Health History Flashcards
Health History
Purpose
gather info educate re: health risks NEGOTIATE A PLAN what to do to ameliorate s/s where they are and how to move them forward offer counseling
Health and illness
Factors affecting
Social factors
Economic factors
Cultural factors—culturally defined
SZ either medical problem or demonic
Interview Rules
FOCUS ON PATIENT'S AGENDA
LISTEN MORE
*** will tell what is wrong and what they want
to do about it.
Talk less
Do not interruptInterview
Rule of 5 vowels
Audition- listen carefully Evaluation-sort relevant/irrelevant data Inquiry-probe areas for clarification Observation- non-verbal communication Understanding- be empathetic
Preparing for the Interview
Prepare Yourself
Appearnce,
Behavior
Nonverbal–posture, gestures, tone
Preparing for the Interview
Prepare the environment
Private
Comfortable/clean
Appropriate seating
Preparing for the Interview
Note taking
Jot down key items with few words
Maintain eye contact
Interview Techniques
Introduce yourself, WASH HANDS Explain role as student Use appropriate title to address patient Visitors? who are they and can they stay?
Interview Techniques
Invite pt's story use open ended questions f/u pt's lead with direct questions Use continuers--I see, yes, ok..... Confront to draw attention to statement or behavior
Interview Techniques
Interpretation
Reflection
Interpret patients behavior based on your understanding of the situation
echo or mirror what the patient is telling you
Interview techniques
Offer reassurance based on fact
Be empathetic–validate the patient’s feelings
Symptoms
What the patient feels/reports
Not absolute/subjective
Influenced by culture, intelligence, SEC
Signs
What the practitioner finds
Pain becomes a sign when elicited with palpation
Symptom Analysis
location quality quantity 0-10 chronology- timing setting precipitating & alleviating factors Associated manifestations- other s/s
Questioning to Avoid
Suggestive
Rapid fire
Do you feel pain in your left arm associated with your chest pain
Multiple questions at once
Questioning to Avoid
Leading (biased)
Medical Jargon
You haven’t used any illicit drugs, have you?
Communication Techniques
Transitions
Sexual health is really important so I am
going to ask some sexual health questions.
Facilitation- continuers
Confrontation, Interpretation, Reflection, Support
Format of History
Source and reliability
Chief Complaint
anything else you want to discuss
have all your questions been answered
Source is usually patient but could include family and friends; also nursing staff
Chief complaint -concerns causing seeking of medical attention
probe for underlying concerns–changes
underlying reasons for seeking health care
Format of History
Hx of present illness
Use 7 symptom analysis
hx present illness-Amplifies the chief complaint, giving full clear chronological account of symptoms
symptoms, when first appeared, character, relevant ROS, (meds,allergies, smoking or.alcohol)
Format of History
Past medical history
General state of health, past illnesses, injuries,
hospitalizations, surgeries, allergies, immunizations, substance abuse (cigarettes/ smokeless tobacco, recreational drugs, alcohol, diet, sleep patterns, current medications, CAM
)
Format of History PMH
Alcohol use
CAGE (cutting down, annoyance, guilt,
eye opener)
** 2+ answers = 77-94% alcohol abuse
HALT (drink to get high, alone, looking
forward to drinking , and tolerance
Teens use RAFFT questions
RAFFT (to relax, use alone, do friends use, SA in family members, trouble from use)
Format of History PMH
Diet
24 hour diet recall representative of routine eating patterns red vs white meat fish H2O intake Caffeine
Format of History PMH
sleep patterns
current medications
when do they go to bed
problems falling asleep or staying asleep
daytime somnolence
feel rested, snoring
current meds otc and prescription
CAM
Format of History
Health Maintenance
Occupational/environmental hx
Routine medical /dental exams
eye exam
gyn exam
cholesterol
occupational exposures = 50,000-70,000 annual deaths
type of work, how long, hazardous
exposures, protective equipment used
environmental –travel outside the US
Format of the history
Biographical Info
Family hx
Biographical -DOB, Sex, Race, Ethnic
background
Family hx= 1st degree relatives
siblings/parents (some add grandparents)
**understand genogram
Format of the History
Psychosocial /Spiritual hx
Sexuality/reproductive/gynecologic hx History
Psychosocial/spiritual
education, life experiences, personal relationships and patient’s lifestyle
Tailor questions to situation
Vernacular terms can be used ( ball sack)
When in doubt ask!
Domestic violence
feel safe at home
sometimes people with this type of history report abuse, has this ever happened to you?
Format of History
Review of Systems
Series of questions from head to toe with yes/no answers
further questioning required for yes answers
FORMAT of HISTORY
source/reliability Chief complaint hx present illness past medical hx health maintenance occupational/environmental hx biographical information family hx psychosocial/spiritual hx sexuality/reproductive, gynecologic hx Review of Systems
ROS Review of Systems
general
usual state of health fever/chills weight changes fatigue/weakness heat or cold intolerance
ROS Review of Systems
Skin
lumps/bumps rashes/itching hives/ dryness bruising color changes in skin nails or hair
ROS Review of Systems
Head
Dizziness
Headaches
Pain
Fainting (can be culturally appropriate)
ROS Review of Systems
Eyes
Vision Excessive tearing Pain Redness Discharge Injuries
ROS Review of Systems
Ears
Hearing Discharge Pain Ringing Infections
ROS Review of Systems
Nose
Bleeding Infections Discharge Sneezing Injury
ROS Review of Systems
Mouth and Throat
Condition of teeth Last dental exam Bleeding Sore throat Hoarseness Post Nasal Drip
ROS Review of Systems
Neck
Lumps Goiter-enlargement or swelling Pain/Tenderness Swollen glands Thyroid trouble
ROS Review of Systems
Chest
Cough Pain SOA Sputum Wheezing Hemoptysis -cough up blood
ROS Review of Systems
Breast
Women and Men Lumps Discharge Pain/Tenderness BSE Breast self exam
ROS Review of Systems
Cardiac
Chest pain Palpitations DOE Dyspnea on exertion SOA while sleeping Heart Murmur
ROS Review of Systems
Peripheral Vascular
Claudication Swelling Varicose Veins Coolness Alopecia Discoloration Ulcers
ROS Review of Systems
Gastrointestinal
Appetite Excessive hunger/thirst N/V/C/D Abdominal pain/heartburn Stool changes Rectal pain Hemorrhoids
ROS Review of Systems
Urinary
Frequency/urgency/dysuria Stream difficulties (esp. aging men) Incontinence Hematuria Infections
ROS Review of Systems
Genital
lesion/itching/discharge
masses-lumps/bumps
Pain
HX VD
Women
age of menarche
duration of periods/amount of flow
# of pregnancies/deliveries/abortions
ROS Review of Systems
Musculoskeletal
Weakness/fatigue
Joint pain/Stiffness
Muscle cramps/paralysis
ROS Review of Systems
Neurologic
Dizziness/Blackouts
Paralysis
Numbness/Tingling/Burning
Loss of Memory
Health History
All are different
It is a legal document
Patient response
Record + symptoms first then record no or denies and list other symptoms
Pt responses
Silence/over talking/seductive/angry/paranoid
