with correct answers
Initial Approach and History Taking Correct Answer-Hi, my name is
Samantha. I am the registered nurse that will be completing your
physical exam. I am just going to gather my supplies and then we will
get started.
Perform hand hygiene.
Needed supplies: gloves, alcohol swabs, cotton ball, cotton swab, tongue
depressor, ophthalmoscope, otoscope, reflex hammer, stethoscope
Initial Approach and History Taking Correct Answer-Obtain patient
identification information.
Can you tell me your name and date of birth?
How old are you?
Gender?
Race?
Initial Approach and History Taking Correct Answer-What brings you in
today? Are you having any pain or other issues?
Can you tell me more about the pain.
Use OPQRST
Onset: when did the symptoms first begin? Was it gradual or sudden?
Provocative or Palliative: What were you doing when the symptoms
started? what makes it better?
Quality and Quantity: Can yo describe the pain?
,Region or Radiation: can you point to where the pain is at? Does it
radiate anywhere?
Severity: how bad is the pain right now on a scale of 0-10? what is the
worst it has been?
Timing and Treatment: how long do the symptoms last? Are they
intermittent or does it come and go? Is there anything you are doing for
the pain?
Past Medical History Correct Answer-Must complete by memory!
-General Health: when was your last physical exam? Do you know the
date? Were there any concerns?
-Chronic Illnesses: do you have any chronic medical conditions? If so,
when did they start and how were/are they being treated?
-Do you have a known history of any infectious diseases? If so, what
and how were/are they treated?
-Do you have any allergies? To medication, food or environmental?
-Have you ever had surgery? If so, what surgery? Were there
complications? Did they use anesthesia?
-Have you ever had any injuries?
,-Have you ever been hospitalized? If so, for what?
-Are all of your immunizations up to date? Including your childhood,
Tdap, Influenza and COVID vaccines?
-If female, do you see a gynecologist? When was your last well woman
exam? When was your last PAP Smear? Do you complete monthly self
breast exams? When was your last period?
-If male, do you complete monthly testicular exams?
Sexual History: The 5 Ps Correct Answer-Partners: Are you currently
having sex? How many partners do you currently have? Are you or your
partner having sex with others?
Practices: What kind of sex do you participate in? Oral, genital or anal?
Protection: Do you and your partner(s) use protection? What kind? Have
you received the HPV or Hepatitis A/B vaccines? If applicable, do you
use pre-exposure prophylactic medications or PrEp?
Past STIs: Have you ever been tested for STIs or HIV? Have you ever
been diagnosed with an STI or HIV? If so, did you get treatment? Do
your partner(s) have STIs?
, Pregnancy: Do you have intentions of getting pregnant? If not, are you
using measures to prevent it?
Family History Correct Answer-Can you please tell me the health status,
age, and if applicable the cause of death for the following family
members:
-Paternal grandparents
-Maternal grandparents
-Mother
-Father
-Siblings
-Children
Family History Disease Presence Correct Answer-Next, I am going to
name some diseases. Please tell me if there is a presence of the named
disease in your grandparents, parents, siblings or children.
-Cancer or Bleeding Disorders
-Neurological Disease
-Seizures
-Mental/Emotional Health Disorders
-Substance Abuse
-Endocrine Disease
-Cardiovascular Disease
-Pulmonary Disease
-Obesity