Health History Flashcards by Jerrina Gusler

Health History

Purpose

gather info
educate re: health risks
NEGOTIATE A PLAN
   what to do to ameliorate s/s
   where they are and how to move           
   them forward 
offer counseling

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Health and illness

Factors affecting

Social factors
Economic factors
Cultural factors—culturally defined
SZ either medical problem or demonic

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Interview Rules

FOCUS ON PATIENT'S AGENDA
LISTEN MORE
*** will tell what is wrong and what they want
      to do about it.
Talk less
Do not interrupt

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Interview

Rule of 5 vowels

Audition- listen carefully
Evaluation-sort relevant/irrelevant  data
Inquiry-probe areas for clarification
Observation- non-verbal communication
Understanding- be empathetic

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Preparing for the Interview

Prepare Yourself

Appearnce,
Behavior
Nonverbal–posture, gestures, tone

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Preparing for the Interview

Prepare the environment

Private
Comfortable/clean
Appropriate seating

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Preparing for the Interview

Note taking

Jot down key items with few words

Maintain eye contact

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Interview Techniques

Introduce yourself, WASH HANDS
Explain role as student
Use appropriate title to address patient
Visitors?
   who are they and can they stay?

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Interview Techniques

Invite pt's story
  use open ended questions
  f/u pt's lead with direct questions
Use continuers--I see, yes, ok.....
Confront to draw attention to statement or behavior

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Interview Techniques
Interpretation

Reflection

Interpret patients behavior based on your understanding of the situation

echo or mirror what the patient is telling you

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Interview techniques

Offer reassurance based on fact

Be empathetic–validate the patient’s feelings

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Symptoms

What the patient feels/reports
Not absolute/subjective
Influenced by culture, intelligence, SEC

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Signs

What the practitioner finds

Pain becomes a sign when elicited with palpation

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Symptom Analysis

location
quality
quantity 0-10
chronology- timing
setting
precipitating & alleviating factors
Associated manifestations- other s/s

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Questioning to Avoid
Suggestive

Rapid fire

Do you feel pain in your left arm associated with your chest pain

Multiple questions at once

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Questioning to Avoid
Leading (biased)

Medical Jargon

You haven’t used any illicit drugs, have you?

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Communication Techniques

Transitions
Sexual health is really important so I am
going to ask some sexual health questions.
Facilitation- continuers
Confrontation, Interpretation, Reflection, Support

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Format of History
Source and reliability

Chief Complaint
anything else you want to discuss
have all your questions been answered

Source is usually patient but could include family and friends; also nursing staff

Chief complaint -concerns causing seeking of medical attention
probe for underlying concerns–changes
underlying reasons for seeking health care

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Format of History
Hx of present illness
Use 7 symptom analysis

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hx present illness-Amplifies the chief complaint, giving full clear chronological account of symptoms
symptoms, when first appeared, character, relevant ROS, (meds,allergies, smoking or.alcohol)

Format of History

Past medical history

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General state of health, past illnesses, injuries,
hospitalizations, surgeries, allergies, immunizations, substance abuse (cigarettes/ smokeless tobacco, recreational drugs, alcohol, diet, sleep patterns, current medications, CAM

)

Format of History PMH

Alcohol use

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CAGE (cutting down, annoyance, guilt,
eye opener)
** 2+ answers = 77-94% alcohol abuse
HALT (drink to get high, alone, looking
forward to drinking , and tolerance
Teens use RAFFT questions
RAFFT (to relax, use alone, do friends use, SA in family members, trouble from use)

Format of History PMH

Diet

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24 hour diet recall
   representative of routine eating patterns
red vs white meat
fish
H2O intake
Caffeine

Format of History PMH
sleep patterns

current medications

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when do they go to bed
problems falling asleep or staying asleep
daytime somnolence
feel rested, snoring

current meds otc and prescription
CAM

Format of History
Health Maintenance

Occupational/environmental hx

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Routine medical /dental exams
eye exam
gyn exam
cholesterol

occupational exposures = 50,000-70,000 annual deaths
type of work, how long, hazardous
exposures, protective equipment used
environmental –travel outside the US

Format of the history Biographical Info Family hx

Biographical -DOB, Sex, Race, Ethnic background Family hx= 1st degree relatives siblings/parents (some add grandparents) **understand genogram

Format of the History Psychosocial /Spiritual hx Sexuality/reproductive/gynecologic hx History

Psychosocial/spiritual education, life experiences, personal relationships and patient's lifestyle Tailor questions to situation Vernacular terms can be used ( ball sack) When in doubt ask! Domestic violence feel safe at home sometimes people with this type of history report abuse, has this ever happened to you?

Format of History | Review of Systems

Series of questions from head to toe with yes/no answers | further questioning required for yes answers

FORMAT of HISTORY

``` source/reliability Chief complaint hx present illness past medical hx health maintenance occupational/environmental hx biographical information family hx psychosocial/spiritual hx sexuality/reproductive, gynecologic hx Review of Systems ```

ROS Review of Systems | general

``` usual state of health fever/chills weight changes fatigue/weakness heat or cold intolerance ```

ROS Review of Systems | Skin

``` lumps/bumps rashes/itching hives/ dryness bruising color changes in skin nails or hair ```

ROS Review of Systems | Head

Dizziness Headaches Pain Fainting (can be culturally appropriate)

ROS Review of Systems | Eyes

``` Vision Excessive tearing Pain Redness Discharge Injuries ```

ROS Review of Systems | Ears

``` Hearing Discharge Pain Ringing Infections ```

ROS Review of Systems | Nose

``` Bleeding Infections Discharge Sneezing Injury ```

ROS Review of Systems | Mouth and Throat

``` Condition of teeth Last dental exam Bleeding Sore throat Hoarseness Post Nasal Drip ```

ROS Review of Systems | Neck

``` Lumps Goiter-enlargement or swelling Pain/Tenderness Swollen glands Thyroid trouble ```

ROS Review of Systems | Chest

``` Cough Pain SOA Sputum Wheezing Hemoptysis -cough up blood ```

ROS Review of Systems | Breast

``` Women and Men Lumps Discharge Pain/Tenderness BSE Breast self exam ```

ROS Review of Systems | Cardiac

``` Chest pain Palpitations DOE Dyspnea on exertion SOA while sleeping Heart Murmur ```

ROS Review of Systems | Peripheral Vascular

``` Claudication Swelling Varicose Veins Coolness Alopecia Discoloration Ulcers ```

ROS Review of Systems | Gastrointestinal

``` Appetite Excessive hunger/thirst N/V/C/D Abdominal pain/heartburn Stool changes Rectal pain Hemorrhoids ```

ROS Review of Systems | Urinary

``` Frequency/urgency/dysuria Stream difficulties (esp. aging men) Incontinence Hematuria Infections ```

ROS Review of Systems | Genital

lesion/itching/discharge masses-lumps/bumps Pain HX VD Women age of menarche duration of periods/amount of flow # of pregnancies/deliveries/abortions

ROS Review of Systems | Musculoskeletal

Weakness/fatigue Joint pain/Stiffness Muscle cramps/paralysis

ROS Review of Systems | Neurologic

Dizziness/Blackouts Paralysis Numbness/Tingling/Burning Loss of Memory

Health History All are different It is a legal document Patient response

Record + symptoms first then record no or denies and list other symptoms Pt responses Silence/over talking/seductive/angry/paranoid

Health History Flashcards

(46 cards)