Flashcards in Chapter 4 The Complete Health History Deck (10)
What are the elements of the Health history?
source of history
reason for seeking care
present health/history of
review of systems
including activities of daily living (ADLs)
What is included in the biographical data section?
Address and phone number
Age and birth date
Occupation: usual and present
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
What is a symptom?
subjective sensation person feels from disorder
What is a sign?
objective abnormality that can be detected on physical examination or in laboratory reports
What is the PQRSTU mnemonic broken down?
P: provocative or palliative
R: region or radiation
S: severity scale 1 to 19
T: timing or onset
U: understand patient's perception of problem
What is included in the past medical history section?
Accidents or injuries
Serious or chronic illnesses
Last examination date
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
What systems are reviewed?
General overall health state
Nose and sinuses
Mouth and throat
Male genital system
Female genital system