N202 Subjective Data, Patient Interview, ROS, Health History

C in COLDSPA

Character: How would you describe the pain? Sharp, dull, stabbing, pressure, ache, etc.

O in COLDSPA

Onset: When did the pain/symptoms start? Quantity: hours, minutes, days, etc.

L in COLDSPA

Location: Where is it? Does it radiate or travel to anywhere else?

D in COLDSPA

Duration: How long does it last? Is it intermittent? Constant?

S in COLDSPA

Severity: How bad is it? How much does it affect you? Rate it from a scale 1-10

P in COLDSPA

Pattern: Aggravating or alleviating factors/What makes it worse/better? Has this happened before?

A in COLDSPA

Associated factors: What other symptoms occur with it? What do you think caused this?

Pruritus

itchiness/feeling or need to scratch for relief on skin

pallor

paleness/loss of color from the skin/mucous membrane

dizziness

describes a range of feelings from faint, wobbly, weak, woozy

vertigo

surroundings are perceived as spinning

syncope

temporary drop in blood flow to the brain causing a loss of conscioussness

tinnitus

ringing in one/both of the ears that is not external

dysphagia

difficulty/inability to swallow

hemoptysis

coughing up blood from the lungs from infection

dyspnea

sensation of difficulty/discomfort when breathing

palpitations

sensation of irregular heartbeat - described as rapid, forceful, or irregular rhythm

cyanosis

bluish tone in the skin, lips, nails from blood lacking oxygen in these areas

orthopnea

SOB when lying down but relieved when sitting/standing up

Paroxysmal Nocturnal Dyspnea (PND)

waking up feeling like you can’t catch your breath/SOB upon waking up

caused by heart, lung, neuro issues

Nocturia

the need to urinate in the middle of the night causing you to wake up

Edema

fluid build up in the feet, legs, ankles, causing swelling

anemia

lack of RBC/Hgb to carry O2 to body tissue

Mottling

pattern of irregular, blotchy, discoloration to the skin

Intermittent claudication

leg pain only occuring during exercise and subsiding with rest

Thrombophlebitis

formation of a blood clot in the veins causing inflammation

jaundice

yellowish discoloration of the eyes from excess bilirubin

flatulence

expulsion of air from digestive tract thru anus

emesis

forceful ejection of some/all stomach contents thru mouth

dysuria

painful/burning sensation during urination

oliguria

low urine output

menarche

first menstrual cycle of a woman

amenorrhea

absence of menstrual periods for more than 3 months in women age 12-50

menorrhagia

heavy menstrual bleeding that lasts for more than a few days

Dysmenorrhea

painful periods/menstrual cramps

Dyspareunia

pain in genitalia before, during, or after sexual intercourse

Tic

sudden, rapid, involuntary motor movement/vocalization

tremor

involuntary shaking/trembling of a body part, usually the hands, arms, or head

polyuria

excessive urine output in a 24 hour period >2.5 L

Polydipsia

excessive thirst causing excessive water consumption

polyphagia

excessive hunger that is not sated by eating