
O-Onset
L-Location
D-Duration
C-Character
A-Aggravating/Alleviating Factors
R-Radiation
T-Timing
OPQRST
O-Onset
P-Palliating/Provoking Factors
Q-Quality
R-Radiation
S-Site
T-Timing
Medications
-List the medication allergies along with the reaction (e.g. PCN gives me hives or E-mycin gives me SOB & throat closes)
-Medication intolerance (e.g. ASA gives me heartburn)
Past Medical History
-Childhood Illness
-Adult Illness
-Surgeries
-Immunizations
-Screening tests
Family History
-Outline age & health of the immediate family then other family members with pertinent hx
-Document age of death and cause.
Personal/Social History
-Use of alcohol, drugs, sexual orientation, living situation, diet/exercise routine (or lack thereof), support structure, safety measures (e.g. seatbelts, yearly physicals)
-Smoking-calculate the number of pack years (e.g. 1.5 ppd * 12 years = 18 pack years)
Review of Systems (ROS)
-IMPORTANT FOR documentation!
-Reviews list of body systems looking for positives as well as important negatives to assist in the diagnosis of the CC.
-Basically everything that you will be checking on the physical exam, you will ask about in review of systems.
Physical Exam
-General Survey
-Vital Signs
-Head, Eyes, Ear, Nose, Throat (HEENT)
-Neck/back/Upper Extremites
-Posterior Thorax and Lungs
-Breast,Axillae, and nodes
-Anterior Thorax and Lungs
-Heart (cardiovascular system)
-Abdomen
-Lower Extremtites*
-Nervous System
-GU/Rectal exam (male)
-GU/Rectal exam (female)
-Osteopathic Exam: (T.A.R.T - Tenderness, Asymmetry, Restriction, Tissue texture change)
SOAP note
S-Subjective
O-Objective
A-Assessment
P-Plan

Problem focused exam on an established patient.
Subjective
-What the patient tells you or chief complaint
-Includes HPI, ROS
Objective
-What you find on exam.
-VS
-Skin
-HEENT
-Heart
-Lungs
-ABD
-Musculoskeletal/Osteopathic
Assessment
-What is the diagnosis of the signs, symptoms and exam of the chief complaint?
-Should give at least 3-4 DDx in assessment (especially for boards/COMLEX 2 PE)-more on that later.
Plan
-What are you going to do to fix the chief complaint
-Match up assessment with plan for better organization documentation.