Chapter 4: The Complete Health History Flashcards
1
Q
Present Health/History of Present illness
A
- location
- character/quality
- quantity/severity
- timing
- setting
- Aggravating or Relieving factors
- associated factors
- pateint’s perception
P: provocative or palliative q: quality or quantity R: region or radiation S: severity scale T: timing U: Understand patient's perception
2
Q
Past health
A
- childhood illness
- accidents or injuries
- serious or chronic illness
- hospitalizations
- operations
- obstetric hx
- Immunizations
- last examination date
- allergies
- current meds
3
Q
Review of systems purposes
A
- evaluate the past and present health state of each body system
- double check in case any significant data were omitted in Present Illness section
- evaluate health promotion practices
4
Q
Review of Systems
A
- General overall health (weight, fatigue, fever, night sweats)
- skin
- hair
- head
- eyes
- ears
- nose and sinuses
- mouth and throat
- neck
- breast
- axilla
- Respiratory system
- Cardiovascular
- Peripheral vascular
- gastrintestinal
- urinary system
- male genital system
18 female genital system - sexual health
- musculoskeletal system
- neurologic system
- hematologic system
- endocrine system
5
Q
Parts of “Complete Health History”
ONLY subjective
A
- biographic data
- source of hx
- reason for seeking care
- present health or history of present illness
- Past health
- Family history
- Review of systems
- Funcitonal Assessment
- Perception of Health
6
Q
Functional Assessment
A
- self-esteem, self-concept
- activity/exercise
- sleep/rest
- nutrition/elimination
- interpersonal relationships/resources
- spiritual resources
- coping and stress management
- personal habits (smoking)
- alcohol
- illicit street drugs
- environment/hazards
- intimate partner violence
- occupational health
7
Q
HEEADSSS for adolescent interview (pg. 65)
A
Home environment Education and employment Eating Activities (peer related) Drugs Sexuality Suicide/depression Safety
