Chapter 4 The Complete Health History Flashcards
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)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
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 Q: quality/quantity 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?
Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations Operations Obstetric history Immunizations Last examination date Allergies Current medications
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 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
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
