QUESTIONS WITH ANSWERS
◉focused assessment. Answer: assessment conducted to assess a
specific problem; focuses on pertinent history and body regions
◉Subjective information includes. Answer: - Chief complaint: main
reason for the visit
- HPI: the story of the chief complaint
- ROS: a checklist of symptoms from all body systems
◉Objective information includes:. Answer: vital signs, physical exam,
orders/results
◉components of comprehensive health history. Answer: ●
Identifying data and source of the history; reliability
● Chief complaint(s)
● Present illness
● Past history
● Family history
● Personal and social history
,● Review of systems
◉Chief Complaint. Answer: The primary symptom or concern
causing the patient to seek care. This may be only 1 or 2 concerns
◉History of Presents Illness (HPI). Answer: ● Amplifies the CC;
describes the clear and concise chronology of events as to how each
symptoms developed.
● includes pt thoughts and feelings about the illness
● pulls in relevant portions of the ROS, called "pertinent positives
and negatives"
◉Review of Systems. Answer: Documents presence or absence of
common symptoms related to each major body system
◉components of medical history. Answer: Medical diagnosis
Previous physical examination findings
History of symptoms
Recent illness, hospitalization, new medical diagnoses, or surgical
procedures
Orthopedic problems
Medication use including supplements and drug allergies
Other habits including caffeine, alcohol, tobacco, or drug use
, Exercise history
Work history
Family history
◉Attributes of a Symptoms. Answer: ● Location
● Quality
● Quantity or severity
● Timing including:
● Onset
● Duration
● Frequency
● Modifying factors
● Associated Manifestations- other s/s that occur when he problem,
symptom or pain occurs.
◉Mnemonic for characterizing the Chief complaint. Answer:
OLDCARTS
● Onset
● Location
● Duration
● Character
● Aggravating or Alleviating Factors