TOPIC 2 Flashcards
what is the purpose of a complete health history?
to collect subjective data and to get a complete picture of a person’s past and present health
what is involved in a complete health history of a well person?
lifestyle, exercise, diet, substance use, risk reduction, health promotion
affirm what they are doing right
what is involved in a complete health history of an ill person?
information about the health problem
what is the health history sequence?
- Biographic data
- Source of history
- Reason for seeking care
- Present health or history of present illness
- Past history
- Family history
- Review of systems
- Functional assessment or activities of daily living (ADLs)
biographical data
Name
Address and phone number
Age and birth date
Birthplace
Sex
Marital status
Race
Ethnic origin
Occupation: usual and present
source of history
Record who furnishes the information, judge how reliable the informant seems and how willing, note any special circumstances
(how reliable is the person providing the information?)
reason for seeking care
Brief, spontaneous statement in the person’s own words that describes the reason for the visit
symptom
subjective sensation person feels from disorder
o What person says is reason for seeking care is recorded and enclosed in “quotation marks” to indicate person’s exact words
sign
objective abnormality that can be detected on physical examination or in laboratory reports
Present Health or History of Present Illness (HPI)
Location (where is the pain)
Character or quality (burning, sharp, dull)
Quantity or severity (using pain scale)
Timing (when did the symptoms appear)
Setting (where/what were you doing when symptoms started)
Aggravating or relieving factors (What makes pain better or worse)
Associated factors (review symptoms related to that body system)
Patient’s perception
HPI and PQRST
mnemonic for pain and symptom
P/P: Provocative or palliative
Q/Q: Quality or quantity
R/R: Region or radiation
S: Severity scale: 1 to 10
T: Timing or onset
U: Understand patient’s perception of problem
Past Health History
-Childhood illnesses (Which ones, how old?)
Accidents or injuries (When, what kinds, lasting effects?)
-Serious or chronic illnesses (HTN, DM, CKD, Lungs… how long, how managed?)
-Hospitalizations
-Operations (When, what, recovery?)
-Obstetric history
-Immunizations
-Last examination date
-Allergies (Note both allergen and reaction)
-Current medications (Med Rec. Prescription and OTC meds and Herbal)
Family Health History
a record of any illnesses or medical conditions that have afflicted members of a person’s family
Functional Assessment
screens the safety of independent living, the need for home health services, and quality of life, THIS INCLUDES ADLs
for a health history on new immigrants what should be included
o Biographical data
o Spiritual resource and religion: assess if certain procedures cannot be done
o Past health: what immunizations, if any
o Health perception
o How does person describe health and illness
o How does person see problems he or she is now experiencing
o Nutrition: taboo foods or food combinations
when assessing an older adult what additional questions/ comments be said?
are ADLs affected by normal aging process or by the effects of chronic illness/disability?
what are they doing to help themselves stay well?
affirm things they are going right and note health strengths
The Older Adult: Past Health History
General health in past 5 years
Accidents or injuries, serious or chronic illnesses, hospitalizations, operations
Last examination
Obstetric status
The Older Adult: Medication Profile
-Current medications (prescription, OTC, herbal)
-consider the individual may be taking a lot of drugs from many different doctors and they may not know they name or what it is used for
-drug adherence
Polypharmacy
use of multiple medications
The Older Adult: Family History
- Not as useful in predicting which familial diseases person may contract, because most of those will have occurred at an earlier age
- describes persons existing social network
CAGE test
used to assess alcohol consumption
-Have you ever thought you should CUT down your drinking?
-Have you ever been ANNOYED by criticism of your drinking?
-Have you ever felt GUILTY about your drinking?
-Do you drink in the morning, an EYE opener?
functional assessment of the older adult
-Requires knowledge of normal aging changes and effects of chronic diseases, heredity, and lifestyle
-Multiple disciplines may participate in assessment
what does a comprehensive geriatric assessment incorporate?
physical examination, mental status, functional status, social and economic status, pain, and examination of physical environment for safety concerns
functional ability
the ability of a person to perform activities necessary to live in modern society; may include driving, using the telephone, or performing personal tasks such as bathing and toileting
