Building and Recording a Health History

Question 1

The history “is the

Answer 1

patient’s story of his or her illness related as the time course of the symptoms” (LeBlond et al., 2015,p. xxxi).

Question 2

The physical examination “reveals

Answer 2

the signs of disordered anatomy and physiology”

Question 3

Based on the H and P, the provider generates

Answer 3

testable pathophysiological and diagnostic hypotheses – the differential diagnosis

Question 4

A provider’s goal in perform a history and physical examination is to

Answer 4

generate diagnostic hypothesis – differential diagnosis

Question 5

The APRN needs to have a

Answer 5

thoughtful, systemic approach to H and P, and the diagnostic process.

Question 6

Diagnostics and imaging are ordered based upon

Answer 6

accurate diagnostic hypothesis which are generated while gathering and H and P.

Question 7

The history is the

Answer 7

patient’s story of their illness.

Question 8

The history is not

Answer 8

the provider’s interpretation of the patient’s history

Question 9

Preparation components

Answer 9

Getting Ready
Chart Review
Goal identification 
Your goals
Patient goals 
Awareness of your clinical behavior and attitude
Environmental accommodation
Greeting
Setting the agenda
Note taking

Question 10

Environmental data

Answer 10

Living situation
Employment/profession
Social Supports
SES/insurance statu

Question 11

Psychosocial history or habits

Answer 11

Sexual 
Chemical
Dietary
Exercise
Sleep

Question 12

Patient-centered approach question examples

Answer 12

”How would you like to be addressed today?”
”How are you feeling today?”
”What would you like for us to do today?”
“What do you think is causing your symptoms?”

Question 13

Additional tips for determining the chief complaint include:

Answer 13

State the chief complaint in the patients own words or paraphrase them.
Be brief but accurate.
If more than one complaint, attempt to have patient prioritize.
If more than one complaint, treat each separately.

Question 14

PMH is the

Answer 14

Essential background information related to the patient’s health and well-being.

Question 15

A brief past medical and social history often include the following elements:

Answer 15

Allergies and reactions to drugs. Ask: “What happened?”
Current medications (including over-the-counter medications, vitamins, and herbal remedies).
Medical, psychiatric illnesses (e.g., diabetes, hypertension, depression, etc.)
Surgeries, injuries, hospitalizations (e.g., appendectomy, accidents, etc.)
Immunizations
Health maintenance (last dental exam, last eye exam, mammogram, colonoscopy, dexascan, lipid screening, diabetes screening if indicated, and cognitive/developmental)

Question 16

Reproductive Health data

Answer 16

Last menstrual period
Last pelvic exam, pap smear result
Pregnancies, births (GP-TPAL)
Contraception
Last pap smear (LPS)
Last menstrual period (LMP)
Number of lifetime partners
Breast self exam (BSE)
Mammogram history
Marital, family status, abuse, safety, stress factors
Sex with women, men, or both
History of STIs

Question 17

The Five Ps of a Sexual History

Answer 17

Partners
Practices
Protection from STIs
Past history of STIs
Prevention of pregnancy (if necessary)

Question 18

Prenatal history:

Answer 18

maternal illness/chronic disease, problems during pregnancy,labor and delivery, neonatal period

Question 19

Pediatric Data

Answer 19

Prenatal history: maternal illness/chronic disease, problems during pregnancy,labor and delivery, neonatal period
Congenital defects/conditions
Growth and development
Illness: otitis media, asthma and allergies, eczema, urinary tract infection, heart murmur, vesicoureteral reflux
Neurodevelopmental disorders

Question 20

Pregnancy Data

Answer 20

HPI – current pregnancy, medical care received, and any specific problems
Obstetric history
Menstrual history - LMP and previous usual/normal menstrual period
Expected date of confinement/deliver (EDC)
GYN history
PMH
FMH
Personal and social history - occupation
ROS
Risk assessment
Postpartum

Question 21

Geriatrics special data

Answer 21

Chronic illness: onset, management, status
Hospitalizations and surgeries
Pay attention to medication history: OTC/herbal/vitamin and prescription
Weight changes
Elimination: stool patterns, urinary incontinence (females) , hesitancy and nocturia (males)
Immunizations
Neurocognitive
Falls
Memory

Question 22

OLD CARTSS

Answer 22

O: Onset
L:Location
D: Duration
C: Characteristics
A: Aggravating and Alleviating symptoms
R: Related Systems
T: Timing
S: Setting
S: Situation

Question 23

The social history often offers insight into

Answer 23

issues that can be identified as patient education needs.

Question 24

The social history includes lifestyle factors or issues related to

Answer 24

Alcohol
Tobacco
Drugs

Question 25

Be specific with your questions about

Answer 25

about alcohol and drug use

Question 26

Tobacco: Do you

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smoke? Ask about pack/year history (i.e., currently, in past, amount, for how long, previous attempts at quitting, current interest in quitting). Do you chew tobacco? Vaping?

Question 27

Alcohol: How many

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drinks per day/week? Any history of "problems" with alcohol? Some clinicians use the CAGE questionnaire for assessment of alcohol Drugs: How often have you taken any illicit or "street drugs?"

Question 28

CAGE

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C - Have you felt the need to CUT down on alcohol? A - When others comment on your intake, do you become ANNOYED? G - Do you feel GUILTY about your use of alcohol? E - Have you ever taken an EYE OPENER (used alcohol for a hangover)? https://www.mdcalc.com/cage-questions-alcohol-use

Question 29

Social History - Data

Answer 29

``` Sexual practices Occupation and work environment Marital status Family relationships and home environment Support systems Leisure activity Travel history Stress, stress related factors Sleep Diet, including caffeine consumption Exercise (document what type, how long, and how often) Safety -- to include seat belts, helmet use, guns, fire alarms and extinguishers in home, safe in home and relationship? History of current or past IPV ```

Question 30

Womans health data

Answer 30

Sexual activity/contraception Chemical use Dietary: calcium and vitamin D Domestic violence

Question 31

Pregnancy Data

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Older children Pets Feelings regarding pregnancy Experiences with parenting Experience with and plans for labor and breastfeeding History of past or present abuse in relationship (IPV)

Question 32

Pediatrics

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Caregivers/child care/after school arrangements Household/family relationships Habits: Nutrition/Feeding, elimination, activity, sleep Safety: car seats, Co2 detectors, seatbelts, bike helmets, water temperature, smoke detectors, poisoning, pets Parenting behaviors

Question 33

Geriatric:

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Activities of daily living (personal self cares) Independent ADLs (ability to live alone such as preparing food, using telephone, doing housekeeping and laundry, paying bills Habits: Sleep, nutrition, elimination, exercise Driving Substance use Support systems

Question 34

Start with general questions about

Answer 34

the family history, then go to specifics: If there is no reply, or the reply is vague, offer examples. For example, ask about any: heart disease, diabetes, cancer, etc.

Question 35

For "positives," be as

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specific as possible. For example, ask about: Breast cancer at what age? What was the outcome? Any genetic testing. Heart attack or other cardiac disease/death at what age?

Question 36

Practice drawing

Answer 36

genograms of people you know as they relate their family health histories to you.

Question 37

You will likely draw genograms in

Answer 37

charts during your clinical rotations, though for this course you can document the family history in narrative form.  For example: Mother (60) HTN and migraines, Father (62) CAD and MI age 52.  Brother (29) healthy.  No children.  MGM died age 68 of colon cancer, MGF (84) HTN, PGM (80) hypercholesterolemia and HTN, PGF died age 50 in MVA.

Question 38

A series of questions grouped by organ system

Answer 38

``` General, constitutional (fever, fatigue, change in appetite, insomnia) Skin Eyes, ears, nose, mouth, throat Cardiovascular Respiratory Breast Gastrointestinal Genitourinary Musculoskeletal Neurologic, mental health Allergic, immunologic, lymphatic, endocrine, hematology ```

Question 39

32 year-old female who is having a health maintenance visit would have a relatively

Answer 39

complete ROS. If she were to seek care for a particular symptom, such as a sore throat, the ROS would focus on systems related to her complaint.

Question 40

In contrast, an 81 year-old with diabetes and hypertension would have a more

Answer 40

detailed ROS in the health maintenance or symptom (problem) oriented visit

Question 41

For a problem oriented visit, it is often incorporated into

Answer 41

For a problem oriented visit, it is often incorporated into

Question 42

Putting Them All Together

Answer 42

Preparation Demographics Medical History

Question 43

Complete history

Answer 43

Not always necessary | Often recorded the first time you see a patient

Question 44

Inventory history

Answer 44

Touches on major points without going into detail

Question 45

Problem (or focused history)

Answer 45

Acute, possibly life-threatening and requires immediate attention

Question 46

Interim history

Answer 46

Chronicles events that have occurred since the patients last office visit Complemented by the patient’s previous record

Question 47

Communication Techniques

Answer 47

``` Open ended questions Proceed from broad to more specific Active listening Allow patient to verbalize Ask one question at a time Clarify patient responses Validate responses Restate and summarize ```

Question 48

Guidelines for Broaching Sensitive Subjects

Answer 48

``` Role play opening statements Sexual history Violence/abuse Chemical use/abuse Death and dying Acknowledge your discomfort Explain why you need the information Be non-judgmental ```

Question 49

Potentially Challenging Encounters

Answer 49

``` The quiet patient The talkative patient The cognitively impaired patient The mentally ill patient The sensory impaired patient The non English-speaking patient The angry or disruptive patient The confusing patient The very old or the very young patient ```