Health Assessment and Diagnostic Tests Flashcards
Health history’s purpose and correlation to physical exam
- Begins client-provider relationship
- Identifies the client’s main concerns
- Provides information concerning client’s SDOH
- Provides infroamtion for risk assessment and health promotion
- Provides focus for physical examination and diagnostic/screening tests
- Provides information about cultural variations in health beliefs and practices
Health history communication principles
- Use inclusive language
- Assess health literacy
- User active listening
- Address sensitive issues
- Adopt cultrual humility
Use inclusive language
“Partner” or “spouse” instead of “boyfriend” or “husband;” client-preferred pronouns if transgender, gender nonconforming, or gender queer; options on forms refarding gender to include transgender and “other,” with option to write in gender identity
Assess health literacy
The degree to which an individual is able to obtain, process, and understand basic health information and services needed to make health decisions; use appropriate written and graphic materials, patient navigators, trained medical interpreters
Use active listening
Start with open-ended questions, focus on what is being said, reflect back on what is heard to confirm mutual understanding, allow silence for client to have time to express thoughts and feelings.
Address sensitive issues
Be nonjudgmental, respectful; ensure confidentiality
Adopt cultural humility
Be humble about recognizing limits of own knowledge of a client’s situation, avoid generalizing assumptions, be aware of own biases, use patient-centered communication
Components of the health history
- Reason for visit/chief concern
- Presenting problem/illness: OLD CARTS
- Past health history
- Current health status
- Family health history
- Psychosocial history
- Obstetric history
- Menstrual history
- Sexual history/contraceptive use
- Review of systems
- Concluding question
Reason for visit/chief concern
Brief statement in client’s own words of reason for seeking health care
Presenting problem/illness
Chronological account of probelm(s) for which client is seeking care
a) Description of principal systems should include OLD-CARTs mnemonic:
1. Onset
2. Location
3. Duration
4. Characteristics
5. Aggravating/associated factors
6. Relieveing factors
7. Temporal factors
8. Severity
b) Include pertinent negatives in symptom descriptions; when a symptom suggests that an abnormality may exist or develop in that area, include documentation of the absence of symptoms that may help eliminate some of the possibilities
c) Describe the impact of illness/problem on client’s usual lifestyle
d) Summarize current health status and health promotion/disease prevention needs if client has no presenting probelm
Past health history
- General state of health as client perceives it
- Childhood illnesses
- Major adult illnesses
- Psychiatric illnesses
- Accidents/injuries
- Surgeries/other hospitalizations
- Blood transfusions - dates and number of units
Current health status
- Current medications: prescription, OTC, herbal, review medications prescribed by all health providers the client sees for care (medication reconcilliation)
- Allergies: name of allergen, type of reaction
- Tobacco, vaping, marijuana, alcohol, substances (e.g. pain fumes), prescription drugs taken as other than intended use, ilicit drugs - type, amount, frequency
- Nutrition: 24-hr diet recall, recent weight changes, eating disorders, special diet
- Screening tests - dates and results
- Immunizations - dates
- Sleep patterns
- Exercise/leisure activities
- Enviornmental/occupational hazars
- Use of safety measures - safety belts, smoke detectors
- Disabilities - funcitonal assessment if indicated
Family Health History
Provides information about possible genetic, familial, and environmental associations with client’s health
1. Age and health or age and cause of death of immediate family members - parents, siblings, children, spouse/significant other
2. Specific conditions to ask about: heart disease, hypertension, stroke, diabetes, cancer, epilepsy, kidney disease, thyroid disease, asthma, arthritis, blood diseases, tuberculosis, alcoholism, allergies, congenital anomalies, mental illness, genetic disorders
3. Include targeted genetic/familial risk assessment for hereditary breast and ovarian cancer syndrome as well as other hereditary cancer syndromes
4. Indicate if client is adopted and/or does not know family health hsitory
Psychosocial history
- Living situation
- Acesses to care
- Support system
- Intimate-partner violence/domestic violence
- Stressors and coping mechanisms
- Religious/spiritual/cultural practices and preferences
- Outlook on present and future
- Special issues to address with adolescent clients include HEADSS: home, education, activities, drugs, sex, suicide
- Cultural assessment considerations:
* Cultural/ethnic identification: place of birth, length of time in country
* Communication: language spoken, use of nonverbal communication, use of silence
* Space: degree of comfort with distance between self and others, degree of comfort with touching by others
* Social organization: family structure and roles, influence of religion/spirtuality
* Time: past-, present-, or future-oriented; view of time - clock-oriented or social-oriented
* Environmental control - internal or external locus of control, belief in supernatural forces
* Use of culturally based healing practices or remedies
Obstetric history
May include in separate section, past health history, or review of systems - includes all pregnancies regardless of outcome
1. Gravidity: total number of pregnancies including a current pregnancy
2. Pariet: total number of pregnancies reaching 20 weeks or greater gestation
* Include term, preterm, and stillbirth deliveries
* Include length of each pregnancy; tyupe of delivery; weight and sex of infnat; length of labor; complications during prenatal, intrapartum, or postpartum periods; infant complications; cause of stillbirth if known
3. Ectopic pregnancies - treatment provided
4. Abortions - spontaneous and induced
5. GTPAL: gravida, term, preterm, abortion, living children is a commonly used method of obstetric history notation
6. Any fertility evaluation and treatment
Menstrual History
May include in separate section or in reivew of systems
1. Age at menarche, regularity, frequency, duration, and amount of bleeding
2. Date of last normal menstrual period
3. USe of pads, tampons, douching
4. Abnormal uterine bleeding
5. Premenstrual symptoms
6. Dysmenorrhea
7. Perimenopausal symptoms
8. Age at menopause, use of hormone therapy, postmenopausal bleeding
Sexual History/Contraceptive Use
May include in separate section, under current health status, or review of systems
1. Age at first sexual intercourse - consensual/nonconsensual
2. History of sexual abuse or sexual assault
3. Sexual orientation
4. Gender identity
5. Current sexual relationship(s)
* Frequency of intercourse
* Satisfaction or concerns with sexual relationship(s)
* Dyuspareunia, orgasmic, or libido problems
6. Sexually transmitted infection (STI)/HIV infection risk assessment
* Total number of sexual partners and number in past 3 months
* Types of sexual contact - vaginal, oral, and/or anal
* Previous history of STIs
* Use of injection drugs or sec with partner who has used injection drugs
* Sex while under the influence of alcohol and/or drugs
* Previous testing for HIV
7. Current and future desire for pregnancy
8. Contraceptive use
* Establish if pregnancy is not a concern - hysterectomy, sterilization, not sexually active, only sexually active with females, menopausal
* Current method, length of time used, satisfaction, problems or concerns
* Previous methods used, when, length of time used, satisfaction, problems or concerns, reason for discontinuation
Review of Systems
Used to assess common symptoms for each major bocy system to avoid missing any potential or existing problems; special focus for gynecologic and reproductive health includes:
Endocrine
1. Amenorrhea or infrequent menses
2. Heavy or prolonged menstrual bleeding
3. Premenstrual symptoms
4. Difficulty becoming pregnant
5. Heat/cold intolerance
6. Excessive hair growth or hair loss
7. Recent weight change
8. Hot flashes
Gentiourinary
1. Painful periods
2. Abnormal vaginal discharge
3. Pain with sex
4. Pain with urination, blood in urine, frequent urination
5. Unintended urine leaking, leaking urine with cough or lifting, urgency to urinate
6. Postmenopausal bleeding
Breasts
1. Pain
2. Lumps/masses
3. Nipple discharge
Concluding Question
Is there anything else I need to know baout your health to provide you with the best health care?
Risk Factory Identification
- Consider prevalence (existing level of disease) and incidence (rate of new disease) in general populatipon and in your client population
- Determine risks specific to the client related tot he following:
* Gender
* Age
* Ethnic or racial background
* Family history
* Environmental exposures
* Military service - currently serving or veteran, deployment locations, role, related phsyical/mental health issues
* Lifestyle
* Geographic area
* Inadequate preventive health care
Problem-Oriented Medical Record
Organized sequence of recording information using SOAP format
1. SOAP format
* S: subjective information obtained during history. When writing history, use terms such as “reports,” “endorses,” or “describes,” rather than “complains of.”
* O: objective information obtained through physical examination and laboratory/diagnostic test results
* A: assessment of objective and subjective data to determine a diagnosis with rational or prioritized diagnosis
* P: plan to include diagnostic tests, therapeutic treatment regimen, client education, referrals, and date for reevaluation
2. Problem list: list each identified exisitng or potential probelm and indicate both onset aresolution date
3. Progress notes: use SOAP format for information documented at follow-up visits
Purpose of Physical Examination
Correlation to health history
1. Findings may indicate need for further health history information
2. Takes into account normal physical variations of different age and racial/ethnic groups
