Comprehensive Health History Flashcards
What 13 subjects make up a comprehensive health history?
- Chief Complaint/Reason for Visit
- History of Present Illness
- Medications
- Allergies
- Past Medical History
- Past Surgical History
- Health Maintenance
- OBGYN Hx/Male Genital Hx
- Social History
- Functional History
- Sexual History
- Family Medical History
- Review of Systems
What questions are asked regarding the history of present illness?
- Onset (when and setting/circumstances when it began)
- Location
- Duration (how long)
- Characteristics (quality, quantity, generalized or effect on other systems (activity, appetite, sleep)
- Aggravating and Alleviating Factors
- Radiation
- Timing and Treatment
o How often & when and what has the patient used for the problem: visits to other health professionals about this problem - Severity (pain scale (1-10), if problem influencing ADL)
- Associated symptoms
o Other symptoms related to the chief complaint that the patient reports having - Pertinent negatives
o Symptoms expected, based on the chief complaint, that the patient denies having
What questions are asked regarding medications?
- Name, dose, route, frequency, reason for taking
- Prescriptions
- OTC including supplements, herbs
- Include PRN medication
What questions are asked regarding allergies?
- Medication
- Food
- Environmental
- Include type of reaction
What three areas of past medical history should be inquired about, and what follow-up questions should be asked?
- Childhood illnesses
- Adult/Chronic illness
- Psychiatric illness
Include year or age of onset and current status
What specific childhood illnesses should be asked about?
Measles, mumps, chickenpox, rheumatic fever, ear infections, congenital problems, sickle cell anemia
What specific Adult/Chronic illnesses should be asked about?
High blood pressure, diabetes, cancer, asthma, thyroid problems, kidney disease, liver disease, high cholesterol, stroke, blood clots, heart attack
What specific psychiatric illnesses should be asked about?
Anxiety, depression
What details should be obtained regarding surgical history?
- Include year
- Surgeries
- Hospitalizations
- Blood transfusions
- Injuries/accidents
What four categories are asked about under health maintenance?
- Health exams
- Screenings
- Labwork
- Immunizations
What 4 health exams are asked about?
- Physical
- Dental
- Vision
- Hearing
What screenings are asked about?
- Pap smear (age 21+)
- Colonoscopy (age 45+)
- Mammogram (age 40+)
What labwork is asked about?
Cholesterol and Glucose
What immunizations are asked about?
- Childhood
- Flu
- Tetanus
What three categories are asked about when discussing OBGYN history?
- Date of last period
- Gynecological diagnoses
- Pregnancy history
What specific gynecological problems should be asked about?
Abnormal Pap, breast disease, endometriosis, infertility
What pregnancy history should be obtained?
- Gravida, Para (i.e. G2P1001)
o Gravida/G - # of pregnancies
o Parity/P
# of term deliveries (T)
# of preterm deliveries (P)
# of miscarriages/abortions (A)
# of living children (L) - Deliveries (vaginal, cesarean section)
- Complications during or after pregnancy and delivery
What three categories should be discussed when asking about male genital history?
- Fathered any children
- Infertility problems
- Genital diagnoses related to penis, testicles, prostate gland
What specific male genital diagnoses should be asked about?
Cancer, undescended testis, varicocele, prostatitis, implants
Five categories of social history?
- Tobacco Use
- Alcohol Use
- Recreational Drug Use
- Personal History
- Safety
Details regarding tobacco use?
Type, packs/day, # years smoking, year if quit
Details regarding alcohol use?
What, how much, and frequency
Details regarding drug use?
o Marijuana, cocaine, abuse of prescription medications
o Drug, last used, frequency
Eight categories of personal history?
- Marital status
- Occupation/Employment
- Highest level of education
- Hobbies/Leisure Activities
- Religious affiliation or spiritual practices
- Support system,
- Recent life stresses
- How copes with stress
What three safety categories should be asked about?
- Relationships
- Protective Measures
- Work Hazards
What safety questions should be asked about relationships?
feel safe with partner & in living situation,
physical/verbal/sexual abuse or neglect in past/current
What protective measures should be asked about?
seat belt, sunblock, smoke detector
What work hazards should be asked about?
toxins, lifting, repetitive movements
What three categories of functional history should be asked about?
- Nutritional/Diet
- Physical activity
- Sleep
What questions should be asked about nutrition/diet?
Usual daily food intake
Balanced diet
Dietary restrictions
Caffeine intake
Water intake
What questions should be asked about physical activity?
Type
Length of time
Frequency of exercise
Perform activities of daily living independently
What questions should be asked about sleep?
Hours per night
Difficulty falling or staying asleep
Use of sleep aids
Naps
What eight questions should be asked about sexual history?
- Sexually active
- Type of sex (oral, vaginal, anal)
- Number of partner(s) in past year
- Gender of partners (male/female/both)
- History of sexually transmitted infection
- Contraceptive measures (contraception, tubal, vasectomy)
- Use of condoms (always, sometimes, never)
- Sexual concerns or difficulties (arousal, erection, desire)
What should be asked about regarding family history?
*2 generations, include children, siblings, parents, grandparents)
*Note age, if alive/deceased, and any health problems:
*Include diseases and hereditary conditions that put patient at risk
What specific diseases or conditions should be asked about when asking about family history?
cancer, heart disease, stroke, DVT/PE, mental illness, addiction, bleeding disorders
Name 15 systems to ask about in your Review of Systems.
- Constitutional
- Skin, hair, nails
- HEENT
- Neck
- Breasts
- Respiratory
- Cardiovascular and peripheral vascular
- Gastrointestinal
- Urinary
- Genital (female or male)
- Musculoskeletal
- Psychiatric
- Neurologic
- Hematologic
- Endocrine
Constitutional symptoms
weight change, fatigue, fever
Skin, hair, nails symptoms
rashes, sores, hair loss, nail changes
Neck symptoms
Stiffness?
Pain?
Lumps?
HEENT symptoms
Headaches or dizziness?
Vision or hearing problems?
Congestion or sore throat?
Breasts symptoms
Lumps?
Pain?
Nipple discharge?
Respiratory symptoms
Shortness of breath
Cough (productive or dry?)
Wheezing?
Cardiovascular and peripheral vascular symptoms
Chest pain?
Palpitation?
Swelling?
Gastrointestinal symptoms
Abdominal pain?
Nausea/Vomiting?
Diarrhea/Constipation?
Change in appetite?
Rectal pain or bleeding?
Urinary symptoms
Pain, frequency, or urgency with urination?
Incontinence or leaking of urine?
Difficulty urinating?
Genital (female or male) symptoms
Unusual discharge?
Sores?
Pain?
Musculoskeletal symptoms
Pain or swelling?
Stiffness or decreased range of motion
Recent falls?
Psychiatric symptoms
Anxiety or Depression
Suicidal thoughts
Hallucinations
Neurologic symptoms
Fainting episodes?
Tremors or involuntary movements?
Numbness or tingling?
Loss of coordination?
Unusual weakness anywhere?
Difficulty speaking or understanding?
Memory loss?
Hematologic symptoms
Bruise easily?
Unusual bleeding?
Swollen glands?
Endocrine symptoms
Increased appetite or thirst?
Excessive urination?
Heat/Cold intolerance?
Excessive sweating?
