Hi I'm a med student, so I think I may be able to help. We are trained to ask these questions or similar in most cases, however many of the questions vary depending on the trauma, disease, illness.
CC: chief complaint (why you are there)
HPI (history of present illness): includes 7 attributes of a symptom
1. cronology (when did it start)
2. location (where did it start, is there any radiation or movement to another body part)
3. quality (how does it feel: sharp, stabbing, burning ect.)
4. quantity (how many times per day, pain on a scale of 1-10 with 10 as the worst)
5. Aggrivating Factors (things that make it worse)
6. Aleviating Factors (things that make it better)
7. Precipitating factors (something you may have done to cause the illness, strain, over working, other things).
The HPI also includes questions to try to gain more information about the illness and the 7 questions listed above.
Medications they are currently taking: perscription, over the counter (aspirin, tylenol, ibprofen, vitamines, and others), herbal or nutritional supplements
Allergies: Seasonal, Drug Allergies: to what and what happens
PMHx: Past Medical History
Major Illnesses
Hospitalizations: any time for anything (trauma, child birth, surgeries, and other things).
Major injuries
Trauma (bone breaks, car accidents and other things)
Immunizations
Current Disease States: do you have........(any number of things, Diabetes, high blood pressure, heart disease, strokes, seizures, depression) anything you are being treated for, they will ask the history of these and treatments you have tried
Personal History:
Home life
Pets
Who do you live with
Military History
Travel History
Where were you born
Alcohol use: how much, how often
Drug use: how much, how often
Smoking or tobacco use: how much, how often
Sexual history: diseases, preferences (men, women, both)
Family History:
Parents/ Grandparents/ Syblings/ Children: medical conditions and treatments, age of death, complications
Other Relatives with similar diseases to what you are in with
ROS: Review of systoms: this is a run through of the other body systems to find symptoms you may have missed. We start at the head and work down.
General: nausea, vomiting, fever, chills, diarrhea, constipation
Head, Ears, Eyes, Nose, Throat: problems with headaches, head pain, ringing in the ears, problems hearing, ear pain, dizziness, is the room spinning, blurred vision, black spots in vision, eye pain, runny nose, bleeding nose, polyps in the nose, trouble breathing through nose, sore throat, difficulty swollowing, pain with swollowing, heart burn, mouth pain, dental pain, tongue pain, lesions in the mouth
Cardiac: Heart
palpitations, fast heart rate, heart problems, pain, shortness of breath
Lungs:
shortness of breath, trouble breathing while laying down or getting up, do you have to sit on the side of the bed at night because you can't breathe, get winded easily, pain with breathing
GI: gasterointestinal
Heart burn, vomiting blood, cramps, stomach pain, intestinal pain, abdominal pain, bloating, gas, blood in the stool, color of the stool, consistency of the stool, pain with defication, incontinance
GU: genitourinary
problems urinating, blood in the urine, painful urination, color of urine, odor of urine, incontinance, problems with menstruation, cramps, burning, frequency or urgency to urinate, genital problems
Skin:
rashes, lesions, hair problems, nail problems, odd moles
Endocrine:
heat or cold intolerance, changes in feeling or sensation in hands aand feet, feel thirsty alot, get up to the bathroom at night frequently, frequent urination during the day time
Musculo-Skeletal:
bone pain, joint pain, inflammations or swelling, muscle pain, soreness in muscles or bones
These are not necessarily the questions they will be asked they may be asked others or not even this many. Hope this helps
2007-01-18 13:26:07
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answer #1
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answered by med student 2
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