Chapter 4 The Complete Health History Flashcards Preview

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Flashcards in Chapter 4 The Complete Health History Deck (10)
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1

What are the elements of the Health history?

biographical data
source of history
reason for seeking care
present health/history of
present illness
past health
family history
review of systems
functional assessment
including activities of daily living (ADLs)

2

What is included in the biographical data section?

Name
Address and phone number
Age and birth date
Birthplace
Sex
Marital status
Race
Ethnic origin
Occupation: usual and present

3

What is included in the source of history section?

Record who furnishes information, usually the person, although source may be relative or friend
Judge reliability of informant and how willing he or she is to communicate
A reliable person always gives same answers when questions are rephrased or are repeated later in interview
Note any special circumstances, such as use of interpreter

4

What is a symptom?

subjective sensation person feels from disorder

5

What is a sign?

objective abnormality that can be detected on physical examination or in laboratory reports

6

What is the PQRSTU mnemonic broken down?

P: provocative or palliative
Q: quality/quantity
R: region or radiation
S: severity scale 1 to 19
T: timing or onset
U: understand patient's perception of problem

7

What is included in the past medical history section?

Childhood illnesses
Accidents or injuries
Serious or chronic illnesses
Hospitalizations
Operations
Obstetric history
Immunizations
Last examination date
Allergies
Current medications

8

What is included in the family history portion?

Age and health or cause of death of relatives
Health of close family members
Family history of various conditions such as heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and tuberculosis
Family tree (genogram) to show this information clearly and concisely

9

What systems are reviewed?

General overall health state
Skin
Hair
Head
Eyes
Ears
Nose and sinuses
Mouth and throat
Neck
Breast
Axilla
Respiratory system
Cardiovascular
Peripheral vascular
Gastrointestinal
Urinary system
Male genital system
Female genital system
Sexual health
Musculoskeletal system
Neurologic system
Hematologic system
Endocrine system

10

What is included in the functional assessment: activities of daily living?

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