Week 4, General Survey, Health Hx

Question 1

What is in Health History?

Answer 1

• Biographical data
• Hx and Family Hx
• perception of health
• Identify needs
• Review of Systems
• Reason for seeking care (chief complaint)
• History of present illness (OLDCARTS)

Question 2

OLDCARTS stands for:

Answer 2

O- Onset
L- Location
D- Duration (trend, intermittent vs constant)
C- characteristics (quality)
A- Aggravating/alleviating factors (what makes it better or worse)
R- Related Symptoms
T- Treatment-what have they taken or tried to help the situation?
S- Severity (pain scale)

Question 3

OPQRST stands for:

Answer 3

O- onset
P- provocation 
Q- quality
R- radiation
S- severity
T- time

Question 4

Signs vs Symptoms

Answer 4

Signs: detectable, observable, use senses; objective
Symptoms: patient self-report, sensations, feelings, attitudes, feelings; subjective data

Question 5

What is a Review of Systems (ROS)?

Answer 5

Information given by patient
-subjective head to toe (roughly), evaluation of past and present state of each body system.
Ask about S&S for each body system
Presence or absence of symptoms

Question 6

What is the BATHE assessment?

Answer 6

psychosocial: screening test for anxiety, depression, + situational stress disorders

Question 7

What does BATHE stand for?

Answer 7

Background: “what is going on in your life?”
Affect: “How do you feel about it?”
Trouble: “what troubles YOU most about this situation?”
Handle: “What helps you handle the situation?” (do you have resources?)
Empathy: “That must be very difficult” (acknowledge the reality of the stressor

Question 8

What is a General Survey?

Answer 8

A global impression of the person. Uses all senses (except taste) to assess the pt.

Question 9

What physical appearances are assessed in the general survey?

Answer 9

Age, sexual development, LOC, skin color, facial features

Question 10

What body structure + development are assessed in the general survey?

Answer 10

Stature, weight, posture, symmetry, body build, deformities

Question 11

What mobility is assessed in the general survey?

Answer 11

Range of Motion, gait (smooth, symmetric)

Question 12

What Behavior is assessed in the general survey?

Answer 12

mood (emotional state), affect (expression of that emotion), facial expression, dress, speech, hygiene

Question 13

Ex. of general survey:

Answer 13

G.L. is a 42 year old black female high school principal, well nourished, well developed, appears stated age. She is alert, oriented, cooperative, with no signs of acute distress. Ht. 163cm (5’4”), Wt 57 kg (126llb), TPR 37C- 76 14, B/P 146/84 right arm sitting