PMH; social hx; family Hx Flashcards
past medical history
overall assessment of pts health before present illness; subjective;
past medical history may include what?
general health and strength; major childhood illnesses; major illnesses; previous hospitalizations; ObGyn history; drug history
family history
4 generations if possible; grandparents, parents, aunts/uncles siblings and children AND spouse
social history
documents factors in person’s lifestyle, environment and personal habits; how person maintains health;
What all falls under the category of social history?
nationality, ethnicity, language; marital status; occupation; military history; sexual orientation; education level; habits (nutrition, care, eating/sleeping patterns etc); violence and safety;
What guidelines are used to determine alcohol usage?
CAGE
c: cutting down
a: annoyance
g: guilty
e: eye-openers
HITS of domestic violence
h: hurt you physically?
i: insult or talk down to you?
t: threaten you w/ physical harm
s: scream or curse at you
FICA of social history
F: faith, belief, meaning
I: importance and influence
C: community
A: address/action in care
important considerations in children’s PMH
age potty trained; school; dentition; growth; pubertal devpt;
Social history = behavioral status; family circumstance
important considerations in adolescent history
flexibility, respect and confidentiality.
important considerations in pregnant women history
LMP; expected date of delivery; occupation; father and occupation; obgyn history
PMH: HIV, hepatits, tb,
Social hx: feelings toward preg.; plans for labor, breastfeeding, tobacco/alochol use
Important considerations in older adults history
sensory loss; memory loss; pain; mobility; upper extremity function; housework ; activities of daily living
Steps in finishing the history taking
- tell the pt you have covered everything
- check that pt has nothing to add
- summarize info and make sure it’s accurate
- explain what will happen next
- thank the patient
