Complete health history with ROS Flashcards
Components of the complete health history
identifying information/patient profile, chief complaint, history of present illness, past medical history, family history, social history, review of systems
identifying information/patient profile
include info such as name, age, sex, race, birthplace, marital status, occupation, religion, source of referral, and reliability of information
chief complaint
the major reason for the encounter as expressed by the patient; includes duration. Best if in the patient’s own words. Not a diagnosis.
Seven attributes of a symptom
location, quality, quantity, timing, setting, modifying factors, and associated manifestations
present illness
clear, chronological narrative account of he problems for which the patient is seeking care. classify symptoms into 8 dimensions (lots of care says take all appropriate measures)
Questions for location
point to spot; radiate?
Questions for onset
Setting in which the symptom occurred. Where, doing what…
Questions for character
dull, sharp, burning, stabbing, colicky?
Questions for severity
grade on scale of 1-10; worse? better? same?
Questions for timing/chronology
duration? frequency? pattern?
What does “lots of care says take all appropriate measures” mean? (mnemonic)
Location, Onset, Character, Severity, Timing/chronology, Aggravating and alleviating factors, Associated symptoms, Meaning of symptom to patient
Past medical history
general health (as the patient perceives it), childhood illnesses, adult illnesses, psychiatric illnesses, accidents/injuries, surgical procedures, hospitalizations, allergies, obstetrical history, immunizations, and current health status
Current health status
current medications, allergies, immunizations, screening tests, habits (tobacco, coffee, alcohol, drugs), diet, sleep, exercise and leisure activities, environmental hazards, safety measures
family history definition
usually a one or two generation analysis for significant diseases that tend to have a familial distribution
family history components
age and cause of death of family members, health status of family members, known family diseases (diabetes, hypertension, cancer, heart disease, bleeding disorders, sickle cell anemia, stroke, long exposure to diseases such as tuberculosis) and include a description of the illness of family members that contain a psychological impact on the patient, a congenital influence, or a genetic factor or symptoms like those of the patient
social history
an outline or narrative description capturing the most important things about the patient as a person. Includes home situation and significant others, habits (smoking, drug use, alcohol), occupation, sex life, religious beliefs, military service, overseas travel, and psychiatric status (emotional adjustment to work or friends)
Review of systems definition
a specific review of each body system from head to toe. These are questions to be asked of all patients. Ask about common symptoms in each system to identify problems the patient has not mentioned.
Integuement questions
any problems with skin, hair, or nails, rashes, sores (any changes in skin, hair, nails, any cracking, dryness, falling out, moistness, sweating, coloration, itching, or biting)
Head questions
headache, dizziness, trauma (detailed nature of complaint)
Eye questions
changes in vision, itching, redness, discharge (blurring, diplopia, scotoma, photophobia, amblyopia, tearing, pain)
Ears
decrease hearing, pain, popping, discharge (tinnitus)
Nose
any problems with nose (stuffy, runny, bleeding, colds, allergies, smell)
Mouth and throat
sore throat, sores in mouth (dysphagia, sore tongue, swelling of tongue, changes in color or appearance of tongue, bleeding gums, voice, hoarseness, bad taste, teeth)
Neck
any problems with neck (pain, swelling, decreased range of motion, lumps)
