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34 Cards in this Set
- Front
- Back
- 3rd side (hint)
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RECORDING INFORMATION (6)
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Date
Time Place Author Refering Physician Occasion |
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SOURCE AND RELIABILITY (2)
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Interview Source
Reliability of History |
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PATIENT PROFILE (7)
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Name
Age Race Sex Marital Status City of Residence Occupation |
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CHIEF COMPLAINT (1)
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Identify Patient Problem(s)
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HISTORY OF PRESENT ILLNESS (8)
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Body Location
Quality Quantity Chronology Setting Aggravating Factors Alleviating Factors Associated Manifestations |
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PAST MEDICAL HISTORY (11)
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General Health
Childhood Health Major illnesses Surgeries Accidents and injuries Obstetrical History Screening Tests Immunizations Medical allergies Current Meds Current Treatment Modalities |
You
Medical |
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FAMILY HISTORY
Ages & Health of: |
Ages & Health of
Father & Mother Siblings Spouse & Children |
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FAMILY HISTORY (18)
DISEASE SCREENING |
Epilepsy
Glaucoma Mental disease Headaches Stroke Bleeding Anemia - sickle cell Hypertension Heart problems Respiration TB Intestinal problems Kidney disease Cancer Diabetes Arthritis Gout Symptomes like patient |
Head
Heart/Blood Breathing Abdominal Overall |
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PERSONAL-SOCIAL HISTORY (2)
HOME ENVIRONMENT |
Past Residence(s)
Home Atmosphere |
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PERSONAL-SOCIAL HISTORY (6)
SOCIAL ACTIVITIES |
Education History
Work History Military History Community Activities Religious Activities Friendships |
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PERSONAL-SOCIAL HISTORY (6)
MARITAL – SEXUAL |
Marriages, duration
Marital Satisfaction Sexual Adjustment Sexual Orientation Use of Contraceptives AIDS Prevention |
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PERSONAL-SOCIAL HISTORY (8)
PERSONAL HABITS |
Sleep
Relaxation Exercise Dietary intake Caffeine Alcohol use/abuse Smoking-tobacco use Drug use/abuse |
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REVIEW OF SYSTEMS
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REVIEW OF SYSTEMS
General (6) |
Fatigue
Weakness Weight Change Fever Chills Night Sweats |
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INTEGUMENT (12)
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Color
Pigmentation Scaling – Dryness Rash Hives – Pruritus Lesions Bleeding Nail Growth Nail Texture Hair Growth Hair Texture Hair Distribution |
Skin (7)
Nail (2) Hair (3) |
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HEAD (5)
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Headache
Dizziness Syncope Convulsion History of Trauma |
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EYES (9)
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Visual Acuity
Eye glasses or contacts Blurring Diplopia Pain Redness Tearing Glaucoma Cataracts |
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EARS (5)
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Hearing
Tinnitus Vertigo Earaches Discharge |
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NOSE (6)
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Frequent Colds
Sinus trouble Hay Fever – Allergies Discharge Nosebleeds Change in Smell |
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THROAT AND MOUTH (10)
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Last Dental Exam
Toothache Dentures Bleeding Gums Sores – Lesions Taste Breath Recurrent Infections Sore Throats Hoarseness |
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NECK (4)
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Swelling – Lumps
Goiter Pain Limitation of movement |
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BREASTS (6)
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Pain
Masses Nipple Discharge Self Breast Exam Last Breast (non-self) Last Mammogram |
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RESPIRATORY (14)
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Pleurisy – Chest Pain
SOB DOE Cough Sputum Production Hemoptysis Asthma Wheezing Bronchitis Emphysema Pneumonia Tuberculosis Night Sweats Last Chest X-Ray |
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CARDIOVASCULAR (14)
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Increased cholesterol
Last EKG Palpitations Heart Murmurs Hypertension Chest Pain Angina Rheumatic Fever Dyspnea Dyspnea on Exertion (DOE) Paroxysmal nocturnal dyspnea (PND) Orthopnea Diaphoresis Edema |
Tests (2)
Heart (6) SOB (4) Other (2) |
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PERIPHERAL VASCULAR (5)
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Leg cramps
Intermittent claudication Varicose veins Thrombophlebitis Raynaud’s phenomenon |
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GASTROINTESTINAL (20)
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Abdominal Pain
Appetite – Food intolerance Weight Change Belching, Reflux Nausea, Vomiting Hematemesis Eructation – Flatulence Diarrhea, Constipation Frequency of Bowel Movements Change in Bowel Movements Hx Laxative use Melena, Hematochezia Steatorrhea Jaundice Hepatitis Cholecystitis Diverticulitis Polyps Hemorrhoids History Upper GI, Barium Enema, Colonoscopy |
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GENITOURINARY (11)
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Frequency of urination
Polyuria Nocturia Dysuria Hematuria Urgency Hesitancy Force of Stream Incontinence History of Infections History of Stones |
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MALE GENITAL TRACT (10)
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Discharge
Lesions History of STD and treatment Hernia Testicular Pain Testicular Masses History of Self – Testicular Exam History of vasectomy Sexual Libido – Intercourse Erection - Ejaculation |
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FEMALE GENITAL TRACT (18)
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Age of Menarche
LMP Regularity Duration/Amount of bleeding Metrorrhagia Dysmenorrhea Discharge/Odor/Irritation Lesions History of STDs and treatment Last Pap/results PMS symptoms Gravida/para/ab Complications of Pregnancy Contraception Age at Menopause Menopausal symptoms Post Menopausal Bleeding Dyspareunia/Libido/Satisfaction |
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MUSCULOSKELETAL (10)
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Joint Pain
Stiffness Weakness Muscle Pain Muscle Cramps Limitations of movement Arthritis Gout Back Pain Disability |
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HEMATOPOIETIC (7)
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Anemia
Fatigue Epistaxis Easy bruising - bleeding Past Transfusions - Reactions Lymphadenopathy HIV Serology |
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ENDOCRINE - METABOLIC (12)
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Growth and Development
Thyroid Trouble Temperature intolerance Diaphoresis Hair Growth and Patterns History of Diabetes Polyuria Polyphagia Polydipsia Galactorrhea History of Gout Increased Cholesterol |
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NERVOUS (11)
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Syncope – Fainting
Seizures Weakness Paralysis Numbness Tingling Tremors Involuntary movements Ataxia Dysphonia History of Stroke |
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PSYCHIATRIC (7)
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Nervousness – Anxiety
Insomnia Mood Memory Personality – Behavior Change History of Depression and Suicide History of Psych Evaluation |
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