Health Hx

Question 1

#1: INTRODUCTION

Answer 1

Hi! My name is [student’s name] and I’m a nursing student here @ OSU. What’s your name?

Question 2

#2: REASON FOR SEEKING CARE

Answer 2

What brings you here today [patient’s name]?

Question 3

#3: PRESENT HEALTH OR HPI

Answer 3

Are there any secondary issues, fears, concerns that caused you to seek care today?

ASK:

• Onset (gradual or acute)
• Location
• Duration (recent or chronic)
• Characteristics
• Aggravating factors
• Relieving factors
• Treatments (previous tx, dose, duration, and reason d/c’d)
• Severity

Question 4

#3: BIOGRAPHIC DATA

Answer 4

Before we get started, I need to collect some basic information for your medical record.

ASK:

• Age: How old are you?
• Race/ethnic origin: How do you identify yourself racially or ethnically?
• Relationship status: Are you married?
• Occupation: Are you currently working outside of the home or enrolled in school?

Question 5

#5: PAST HEALTH

Answer 5

Next, I’d like to learn more about your health hx to date so that I can get a better sense of your current health needs. How would you describe your general health up until now?

Question 6

#6: MAJOR CHILDHOOD ILLNESSES

Answer 6

Did you ever experience any illnesses or conditions as a child?

EXAMPLES:

• Mumps
• Whooping cough
• Chicken pox
• Scarlet fever
• Rheumatic fever

Question 7

#7: ACCIDENTS OR INJURIES

Answer 7

Have you ever experienced an accident or injury as either a child or adult?

EXAMPLES:

• TBI
• Organ damage
• Spinal injury
• Fractures

ASK:

• Type: What happened?
• Outcome: Did you experience any long-term disability as a result?
• Age: How old were you when this happened?

Question 8

#__: Allergies

Answer 8

Do you have any allergies?

• Drugs
• Food
• Environmental

What type of reaction do you have?

• Rash
• Anaphylaxis

Question 9

12. Course of pregnancy

Answer 9

1. Delivery date 2. Length of pregnancy 3. Length of labor 4. Baby’s weight & sex 5. Delivery type (vaginal or cesarean) 6. Complications 7. Baby’s condition

Question 10

24. CV system

Answer 10

1. Precordial or retrosternal pain (front of ❤️ or behind sternum) 2. Palpitations (rapid, fast, or irregular ❤️ beat) 3. Cyanosis (blue skin) 4. Dyspnea on exertion (difficult, labored breathing, or SOB) –> amount of exertion 5. Orthopnea (# of pillows @ night) 6. Paroxysmal nocturnal dyspnea (wake up @ night coughing or gasping for air) 7. Nocturia (# of times wake up @ night to pee) 8. Edema 9. Hx of heart murmur (turbulent blood flow w/in ❤️) 10. HTN (⬆️ BP) 11. CAD (aka atherosclerosis, plaque build ⬆️ in ❤️’s arteries) 12. Anemia (weakness and paleness c/b by too - RBCs or hemoglobin in blood) HP: Date of last EKG or other ❤️ test & results!

Question 11

17. Family hx

Answer 11

Now for this next part of your health history, I want to know not just about you but you family as well b/c some health conditions are genetic or tend to run in families. By identifying them now, we can work together to reduce your risk. So please let me know if you, your parents, or grandparents have or had any following medical conditions. 1. ❤️ dis 2. ⬆️ BP 3. Stroke 4. Diabetes 5. Blood disorders 6. Breast/ovarian cancer 7. Other cancers 8. Sickle cell 9. Arthritis 10. Allergies 11. Asthma 12. Obesity 13. Alcoholism or drug addiction 14. Mental illness 15. Suicide 16. Seizure dx 17. Kidney dis 18. TB Do you or family members have any other conditions that I didn’t mention? Or, did I cover everything?

Question 12

18. General constitutional symptoms

Answer 12

1. Temperature (fever, chills, or sweats) 2. Weakness or fatigue 3. Weight –> normal, current, recent +/- by what means

Question 13

26. GI system

Answer 13

1. Appetite 2. Food intolerance (feel ill or have pain p eating particular foods) 3. Dysphagia (difficulty or discomfort c swallowing) 4. ❤️ burn 5. Indigestion (pain or discomfort p eating) 6. Pain associated c eating 7. Other abd pain 8. Pyrosis (burning @ esophagus [throat] & stomach + sour stomach) 9. Vomiting –> character 10. Vomiting blood 11. Hx of abd dis (ulcer, liver, GB, jaundice, appendicitis, colitis) 12. Flatulence (gas) 13. Frequency of bm (normal or recent 🔼) 14. Stool characteristics 15. Constipation or diarrhea 16. Black stools 17. Rectal bleeding 18. Rectal conditions (hemorrhoids, fistula [pain/swelling @ rectum) HP: Use of antacids or laxatives!

Question 14

20. Hair

Answer 14

1. Recent hair - 2. 🔼 in texture

Question 15

9. Hospitalizations

Answer 15

1. Dx 2. Outcome 3. Age @ 4. Duration 5. Hospital name

Question 16

13. Immunizations

Answer 16

1. Childhood vaccinations (MMR, 🐔 pox, DTaP [diptheria, tetanus, & whooping cough], polio, rotavirus, Hib [baby flu], hep B, PCV/MCV4 [meningitis] 2. Annual vaccinations (flu) 3. Prophylactic testing (PPD) ❗️hep A, HPV, pneumonia, shingles, cholera, typhus, typhoid, anthrax, smallpox

Question 17

10. Inpatient and outpatient surgeries

Answer 17

1. Procedure type 2. Age @ 3. Outcome

Question 18

14. Last physical exam

Answer 18

1. Date 2. Findings

Question 19

8. Major adult illnesses

Answer 19

1. Name 2. Age @ ❗️TB, hepatitis, DM, ⬆️ BP, ❤️ attack, tropical or parasitic dis, other infections

Question 20

16. Current medications

Answer 20

1. Prescribed 2. OTC 3. Herbal ⚠️ dose + route + frequency

Question 21

21. Nails

Answer 21

1. 🔼 in shape 2. 🔼 in color 3. 🔼 in texture (+ brittle)

Question 22

22. Neck

Answer 22

1. Musculature (ROM) –> pain c movement 2. Lumps or swelling 3. Lymph nodes (enlarged or tender) 4. Goiter

Question 23

11. OB/GYN hx

Answer 23

1. # pregnancies 2. # full term 3. # preterm 4. # abortions or miscarriages 5. # children living

Question 24

25. Peripheral vascular system

Answer 24

1. Coldness 2. Numbness and tingling 3. Swelling of legs –> time of day + activity 4. Discoloration in hands/feet (bluish red, pallor [paleness], mottling [patchy]), esp. in feet & ankles –> position 5. Varicose veins (twisted & enlarged veins @ skin’s surface, typically @ legs & ankles) –> complications 6. Intermittent claudication (muscle pain c/b early PAD AEB aching, cramping, tired, & sometimes pain in legs, esp. calves, @ walking but subsides c rest) 7. Thrombophlebitis (blocked vein AEB areas on leg that are swollen, irritated, or hard to the touch) 8. Ulcers (chronic sore or wound, esp. legs) HP: If work involves long-term sitting or standing, avoid crossing legs @ knees and wear support hose!

Question 25

23. Respiratory system

Answer 25

1. Hx of lung dis (asthma, emphysema, bronchitis, pneumonia, TB) 2. CP c breathing 3. Wheezing or noisy breathing 4. Amount of activity for SOB 5. Cough 7. Sputum (color + amount) 8. Blood 9. Toxin/pollution exposure (dust or smoke) HP: Date of last chest x-ray!

Question 26

19. Skin

Answer 26

1. Hx of skin dis (eczema, psoriasis, hives) 2. Pigment or color 🔼 3. 🔼 in a mole 4. + Dryness, moisture, or itching 5. + Bruising 6. Rashes or lesions 7. Skin care routine HP: Amount of sun exposure and use of sunscreen!

Question 27

27. Urinary system

Answer 27

1. Frequency (# of times per day) 2. Urgency 3. Nocturia (# of times wake up @ night to urinate) –> normal or recent 🔼) 4. Dysuria (painful/difficult urination) 5. Polyuria/oliguria (too +/- urine) 6. Hesitancy/straining 7. Narrowed stream 8. Color (cloudy, blood +) 9. Incontinence 10. Hx of urinary dis (kidney dis, kidney stones, UTIs, prostate) 11. Pain in flank (hip), groin, suprapubic region (⬇️ belly button & ⬆️ genitals), or lower back HP1: Measures to avoid or treat UTIs! HP2: Use of Kegel exercise p childbirth!