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130 Cards in this Set
- Front
- Back
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History and Physical (H&P) Template |
History of Present Illness (HPI) Review of Symptoms (ROS) Past History Physical Exam (PE) Hospital Course Assessment and Plan (A/P) |
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Which of the H&P parts are subjective? Objective? |
Subjective: HPI, ROS Objective: PE, Hospital Course, A/P |
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When is H&P filled out? |
First day of admission to inpatient |
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History of Present Illness |
The story and context of the chief complaint |
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Review of Systems |
List of all pertinent positive and negative symptoms |
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Past History (PMSHx, SHx, FHx) |
Past diseases/surgeries, tobacco/EtOH |
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Physical Examination (PE) |
Physician's objective findings |
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Hospital Course |
Objective results (XRs, Labs), re-eval, consults Re-evals are changes in condition after treatment |
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Assessment and Plan (A/P) |
List of all DDx, comorbidities, and treatment plan |
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General Progress Note Template |
Subjective Summary Physical Examination (PE): same Hospital Course: Any new results Assessment and Plan (A/P): same |
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When is the progress note filled out? |
Every day after the admission until discharge. |
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Subjective Summary |
Quick check up: Update on Patient Status Complaints, appetite, ability to ambutate |
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Rounding vs Progress Note |
Rounding is the act of taking progress notes, but the official name of the chart is 'Progress Note' |
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General Discharge Summary Template |
Admitting Dx Discharge Dx Hospital Course Discharge Plan Medication Reconciliation |
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When is general discharge filled out? |
Last day of admission |
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Admitting Dx |
Patient's chief complaint on admission |
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Discharge Dx |
List of all final Dx and co-morbidities |
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Hospital Course (discharge) |
Detailed summary of all objective findings, procedures, consultations, and treatments throughout admission |
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Discharge Plan |
Instructions for patient diet, activity, follow-up |
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Medication Reconciliation |
Updated list of medications patient will be discharged on |
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Where to document what? |
Pt complaints ---> HPI or ROS Past Dx or surgery ---> Past History *Top 2 are subjective as they come from patient's mouth* Physician's observation --> PE Diagnoses --> A/P |
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Vital Signs |
BP: 90/60 - 140/90 HR: 60-100 BPM Respiratory Rate: 12-18 breath per min Temp: 98.6F/37C (100.4F is fever) O2 Sat: SpO2 100% - 96% |
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PMHx |
Past Medical History, all conditions/illnesses discussed by patient during interview (all the conditions in this flashcard set) You'll be given the laymen's term and must recall the medical term |
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Gastrointestinal PMHx List |
Reflux Ulcer Pancreatitis Hepatitis Diverticulitis Chron's/UC Irritable Bowel |
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Reflux |
Gastroesophageal Reflux Disease (GERD) |
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Ulcer |
Gastric Ulcer or Peptic Ulcer Disease (PUD) |
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Pancreatitis |
Pancreatitis |
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Hepatitis |
Hepatitis A, B, C |
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Diverticulitis |
Diverticulitis |
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Chron's/UC |
Chron's Disease or Ulcerative Colitis (UC) |
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Irritable Bowel |
Irritable Bowel Syndrome (IBS) |
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Itis means... |
Inflammation |
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Genitourinary (GU) PMHx List |
Bladder infection Kidney infection Stones Dialysis Enlarged Prostate |
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Bladder infection |
Urinary Tract Infection (UTI) |
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Kidney infection |
Pyelonephritis (Pyelo) |
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Stones |
Renal Calculi |
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Dialysis |
Chronic Renal Failure (CRF) or End-stage Renal Disease (ESRD) |
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Enlarged Prostate |
Benign prostatic hyperplasia (BPH) |
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Gynecological PMHx |
Gravida/Para/Abortion (GPA) |
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Gravida/Para/Abortion (GPA) |
Gravida: # times pregnant + current Para: # live births Abortion: Miscarriage and elective |
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Neurological PMHx List |
Stroke Mini-stroke Seizures |
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Stroke |
Cerebrovascular Accident (CVA) Entails permanent damage Can be hemorrhagic (bleeding) or ischemic (clot) |
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Mini-stroke |
Transient Ischemic Attack (TIA) Non-permanent Damage |
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Seizures |
Seizure Disorder / Epilepsy Lots of different reasons, record it if doctor asked patient |
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Psychological PMHx List |
Bipolar Schizophrenia Drink a lot Drugs |
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Bipolar |
Bipolar disorder |
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Schizophrenia |
Schizophrenia |
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Drink a lot |
EtOH abuse |
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Drugs |
Substance abuse |
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Vascular PMHx List |
"Blood clot in my leg" "Bulge in my aorta" or "triple A" "Bad blood flow to my legs" "Numbness in my legs" |
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"Blood clot in my leg" |
Lower Extremity Deep Vein Thrombosis (DVT) |
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"Bulge in my aorta" or "triple A" |
Abdominal Aortic Aneurysm (AAA) |
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"Bad blood flow to my legs" |
Peripheral Vascular Disease (PVD) |
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"Numbness in my legs" |
Peripheral Neuropathy |
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Musculoskeletal PMHx List |
Low back pain Bulging/herniated disk Arthritis Joint pain (chronic) Weak/fragile bones |
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Chronic vs Acute in PMHx |
Chronic and acute symptom will be probably differentiated in the interview. Record if chronic or not, as chronic conditions will be put in PMHx. |
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Low back pain |
Chronic low back pain |
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Bulging/herniated disc |
Degenerative Disc Disease (DDD) |
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Arthritis |
Usually Osteoarthritis (OA), sometimes Rheumatoid Arthritis (RA) |
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Joint pain (chronic) |
Degenerative Joint Disease (DJD) |
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Weak/fragile bones |
Often Osteoporosis |
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Cancer PMHx List |
Cancer Spread to my... Chemo Radiation They cut it out It's gone |
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Cancer |
Cancer or Carcinoma (CA) Record whether its brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, or lymphoma |
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Spread to my... |
With metastases to the... |
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Chemo |
Chemotherapy |
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Radiation |
Radiation Therapy |
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They cut it out |
Status-post surgical resection |
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It's gone |
In remission |
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PSHx |
Past Surgical History Often will have -ectomy (removal) |
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Tonsils removed |
Tonsillectomy |
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Adenoids removed |
Adenoidectomy |
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Ear tubes |
Pressure equalizer (P.E.) tubes |
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Heart bypass |
Coronary Artery Bypass Graft (CABG) Indicates patient had CAD (record on PMHx too) CABG is adding another blood vessel to heart Double/triple bypass means 2/3 valves |
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Stents |
Coronary Stents Indicates patient had CAD |
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Heart cath |
Cardiac catheterization |
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Balloon |
Angioplasty Got rid of plague build up in artery by inflating balloon inside Indicates CAD, BUT NOT ALWAYS THE CASE |
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Valve surgery |
Valve repair or replacement (bovine vs mechanical) |
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Pacer |
Pacemaker |
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Defribillator |
Automatic Implanted Cardiac Defibrillator (AICD) |
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Pacer vs. Defribillator |
The pacer prevents an arrhythmic heart Defibrillator will shock the heart back up if it stops Patients will often confuse one for the other, so must clarify Sometimes, one device will have both functions |
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Surgery for afib |
Afib s/p cardiac ablation |
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Appendix removed |
Appendectomy |
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Gallbladder removed |
Cholecystectomy |
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Hernia repair |
Herniorraphy |
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Part of my colon removed |
Partial colectomy |
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Bag to collect stool |
Colostomy (often confused with partial colectomy) |
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Spleen removed |
Splenectomy |
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Stomach stapled |
Gastric bypass Many different kinds (areas) of gastric bypass. Important to consider for later treatment. |
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Exploratory |
Exploratory Laproscropy (ExLap) Strictly for exploration (camera), no operation |
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Kidney removed |
Nephrectomy |
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Uterus removed |
Hysterectomy (partial vs total) |
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Ovary removed |
Oophorectomy |
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Ovary and Fallopian tubes removed |
Salpingo-oophorectomy (on final) |
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Tubes tied |
Tubal ligation (female) or Vasectomy (male) |
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C-Section |
Cesarean Section |
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Prostate removed |
Prostatectomy (most often Trans-Urethral Removal of the Prostate or TURP) |
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Uterine product removed |
Dilation and curettage (D&C) Remove anything including miscarriage tissue |
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Neck artery cleaned |
Carotid Endarterectomy Still considered neurological PSHx because carotid is brain's blood supply |
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Brain surgery |
Craniotomy (brain bleed vs brain CA) |
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Shunt |
Ventriculoperitoneal (VP) Shunt Excess brain fluid causing too much pressure is released into abdomen |
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Why are details of orthopedic PSHx not always important? |
Because orthopedic surgery hardly ever causes complication for future treatment except leg amputation |
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Leg amputated |
Above Knee Amputation (AKA) Below Knee Amputation (BKA) |
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Joint repair |
Anthroplasty |
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Metal plates/pins |
Hardware |
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Neck fused |
Cervical spinal fusion |
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Back fused |
Lumbar spinal fusion |
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Hip surgery |
Open Reduction with Internal Fixation (ORIF) |
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What is FHx and why is it important? |
Family history, good to know what conditions patient are susceptible to and exposed to |
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General FHx Conditions |
Hypertension (HTN) Diabetes Mellitus (DM) Cancer or carcinoma (CA) MI/CAD if family member had before 55 |
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Tobacco use |
Smoking status Current (#ppd, #yrs) Former (year quit) Never Second-hand exposure (pediatrics) |
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Alcohol use |
Find how often they drink 'Daily' drinker is wide range |
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Illicit drug use |
Find route of administration If it's IVDA, ask for details because it's infection |
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Occupation |
Job can relate to symptoms |
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Living circumstances |
Must know support system for older people for future planning (rehab, care home, home) |
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Pediatrics |
If caretaker not mom/dad, then note Exposure to siblings/other children can cause illness *Immunizations important* |
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High BP
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HTN
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High Cholesterol
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HLD
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Thyroid Problem
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Usually hypothyroidism, sometimes hyper
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Diabetes
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DM
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"Only pills"
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NIDDM
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"Insulin"
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IDDM
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Heart Disease
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CAD
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Heart Attack
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MI + CAD
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Heart Failure
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CHF
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Irregular Heartbeat
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A fib
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Murmur
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Heart murmur
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Episodes of abnormal fast/racing heartbeat
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Supraventricular Tachycardia (SVT)
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Asthma
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Asthma
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Emphysema/Chronic Bronchitis
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COPD
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Blood clot in lung
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PE
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