Physical Examination and History Taking Quiz 1
Questions all answered correctly
Subjective Data
What the patient tells you
Objective Data
What you detect during the examination.All physical examination findings.
Identifying data
age, gender, occupation,marital status
Source of the history
—
the patient, but can be a family member or friend, letter of referral, or the medical record
Reliability
The one or more symptoms or concerns causing the patient to seek care
Present Illness
Amplifies the Chief Complaint;Includes patient's thoughts and feelings about the illness
●Pulls in relevant portions of the
Review of Systems,called "pertinent positives and negatives" (see p. 10)
●May include medications, allergies,
habits of smoking and alcohol,which are frequently pertinent to the present illness
describes how each symptom developed
Past History
Childhood Illness Measles, rubella, mumps, whooping cough, chicken pox
Chronic childhood illnesses: asthma, diabetes
●Lists adult illnesses with dates for at least four categories:medical; surgical; obstetric/gynecologic; and
psychiatric
●Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and
home safety
Family History
●Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents
●Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery
disease, HTN,CAD
Hypercholesterolemia, Stroke, DM, Thyroid Dz
, Renal Dz, CA, Arthritis, TB, Asthma, HA
Seizure, Psych, Drug/ETOH addiction
Personal and Social History
Describes educational level, family of origin, curren thousehold, personal interests, and lifestyle.Living
situation,Significant other
Sources of stress,Important life experiences
Present job, Religious affiliation, ADL
Review of Systems
Documents presence or absence of common symptoms related to each major body system
Chief Complaint
Make every attempt to quote the patient's own words Ex: I have had chest pain for the past 3 hours and
I feel like I can't breath
Sometimes the patient may not have a complaint and will instead state their goals
Ex: I have come for my regular checkup
HPI
This section is a complete, clear, and chronological account of the present illness.
It should include the onset of the problem, the setting in which it has developed, its manifestations and
any treatments.
The principal symptoms should be well described using LMNOPQRST. Include pertinent negatives and
positives form the ROS
Also include current medications, allergies, tobacco, alcohol and drug use
HPI (history of present illness)
L- Location
M-Management of Disease
N- New or Old
O-Onset
P-Precipitating Factors
Q- Quality
R- Relieving Factors
S- Severity
T- Treatment/Timing
Alcohol and Drug History
CAGE Questions
C- Cut down?
A- Annoyed/Angry
G- Guilty?
E- Eye-opener
Questions all answered correctly
Subjective Data
What the patient tells you
Objective Data
What you detect during the examination.All physical examination findings.
Identifying data
age, gender, occupation,marital status
Source of the history
—
the patient, but can be a family member or friend, letter of referral, or the medical record
Reliability
The one or more symptoms or concerns causing the patient to seek care
Present Illness
Amplifies the Chief Complaint;Includes patient's thoughts and feelings about the illness
●Pulls in relevant portions of the
Review of Systems,called "pertinent positives and negatives" (see p. 10)
●May include medications, allergies,
habits of smoking and alcohol,which are frequently pertinent to the present illness
describes how each symptom developed
Past History
Childhood Illness Measles, rubella, mumps, whooping cough, chicken pox
Chronic childhood illnesses: asthma, diabetes
●Lists adult illnesses with dates for at least four categories:medical; surgical; obstetric/gynecologic; and
psychiatric
●Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and
home safety
Family History
●Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents
●Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery
disease, HTN,CAD
Hypercholesterolemia, Stroke, DM, Thyroid Dz
, Renal Dz, CA, Arthritis, TB, Asthma, HA
Seizure, Psych, Drug/ETOH addiction
Personal and Social History
Describes educational level, family of origin, curren thousehold, personal interests, and lifestyle.Living
situation,Significant other
Sources of stress,Important life experiences
Present job, Religious affiliation, ADL
Review of Systems
Documents presence or absence of common symptoms related to each major body system
Chief Complaint
Make every attempt to quote the patient's own words Ex: I have had chest pain for the past 3 hours and
I feel like I can't breath
Sometimes the patient may not have a complaint and will instead state their goals
Ex: I have come for my regular checkup
HPI
This section is a complete, clear, and chronological account of the present illness.
It should include the onset of the problem, the setting in which it has developed, its manifestations and
any treatments.
The principal symptoms should be well described using LMNOPQRST. Include pertinent negatives and
positives form the ROS
Also include current medications, allergies, tobacco, alcohol and drug use
HPI (history of present illness)
L- Location
M-Management of Disease
N- New or Old
O-Onset
P-Precipitating Factors
Q- Quality
R- Relieving Factors
S- Severity
T- Treatment/Timing
Alcohol and Drug History
CAGE Questions
C- Cut down?
A- Annoyed/Angry
G- Guilty?
E- Eye-opener
