2nd semester phys diag week 1 & 2
Terms
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- Format of the history and physical 14 components
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1 Source and reliabiliyt
2 Chief complaint
3 History of present Illness
4 Past medical History
5 Occupational and environmental History
6 Biographic Information (race, sex, ethnicity)
7 Family History
8 Psychosocial History (education, relationships, etc)
9 Sexual, reproductive, gynecologic history
10 review of symptoms
11 Physical Exam
12 Laboratory Data
13 Problem List
14 Assessment and plan - 4 components to include in HPI
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1 the patient's symptoms chronologically
2 Pertinent past history-previous medical evaluation
3 Pertinent positive and negatives
4 Affects of the illness on the patient's quality of life - 9 components of Past Medical History
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1 All past illnesses
2 All prior hospitalizations and Dates
3 All prior surgery and dates
4 Allergies--Type Reaction
5 Immunizations
6 All medications and dosages--DO NOT forget OTC and HERBAL
7 Substance Abuse
8 Transfusions
9 Smoking and Alcohol - Components of personal Profile, 7
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1 Social History--Birthplace, education, religion, residencies
2 Family Relationships--Single, married, divorced
3 Average Day
4 Occupational History--All
5 Habits--Exercise, Diet
6 Stress and Support
7 Self Care - Review of systems--name the systems (20, inc general)
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1 General
2 Skin
3 Head
4 Eyes
5 Ears
6 Nose
7 Mouth, throat
8 Neck
9 Chest
10 Heart
11 Breasts
12 Gastrointestinal
13 urinary
14 Genitalia
15 Extremities
16 Musculoskeletal
17 Neurological
18 Psychiatric
19 Endocrine
20 Hematologic - ROS General questions, 5
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1 Appetite
2 Weight
3 Fever
4 Chills
5 Night Sweats - ROS Skin questions, 4
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1 Rashes
2 Itching
3 Dryness
4 Changes - ROS head questions, 3
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1 Headache
2 Dizziness
3 Fainting - ROS Eyes questions, 5
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1 Glasses
2 Vision
3 Redness
4 Pain
5 Glaucoma - ROS ears questions, 3
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1 Hearing
2 Infections
3 Discharge - ROS nose questions, 4
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1 bleeding
2 congestion
3 pain
4 sense of smell - ROS mouth and throat questions, 4
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1 Teeth
2 Bleeding gums
3 Sore throat
4 hoarseness - ROS neck questions, 3
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1 Lumps
2 Swollen glands
3 Goiter - ROS chest (lungs) questions, 3
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1 Cough
2 Shortness of Breath
3 Sputum - ROS heart questions, 4
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1 Pain
2 Pressure
3 Palpitations
4 Swelling - ROS breasts, 3
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1 Lumps
2 Pain
3 Discharge - ROS GI, 7
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1 Nausea
2 Vomiting
3 pain
4 Jaundice
5 bloating
6 constipation
7 diarrhea - ROS urinary, 5
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1 infection
2 pain
3 discharge
4 frequency
5 nocturia - ROS genitalia, 5
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1 lesions
2 discharge
3 itching
4 hernias
5 menarche - ROS extremities, 4
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1 joint pain
2 muscle pain
3 stiffness
4 cramps - ROS neurological, 5
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1 fainting
2 dizziness
3 numbness
4 tingling
5 tremor - ROS psychiatric, 4
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1 mood
2 anxiety
3 hallucinations
4 impulse control - ROS endocrine, 3
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1 Excessive thirst
2 Poor wound healing
3 heat or cold intolerance - ROS hematologic, 3
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1 easy bruising
2 bleeding
3 fatigue - four principles of physical exam
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1 inspection
2 palpation
3 percussion
4 auscultation - Steps of the physical exam as described in notes, 11
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1 Have patient dressed appropriately
2 Wash your hands
3 Perform exam in presence of a chaperone
4 begin with the vital signs
5 Respect patient's privacy
6 Speak to patient--good time to review history, remember missed questions
7 Do not comment on exam as it is performed
8 Review the precautions to take during exam swartz p 88
9 try to perform exam in least number positions
10 Keep the pt comfortable
11 Inform patient when exam completed - Recording data from physical exam, 3 steps
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1 Record vital signs: BP, HR, T, R
2 Describe what you see, i.e. a well developed well nourished patient
3 Recod findings as they relate to each major organ system