Chapter 4 The Complete Health History Guided Reading

Chapter 4: The Complete Health History Guided Reading              Heath History Purpose of Health History is to collect subjective data. o Subjective Data: What the patient says about themselves o Objective Data: What is observed through measurement, inspection, palpation, percussion Record date and time of interview Record source of history: o Record of who furnishes info: patient, parent, translator, family member, guardian o Judge how reliable info seems (if not, why-intoxicated, appears to not have patient’s best interest..) and if he or she is willing to communicate. o Note if they appear ill or well at time of interview The health history includes: biographical data, source of history, reason for seeking care, present health or history of present illness, past health, family history, review of systems and functional assessment including activities of daily living (ADLs).          Biographical Data Includes the following information: Name and preferred name, address, phone number, age, birthdate, birthplace, gender, marital/partner status, language, special needs, race, ethnic origin and occupation. Cultural awareness is important as some ethnic, cultural and spiritual practices impact healthcare (scientologists, Jehovah’s witness, etc.)             Reason for Seeking Care Includes a brief, spontaneous statement in the person’s own words that describes the reason for the visit. May include 1-2 signs and/or symptoms. Signs: Objective abnormality that the examiner could detect on physical examination or labs. Symptoms: Subjective sensation the person feels from the disorder.   Include eight critical characteristics, include the PQRSTU pneumonic and the questions you would ask the client to illicit the information for PQRSTU: P- Provocative or Palliative Provocative- what causes is or exacerbates it? Palliative: what makes it better? Ex. What brings it on? What were you doing when you first noticed it? What makes it better? Q- Quality or Quantity              Present Health or History of Present Illness                                                           Ex. Can you describe the symptom? How does it look, feel, sound? How intense/severe? What does it feel like? R- Region/Radiation Radiation: Does it spread, do you feel it anywhere else? Region: Where is the pain Ex. Where is it? Does it spread anywhere? S- Severity Scale Ex. On a scale of 0-10, 0 being no pain and 10 being the worse pain you have ever felt in your life, what is your pain level? Is this an acceptable level of pain? T- Timing Onset, Duration, Frequency Ex. When did it first start? How long does it last? How Often? U- Understand patients’ perceptions/perspective This may or may not be helpful, but it’s important to get this insight. Ex. What do you think is going on? What do you think it means? OLD CARDS: (not on test, another way to remember same thing..) O- Onset L- Location D- Duration C- Character A- Aggravating R- Relieving T- Timing S- Severity  Childhood illnesses: Measles, mumps, rubella, chicken pox, pertussis, and strep. Ask about serious illnesses that may have severe problems for the person in later years (rheumatic fever, scarlet fever, poliomyelitis). ear tubes, etc. Accidents of injuries: Auto accidents, fractures, penetrating wounds, head injuries (if associated with unconsciousness) and burns. Serious or chronic illnesses: Asthma, depression, diabetes, hypertension, heart disease, HIV, Hepatitis, Sickle cell anemia, cancer and seizure disorders, skin conditions, etc. Hospitalizations: Cause, name of hospital, how condition was treated, how long the person was hospitalized, name of physician. Operations/Surgeries: Types of surgeries (including which side if applicable), date, name of surgeon, name of hospital, how person recovered. Obstetric history: Number of pregnancies/Gravidity, number of live births, vaginal of c-section birth, number of preterm births, number of incomplete pregnancies, number of living children.                     Past Health includes:                         For each pregnancy note course, labor and delivery, sex, weight, and condition of infant as well as postpartum course. Immunizations: Assess vaccination history and urge recommended vaccines. Last examination date: Physical date, dental, vision and dental exam dates, ECG, Chest X-ray, Mammogram, pap test, stool, occult blood and serum cholesterol. Allergies: Note allergen and reaction to: medications, food, contact, environmental Include specific reaction for each allergen (this helps know if it is an allergy or if they just don’t like the side effects ex. Morphine) Current medications: All currently prescribed medications- note name, dose, schedule All OTC and nonprescription drugs Herbal remedies and supplements Highlights diseases and conditions that a patient may have an increase risk in getting, Best way to get info is through detailed questionnaire. Record medical condition or disorder and who had it Include coronary heart disease, High BP, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle cell, arthritis, allergies, addiction, mental illness, suicide, seizure disorder, kidney disease, TB etc. Genogram or pedigree is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations such as parents, grandparents, and siblings Family History Tools in Electronic and Print Format: U.S. Surgeon General (My Family Health Portrait) Utah Health Family Tree American Medical Association:            Family History includes: Purpose is to evaluate the past and present health state of each body system What is going on right now and in the recent past (since last assessment-4 hours, weeks?) Presence or absence of all symptoms Remember that this is SUBJECTIVE, reported by patient Evaluate health promotion practices Double check if any significant data was missed       Review of Systems:   Functional Assessment: Measures a person’s self-care abilities in the areas of general physical or absence of illness ADLs: bathing, dressing, toileting, eating, walking,                  Instrumental ADLs (IADLs) needed for independent living: driving, cooking, managing finances, using phone/computer, housekeeping Nutritional/Elimination habits 24 diet recall Food allergies Any unusual bowel or elimination issues Self esteem, self-concept Education level Spirituality and spiritual resources Coping and Stress management Threat of suicide and homicide must be reported? Personal Habits Drug, nicotine and alcohol use/abuse Interpersonal relationships and resources Domestic Violence (spousal, child, elder abuse) Under 18 must report, elderly must report Occupational Health Home environment Financial Situation    What additional information would you include in the biographical data and source of history for children (p. 59)? Name, nickname, address, phone numbers, parents names and work numbers, child’s age, birthdate, birth place, sex, race, ethnic origin, info about child and family members name. Person providing info based on child, impression of reliability, any special circumstances Developmental and Nutritional history are separate sections, due to importance            What specific information should you include in the health history of an adolescent (p. 65)? H: Home environment E: Education and employment E: Eating A: Activities D: Drugs S: Sexuality S: Mental Health: Suicide/depression S: Safety from injury and violence How many hours of sleep and when Social wellbeing and Peer related activities Substance Use/Abuse: Drugs and alcohol, nicotine, caffeine