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Bates Guide to Physical Assessment > Comprehensive Health History > Flashcards

Comprehensive Health History Flashcards

1
Q

What 13 subjects make up a comprehensive health history?

A
  1. Chief Complaint/Reason for Visit
  2. History of Present Illness
  3. Medications
  4. Allergies
  5. Past Medical History
  6. Past Surgical History
  7. Health Maintenance
  8. OBGYN Hx/Male Genital Hx
  9. Social History
  10. Functional History
  11. Sexual History
  12. Family Medical History
  13. Review of Systems
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2
Q

What questions are asked regarding the history of present illness?

A
  • 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
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3
Q

What questions are asked regarding medications?

A
  • Name, dose, route, frequency, reason for taking
  • Prescriptions
  • OTC including supplements, herbs
  • Include PRN medication
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4
Q

What questions are asked regarding allergies?

A
  • Medication
  • Food
  • Environmental
  • Include type of reaction
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5
Q

What three areas of past medical history should be inquired about, and what follow-up questions should be asked?

A
  1. Childhood illnesses
  2. Adult/Chronic illness
  3. Psychiatric illness

Include year or age of onset and current status

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6
Q

What specific childhood illnesses should be asked about?

A

Measles, mumps, chickenpox, rheumatic fever, ear infections, congenital problems, sickle cell anemia

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7
Q

What specific Adult/Chronic illnesses should be asked about?

A

High blood pressure, diabetes, cancer, asthma, thyroid problems, kidney disease, liver disease, high cholesterol, stroke, blood clots, heart attack

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8
Q

What specific psychiatric illnesses should be asked about?

A

Anxiety, depression

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9
Q

What details should be obtained regarding surgical history?

A
  • Include year
  • Surgeries
  • Hospitalizations
  • Blood transfusions
  • Injuries/accidents
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10
Q

What four categories are asked about under health maintenance?

A
  1. Health exams
  2. Screenings
  3. Labwork
  4. Immunizations
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11
Q

What 4 health exams are asked about?

A
  1. Physical
  2. Dental
  3. Vision
  4. Hearing
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12
Q

What screenings are asked about?

A
  1. Pap smear (age 21+)
  2. Colonoscopy (age 45+)
  3. Mammogram (age 40+)
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13
Q

What labwork is asked about?

A

Cholesterol and Glucose

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14
Q

What immunizations are asked about?

A
  1. Childhood
  2. Flu
  3. Tetanus
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15
Q

What three categories are asked about when discussing OBGYN history?

A
  1. Date of last period
  2. Gynecological diagnoses
  3. Pregnancy history
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16
Q

What specific gynecological problems should be asked about?

A

Abnormal Pap, breast disease, endometriosis, infertility

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17
Q

What pregnancy history should be obtained?

A
  • 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
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18
Q

What three categories should be discussed when asking about male genital history?

A
  • Fathered any children
  • Infertility problems
  • Genital diagnoses related to penis, testicles, prostate gland
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19
Q

What specific male genital diagnoses should be asked about?

A

Cancer, undescended testis, varicocele, prostatitis, implants

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20
Q

Five categories of social history?

A
  1. Tobacco Use
  2. Alcohol Use
  3. Recreational Drug Use
  4. Personal History
  5. Safety
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21
Q

Details regarding tobacco use?

A

Type, packs/day, # years smoking, year if quit

22
Q

Details regarding alcohol use?

A

What, how much, and frequency

23
Q

Details regarding drug use?

A

o Marijuana, cocaine, abuse of prescription medications
o Drug, last used, frequency

24
Q

Eight categories of personal history?

A
  1. Marital status
  2. Occupation/Employment
  3. Highest level of education
  4. Hobbies/Leisure Activities
  5. Religious affiliation or spiritual practices
  6. Support system,
  7. Recent life stresses
  8. How copes with stress
25
Q

What three safety categories should be asked about?

A
  1. Relationships
  2. Protective Measures
  3. Work Hazards
26
Q

What safety questions should be asked about relationships?

A

feel safe with partner & in living situation,
physical/verbal/sexual abuse or neglect in past/current

27
Q

What protective measures should be asked about?

A

seat belt, sunblock, smoke detector

28
Q

What work hazards should be asked about?

A

toxins, lifting, repetitive movements

29
Q

What three categories of functional history should be asked about?

A
  1. Nutritional/Diet
  2. Physical activity
  3. Sleep
30
Q

What questions should be asked about nutrition/diet?

A

Usual daily food intake
Balanced diet
Dietary restrictions
Caffeine intake
Water intake

31
Q

What questions should be asked about physical activity?

A

Type
Length of time
Frequency of exercise
Perform activities of daily living independently

32
Q

What questions should be asked about sleep?

A

Hours per night
Difficulty falling or staying asleep
Use of sleep aids
Naps

33
Q

What eight questions should be asked about sexual history?

A
  • 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)
34
Q

What should be asked about regarding family history?

A

*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

35
Q

What specific diseases or conditions should be asked about when asking about family history?

A

cancer, heart disease, stroke, DVT/PE, mental illness, addiction, bleeding disorders

36
Q

Name 15 systems to ask about in your Review of Systems.

A
  • Constitutional
  • Skin, hair, nails
  • HEENT
  • Neck
  • Breasts
  • Respiratory
  • Cardiovascular and peripheral vascular
  • Gastrointestinal
  • Urinary
  • Genital (female or male)
  • Musculoskeletal
  • Psychiatric
  • Neurologic
  • Hematologic
  • Endocrine
37
Q

Constitutional symptoms

A

weight change, fatigue, fever

38
Q

Skin, hair, nails symptoms

A

rashes, sores, hair loss, nail changes

39
Q

Neck symptoms

A

Stiffness?
Pain?
Lumps?

39
Q

HEENT symptoms

A

Headaches or dizziness?
Vision or hearing problems?
Congestion or sore throat?

40
Q

Breasts symptoms

A

Lumps?
Pain?
Nipple discharge?

41
Q

Respiratory symptoms

A

Shortness of breath
Cough (productive or dry?)
Wheezing?

42
Q

Cardiovascular and peripheral vascular symptoms

A

Chest pain?
Palpitation?
Swelling?

43
Q

Gastrointestinal symptoms

A

Abdominal pain?
Nausea/Vomiting?
Diarrhea/Constipation?
Change in appetite?
Rectal pain or bleeding?

44
Q

Urinary symptoms

A

Pain, frequency, or urgency with urination?
Incontinence or leaking of urine?
Difficulty urinating?

45
Q

Genital (female or male) symptoms

A

Unusual discharge?
Sores?
Pain?

46
Q

Musculoskeletal symptoms

A

Pain or swelling?
Stiffness or decreased range of motion
Recent falls?

47
Q

Psychiatric symptoms

A

Anxiety or Depression
Suicidal thoughts
Hallucinations

48
Q

Neurologic symptoms

A

Fainting episodes?
Tremors or involuntary movements?
Numbness or tingling?
Loss of coordination?
Unusual weakness anywhere?
Difficulty speaking or understanding?
Memory loss?

49
Q

Hematologic symptoms

A

Bruise easily?
Unusual bleeding?
Swollen glands?

50
Q

Endocrine symptoms

A

Increased appetite or thirst?
Excessive urination?
Heat/Cold intolerance?
Excessive sweating?

Bates Guide to Physical Assessment (28 decks)

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