Elements of Comprehensive Health History Flashcards
Why is history taking important?
It directs the focus of the physical exam
Name Age Birthplace Sex Marital Status Nationality Religion Occupation Present address # of admission Exact date of admission
Components of General Data
The single most critical concern to the patient
Chief complaint
Best type of question asked during history taking
Close-ended Questions
Explores the chief complaint in more detail
History of Present Illness
Should reveal the patient’s responses to his or her symptoms and what effect it had on his or her life
History of Present Illness
PQRST of Symptoms
Provocative/Paliative factors Quality Radiation Severity Timing
Reference point in History of Present Illness
Admission
Health Maintenance
Diagnosed Illness since childhood
Previous hospitalizations
Previous accident/trauma
Past Medical History
In taking the patient’s past medical history, you must provide information relative to Adult Illnesses in this 4 areas
Medical, Surgical, Obstetric, Psychiatric
Age, health or cause of death of parents, grandparents, uncles, aunts and siblings
Family History
Marital duration, health of partner Place of birth Highest level of education Habits Occupation Personality traits Weight Type of residence Neighborhood Nutritional History
Personal or Social History
Give the difference between signs and symptoms
Symptom-subjective
Sign-objective
In this section, the duration, severity and provocative and paliative factors of the signs and symptoms must be described in detail
Review of Sytems
What must you observe in the General Survey part of the PE?
State of awareness Orientation to 3 spheres Build Sexual Development Posture, Gait, Motor Activity Signs of Distress Skin Color and Lesions Body Habits Degree of Nourishment Odors of the breath and body Facial Expressions
