Chapt 4: The Complete Health History Flashcards
What is subjective data?
what the person says about himself or herself.
What is objective data?
what you observe through measurement, inspection, palpation, percussion, and auscultation.
What is a symptom?
is a subjective sensation that the person feels from the disorder.
What is a sign?
objective abnormality that you as the examiner could detect on physical examination or through diagnostic testing.
What acronym do we use for history?
OLDCARTS, OPQRST, SAMPLE
What is medication reconciliation?
comparison of a list of current medications with a previous list, which is done at every hospitalization and every clinic visit.
How to evaluate location?
Be specific; ask the person to point to the location. If the problem is pain, note the
precise site. “Head pain” is vague, whereas descriptions such as “pain behind the eyes,”
“jaw pain,” and “occipital pain” are more precise and diagnostically significant. Is the pain
localized to one site or radiating? Is the pain superficial or deep?
How to eval character/quality?
This calls for specific descriptive terms such as burning, sharp, dull,
aching, gnawing, throbbing, shooting, viselike when describing pain. You also need to ask
about the character of other symptoms. Use similes: Blood in the stool looks like sticky tarm
whereas blood in vomitus looks like coffee grounds.
How to eval quantity/severity?
Attempt to quantify the sign or symptom, such as “profuse menstrual flow soaking five pads per hour.” Quantify the symptom of pain using the scale shown on the right. With pain, avoid adjectives, and ask how it affects daily activities. Then record if the person says, “I was so sick I was doubled over and couldn’t move” or “I was able to go to work, but then I came home and went to bed.”
How to eval time?
Onset, Duration, Frequency. When did the symptom first appear? Give the
specific date and time or state specifically how long ago the symptom started prior to
arrival (PTA). “How long did the symptom last (duration)?” “Was it steady (constant) or did it
come and go (intermittent)?” “Did it resolve completely and reappear days or weeks later
(cycle of remission and exacerbation)?”
How to eval setting/events leading up to?
Where was the person or what was the person doing when the symptom started? What brings it on? For example, “Did you notice the chest pain after shoveling snow, or did
the pain start by itself?”
What are aggravating/relieving factors?
What makes the pain worse? Is it aggravated by weather, activity, food, medication, standing, fatigue, time of day, or season? What relieves it (e.g., rest, medication, or ice pack)? What is the effect of any treatment? Ask, “What have you tried?” or “What seems to help?
How to eval associated factors?
Is this primary symptom associated with any others (e.g., urinary frequency and burning associated with fever and chills)? Review the body system related to this symptom now rather than waiting for the Review of Systems section later. Many clinicians review the person’s medication regimen now (including alcohol and tobacco use) because the presenting symptom may be a side effect or toxic effect of a chemical.
