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
Pregnancy Data
HPI – current pregnancy, medical care received, and any specific problems
Obstetric history
Menstrual history - LMP and previous usual/normal menstrual period
Expected date of confinement/deliver (EDC)
GYN history
PMH
FMH
Personal and social history - occupation
ROS
Risk assessment
Postpartum
Geriatrics special data
Chronic illness: onset, management, status
Hospitalizations and surgeries
Pay attention to medication history: OTC/herbal/vitamin and prescription
Weight changes
Elimination: stool patterns, urinary incontinence (females) , hesitancy and nocturia (males)
Immunizations
Neurocognitive
Falls
Memory
OLD CARTSS
O: Onset L:Location D: Duration C: Characteristics A: Aggravating and Alleviating symptoms R: Related Systems T: Timing S: Setting S: Situation
The social history often offers insight into
issues that can be identified as patient education needs.
The social history includes lifestyle factors or issues related to
Alcohol
Tobacco
Drugs
Be specific with your questions about
about alcohol and drug use
Tobacco:Do you
smoke? Ask about pack/year history (i.e., currently, in past, amount, for how long, previous attempts at quitting, current interest in quitting). Do you chew tobacco? Vaping?
Alcohol:How many
drinks per day/week? Any history of “problems” with alcohol?
Some clinicians use the CAGE questionnaire for assessment of alcohol
Drugs: How often have you taken any illicit or “street drugs?”
CAGE
C- Have you felt the need to CUT down on alcohol?
A- When others comment on your intake, do you become ANNOYED?
G- Do you feel GUILTY about your use of alcohol?
E- Have you ever taken an EYE OPENER (used alcohol for a hangover)?
https://www.mdcalc.com/cage-questions-alcohol-use
Social History - Data
Sexual practices Occupation and work environment Marital status Family relationships and home environment Support systems Leisure activity Travel history Stress, stress related factors Sleep Diet, including caffeine consumption Exercise (document what type, how long, and how often) Safety -- to include seat belts, helmet use, guns, fire alarms and extinguishers in home, safe in home and relationship? History of current or past IPV
Womans health data
Sexual activity/contraception
Chemical use
Dietary: calcium and vitamin D
Domestic violence
Pregnancy Data
Older children
Pets
Feelings regarding pregnancy
Experiences with parenting
Experience with and plans for labor and breastfeeding
History of past or present abuse in relationship (IPV)
Pediatrics
Caregivers/child care/after school arrangements
Household/family relationships
Habits: Nutrition/Feeding, elimination, activity, sleep
Safety: car seats, Co2 detectors, seatbelts, bike helmets, water temperature, smoke detectors, poisoning, pets
Parenting behaviors
Geriatric:
Activities of daily living (personal self cares)
Independent ADLs (ability to live alone such as preparing food, using telephone, doing housekeeping and laundry, paying bills
Habits: Sleep, nutrition, elimination, exercise
Driving
Substance use
Support systems
Start with general questions about
the family history, then go to specifics:
If there is no reply, or the reply is vague, offer examples. For example, ask about any: heart disease, diabetes, cancer, etc.
For “positives,” be as
specific as possible. For example, ask about:
Breast cancer at what age? What was the outcome? Any genetic testing.
Heart attack or other cardiac disease/death at what age?
Practice drawing
genograms of people you know as they relate their family health histories to you.
You will likely draw genograms in
charts during your clinical rotations, though for this course you can document the family history in narrative form.
For example: Mother (60) HTN and migraines, Father (62) CAD and MI age 52. Brother (29) healthy. No children. MGM died age 68 of colon cancer, MGF (84) HTN, PGM (80) hypercholesterolemia and HTN, PGF died age 50 in MVA.
A series of questions grouped by organ system
General, constitutional (fever, fatigue, change in appetite, insomnia) Skin Eyes, ears, nose, mouth, throat Cardiovascular Respiratory Breast Gastrointestinal Genitourinary Musculoskeletal Neurologic, mental health Allergic, immunologic, lymphatic, endocrine, hematology
32 year-old female who is having a health maintenance visit would have a relatively
complete ROS. If she were to seek care for a particular symptom, such as a sore throat, the ROS would focus on systems related to her complaint.
In contrast, an 81 year-old with diabetes and hypertension would have a more
detailed ROS in the health maintenance or symptom (problem) oriented visit
For a problem oriented visit, it is often incorporated into
For a problem oriented visit, it is often incorporated into
Putting Them All Together
Preparation
Demographics
Medical History
Complete history
Not always necessary
Often recorded the first time you see a patient
Inventory history
Touches on major points without going into detail
Problem (or focused history)
Acute, possibly life-threatening and requires immediate attention
Interim history
Chronicles events that have occurred since the patients last office visit
Complemented by the patient’s previous record
Communication Techniques
Open ended questions Proceed from broad to more specific Active listening Allow patient to verbalize Ask one question at a time Clarify patient responses Validate responses Restate and summarize
Guidelines for Broaching Sensitive Subjects
Role play opening statements Sexual history Violence/abuse Chemical use/abuse Death and dying Acknowledge your discomfort Explain why you need the information Be non-judgmental
Potentially Challenging Encounters
The quiet patient The talkative patient The cognitively impaired patient The mentally ill patient The sensory impaired patient The non English-speaking patient The angry or disruptive patient The confusing patient The very old or the very young patient
