Chapter 4: The Complete Health History

Question 1

State the purpose of the complete health history.

Answer 1

To collect subjective data; what the person says about themself. Combined with objective data to make a judgment or diagnosis. Provides a complete picture of a person’s past and present health.

Question 2

List and define the critical characteristics used to explore each symptom the patient identifies.

Answer 2

OLDCARTS O = onset L = location D = duration C = characteristic/quality A = aggravating/relieving factors R = region/radiation T = timing S = severity

Question 3

Define the elements of the health history: reason for seeking care; present health state or present illness; past history, family history; review of systems; functional patterns of living.

Answer 3

Reason for seeking care: describes the reason for the visit; states symptoms or signs; in patients own words; may be many reasons and can include wellness Present health state/illness: chronological record of symptoms and signs; use OLDCARTS Past history: past medical history may have residual effects on current health status; may give additional clues. Includes injuries, illnesses, accidents, medications, hospitalization, immunization, environment, surgeries/operations, and allergies Family history: can help identify increased risks for certain diseases/conditions Review of systems: roughly head to toe overview to evaluate past and present stat of each body system; helps to double-check information; evaluates health promotional practices Functional patterns of living: includes activities of daily living (ADLs); assessment of a person’s self-care ability in areas of general physical health

Question 4

Discuss the rationale for obtaining a family history.

Answer 4

To determine any increased risks to any diseases/conditions. Can help patient seek early screening/monitoring and prevention.

Question 5

Define pedigree or genogram.

Answer 5

Graphic family tree that uses symbols to depict the gender, relationships, and age of immediate blood relatives in at least 3 generations

Question 6

Discuss the rationale for obtaining a systems review.

Answer 6

Subjective data from patient statements. Evaluates past and present health state of each body system. Double-checks to make sure no significant data were omitted in present illness. Evaluates health promotion practices.

Question 7

Describe the items included in a functional assessment.

Answer 7

• Self-esteem/self-concept
• Activity/exercise
• Sleep/rest
• Nutrition/Elimination
• Interpersonal relationships
• Spiritual resources
• Coping and stress management
• Personal habits
• Alcohol
• Illicit or street drugs
• Environment/hazards
• Intimate partner violence
• Occupational health

Question 8

When reading a medical record, you see the following notation: Patient states, “I have had a cold for about a week, and now I am having difficulty breathing.” This is an example of:

a. A past health history
b. A review of systems
c. A functional assessment
d. A reason for seeking care

Answer 8

d. A reason for seeking care

Question 9

You have reason to question the reliability of the information being provided by a patient. One way to verify the reliability within the context of the interview is to:

a. Rephrase the same questions later in the interview
b. Review the patient’s previous medical records
c. Call the person identified as the emergency contact to verify the data provided
d. Provide the patient with a printed history to complete and then compare the data provided

Answer 9

a. Rephrase the same questions later in the interview

Question 10

The statement “Reason for seeking care” has replaced “chief complaint.” This change is significant because:

a. The “chief complaint” is really a diagnostic statement
b. The newer terms allows anther individual to supply the necessary information
c. The newer term incorporates wellness needs
d. The “reason for seeking care” can incorporate the history of the present illness

Answer 10

c. The newer term incorporates wellness needs

Question 11

During an initial interview, the examiner says, “Mrs. J., tell me what you do when your headaches occur?” This is an example of which type of information?

a. The patient’s perception of the problem
b. Aggravating or relieving factors
c. The frequency of the problem
d. The severity of the problem

Answer 11

b. Aggravating or relieving factors

Question 12

Which is an appropriate recording of a patient’s reason for seeking health care?

a. Angina pectoris, duration 2 hours
b. Sub-sternal pain radiating to left axilla, 1 hour duration
c. “Grabbing” chest pain for 2 hours
d. Pleurisy, 2 days’ duration

Answer 12

c. “Grabbing” chest pain for 2 hours

Question 13

A genogram is used for which reasons?

a. Past history
b. Past history, specifically hospitalizations
c. Family history
d. The 8 characteristics of presenting symptoms

Answer 13

c. Family history

Question 14

What is the best description of “review of systems” as a part of the health history?

a. The evaluation of the past and present health state of each body system
b. A documentation of the problem as described by the patient
c. The recording of the objective findings of the practitioner
d. A statement that describes the overall health state of the patient

Answer 14

a. The evaluation of the past and present health state of each body system

Question 15

Which finding is considered subjective?

a. Temperature of 101.2F
b. Pulse rate of 96 beats/min
c. Measured weight loss of 20 pounds since the previous measurement
d. Pain lasting 2 hours

Answer 15

d. Pain lasting 2 hours

Question 16

When taking a health history for a child, what information, in addition to that for an adult is usually obtained?

a. Coping and stress management
b. A review of immunizations received
c. Environmental hazards
d. Hospitalization history

Answer 16

b. A review of immunizations received

Question 17

Functional assessment measures how a person manages day-to-day activities. The impact of adoption on the daily activities of a child is referred to as:

a. Developmental history
b. Instrumental activities of daily living
c. Reason for seeking care
d. Interpersonal relationship assessment

Answer 17

d. Interpersonal relationship assessment

Question 18

Which two sections of the child’s health history became separate sections because of their importance to the child’s current health status?

a. Play activities and rest patterns
b. Prenatal and postnatal status
c. Developmental and nutritional history
d. Accidents, injuries, and immunizations

Answer 18

c. Developmental and nutritional history

Question 19

Which statement best describes the purpose of a health history?

a. To provide an opportunity for interaction between the patient and examiner
b. To provide a form for obtaining the patient’s biographic information
c. To document the normal and abnormal findings of a physical assessment
d. To provide a database of subjective information about the patient’s past and present health

Answer 19

d. To provide a database of subjective information about the patient’s past and present health

Question 20

While assessing a man for allergies, he states he is allergic to penicillin. Which response is best?

a. “Are you allergic to any other drugs?”
b. “How often have you received penicillin?”
c. “I’ll write your allergy on your chart so you don’w receive any.”
d. “Please describe what happens to you when you take penicillin.”

Answer 20

d. “Please describe what happens to you when you take penicillin.”