WEEK 4 - Health history

Question 1

purpose of a health history

Answer 1

• actual, potential and anticipated problems can be identified
• goals of care can be developed
• interventions can be devised
• effectiveness can be evaluated
• provides mechanism for establishing rapport with patients

Question 2

components of health history interview

Answer 2

1. biological data
2. reasons for seeking care
3. perception of the present state of health
4. past health and medical history
5. family history
6. general overall health and wellbeing
7. health and lifestyle management

Question 3

communication - good skills

Answer 3

questioning - active listening - clarification - providing support - managing awkward moments

Question 4

communication - avoid

Answer 4

medical jargon - expressing judgement - using leading questions - talking too much - providing false reassurance

Question 5

principles of documentation

Answer 5

• relevant, accurate, organised, timely, complete and concise
• the integrity of the document should be maintained
• do not share username and password
• only access medical information that is related to your patient
• don’t take hard copy patient records home

Question 6

preparation for physical examination

Answer 6

1. prepare the environment
2. prepare the equipment
3. prepare the patient

Question 7

positioning the patient

Answer 7

• sitting, standing, supine, sims (laying face down with leg bent up), lithotomy (laying on back with legs bent in air), dorsal recumbent (laying on back with legs bent on bed), prone

Question 8

inspection

Answer 8

• commences upon first meeting with the patient
• involves vision, smell and hearing
• sounds, movement, colour, the effort of breathing, overall appearance, interaction, distress, secretion, muscles

Question 9

ausculation

Answer 9

• listening to sounds produced in the body such as breath, heart, blood and bowel sounds
• pitch, intensity, duration, quality
• can be direct or indirect
• requires use of stethoscope

Question 10

percussion

Answer 10

• tapping of a portion of the body to elicit tenderness, or sounds that vary the density of the underlying structures
• assists in locating organ borders, identifying organ shape, position and consistency
• flat, dull, resonance, hyper resonance, tympany
• direct or indirect

Question 11

palpation

Answer 11

• involves touching and feeling body parts with the hands to determine texture, temperature, moisture, motion, consistency and distension
• fingertips: pulsations
• palmar/ulnar: vibrations
• dorsal surface: temperature