Building and Recording a Health History Flashcards
The history “is the
patient’s story of his or her illness related as the time course of the symptoms” (LeBlond et al., 2015,p. xxxi).
The physical examination “reveals
the signs of disordered anatomy and physiology”
Based on the H and P, the provider generates
testable pathophysiological and diagnostic hypotheses – the differential diagnosis
A provider’s goal in perform a history and physical examination is to
generate diagnostic hypothesis – differential diagnosis
The APRN needs to have a
thoughtful, systemic approach to H and P, and the diagnostic process.
Diagnostics and imaging are ordered based upon
accurate diagnostic hypothesis which are generated while gathering and H and P.
The history is the
patient’s story of their illness.
The history is not
the provider’s interpretation of the patient’s history
Preparation components
Getting Ready Chart Review Goal identification Your goals Patient goals Awareness of your clinical behavior and attitude Environmental accommodation Greeting Setting the agenda Note taking
Environmental data
Living situation
Employment/profession
Social Supports
SES/insurance statu
Psychosocial history or habits
Sexual Chemical Dietary Exercise Sleep
Patient-centered approach question examples
”How would you like to be addressed today?”
”How are you feeling today?”
”What would you like for us to do today?”
“What do you think is causing your symptoms?”
Additional tips for determining the chief complaint include:
State the chief complaint in the patients own words or paraphrase them.
Be brief but accurate.
If more than one complaint, attempt to have patient prioritize.
If more than one complaint, treat each separately.
PMH is the
Essential background information related to the patient’s health and well-being.
A brief past medical and social history often include the following elements:
Allergies and reactions to drugs. Ask: “What happened?”
Current medications (including over-the-counter medications, vitamins, and herbal remedies).
Medical, psychiatric illnesses (e.g., diabetes, hypertension, depression, etc.)
Surgeries, injuries, hospitalizations (e.g., appendectomy, accidents, etc.)
Immunizations
Health maintenance (last dental exam, last eye exam, mammogram, colonoscopy, dexascan, lipid screening, diabetes screening if indicated, and cognitive/developmental)
Reproductive Health data
Last menstrual period Last pelvic exam, pap smear result Pregnancies, births (GP-TPAL) Contraception Last pap smear (LPS) Last menstrual period (LMP) Number of lifetime partners Breast self exam (BSE) Mammogram history Marital, family status, abuse, safety, stress factors Sex with women, men, or both History of STIs
The Five Ps of a Sexual History
Partners Practices Protection from STIs Past history of STIs Prevention of pregnancy (if necessary)
Prenatal history:
maternal illness/chronic disease, problems during pregnancy,labor and delivery, neonatal period
Pediatric Data
Prenatal history: maternal illness/chronic disease, problems during pregnancy,labor and delivery, neonatal period
Congenital defects/conditions
Growth and development
Illness: otitis media, asthma and allergies, eczema, urinary tract infection, heart murmur, vesicoureteral reflux
Neurodevelopmental disorders
