Midterm NR569 Differential Dx – Questions With
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Terms in this set (62)
comprehensive assessment health history and complete physical examination,
usually conducted when a patient first enters a health
care setting; provides a baseline for comparing later
assessment
focused assessment assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
Subjective information includes - 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: vital signs, physical exam, orders/results
components of comprehensive health ● Identifying data and source of the history; reliability
history ● Chief complaint(s)
● Present illness
● Past history
● Family history
● Personal and social history
● Review of systems
Chief Complaint The primary symptom or concern causing the patient
to seek care. This may be only 1 or 2 concerns
, History of Presents Illness (HPI) ● 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 Documents presence or absence of common
symptoms related to each major body system
components of medical history 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 ● 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.
Detailed Solutions
Save Groups
Terms in this set (62)
comprehensive assessment health history and complete physical examination,
usually conducted when a patient first enters a health
care setting; provides a baseline for comparing later
assessment
focused assessment assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
Subjective information includes - 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: vital signs, physical exam, orders/results
components of comprehensive health ● Identifying data and source of the history; reliability
history ● Chief complaint(s)
● Present illness
● Past history
● Family history
● Personal and social history
● Review of systems
Chief Complaint The primary symptom or concern causing the patient
to seek care. This may be only 1 or 2 concerns
, History of Presents Illness (HPI) ● 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 Documents presence or absence of common
symptoms related to each major body system
components of medical history 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 ● 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.
