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What are the overarching categories/areas to ask about in the health hx?
- I. Identifying Data
- II. CC
- III. HPI
- IV. PMH
- V. PSH
- VI. Meds
- VII. Allergies
- VIII. Family Hx
- IX. Social Hx
- X. ROS
- XI RHM
- Have I addressed all of your concerns? Do you have anything to add? Do you have any questions?
- Review
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What systems to ask about as part of PMH?
- 1. General
- 2. Neuro
- 3. Psych
- 4. Vision
- 5. Ears, Nose, Throat
- 6. Neck
- 7. Endocrine
- 8. CV
- 9. Hematological
- 10. Respiratory
- 11. GI
- 12. GU
- 13. Genitals (men); GYN (women)
- 14. Skin
- 15. Ortho/musculoskeletal
- 16. Cancer (if not covered elsewhere)
- 17. Childhood
- 18. Hospitalizations
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In PMH, what to ask under "General?"
- Usual State of health
- Energy level - weakness/fatigue
- Appetite changes
- Wt gain/loss/BMI
- Fever/chills/night sweats
- Pain
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In PMH, what to ask under "Neuro?"
- HA/migraines
- Seizures
- Tremors
- CVA/TIA (mini-stroke)
- Stroke
- Gait disturbance
- Parkinsons Disease
- Myasthenia Gravis
- Memory changes
- Disorientation
- Paralysis
- Lyme
- Bells palsy
- IF DM -- neuropathy
- Syncope or pre-syncope
- Dizziness
- Head injuries
- Any FH of Parkinsons, MG, Lyme, neuropathies
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In PMH, what to ask under "Psychiatric?"
- Nervousness
- Anxiety
- Stress
- Depression
- Hallucinations: see or hear things that others don't see or hear?
- Mood changes
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In PMH, what to ask under "Vision?"
- Acuity
- Blind spots
- Blurred vision (worry about macular degeneration)
- Diplopia (double vision)
- Eye discharge, watering
- Dry eyes & constant tearing (tearing often s/s of dry eyes)
- Corrective wear -- contacts, glasses
- Eye pain
- Redness, swelling
- Photophobia
- Glaucoma, cataracts
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In PMH, what to ask under "ENT?"
- E:
- Earaches
- Discharge
- Tinnitus
- Vertigo
- Tubes?
- Hearing loss, exposure to noise, aids
- N:
- Deviated septum
- Epistaxis (nose bleed)
- Loss of smell (anosmia)
- Chronic congestion, sinus infections, gum pain
- Altered smell or taste
- T:
- Mouth pain
- Daily dental care
- Bleeding gums, lesions
- Hoarseness, voice change
- Sore throat
- Odynophagia (painful swallowing)
- Dysphagia (difficulty swallowing)
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In PMH, what to ask under "Neck?"
- Neck discomfort
- Limited ROM
- Neck lumps or swelling
- Goiter
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In PMH, what to ask under "Endocrine?"
- **Diabetes
- **Hyper/Hypothyroid
- ==> Hot / cold intolerance
- ==> Hair changes/distribution
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In PMH, what to ask under "CV?"
- BP/HTN
- Dyslipidemia, TGs
- MI (heart attack)/Angina/Chest Pain
- CAD
- CHF
- Congenital defects
- Murmurs, arrhythmias
- SOB/dyspnea
- Cyanosis
- Edema
- Varicose veins
- Claudication (limping)
- Ulcers (venous/arterial)
- Mitral valve problem/Rheumatic fever
- DVT
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In PMH, what to ask under "Hematological?"
- Bleeding/bruising tendency
- Radiation exposure
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In PMH, what to ask under "Respiratory?"
- COPD:
- *Asthma
- *Emphysema
- *Chronic bronchitis
- Smoking hx (pack-yrs)
- Cough: if productive ==> color, amnt, consistency
- Last PPD/TB
- Asbestosis: MUST ask carpenters, plumbers, pipe fitters, navy
- PE
- PND/orthopnea (#pillows)
- Wheezing, SOB
- Pneumonia
- Fractured ribs
- Cystic fibrosis
- Pain with breathing
- Hemoptysis
- Last CXR
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In PMH, what to ask under "GI?"
- N/V/D
- GERD
- Appearance of output (melena, blood)
- Heartburn, indigestion
- Jaundice
- Colitis
- BMs/Constipation
- Bloating/gas
- Incontinence
- Hemorrhoids
- Ulcers
- Hepatitis
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In PMH, what to ask under "GU?"
- Burning
- Color of urine
- Urgency, frequency
- Nocturia
- Dysuria
- Polyuria, Oliguria
- Narrowed stream
- Difficulty voiding completely
- Incontinence
- Flank pain, kidney stones
- Hx of UTIs
- Last PSA (men)
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In PMH, what to ask under "Genitals (Men)?"
- Penile or testicular pain
- STIs
- Itch
- Sores of lesions
- Discharge
- Lumps
- Hernia
- Rash
- Erectile function/libido
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In PMH, what to ask under "GYN (Women)?"
- Sexual function/libido
- Menstrual hx
- Age of menarche
- LMP
- Duration
- Amenorrhea
- Menorrhagia
- Premenstrual pain
- Spotting
- Vaginal itch, recurrent/chronic infections
- Menopause
- Post-menopausal bleeding
- Last GYN and Pap
- STIs
- Pregnancies:
- # pregnancies
- # births
- # live children
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In PMH, what to ask under "Dermatology?"
- Skin cancer
- Mole changes
- Pigment changes
- Lesions
- Rashes
- Scars
- Psoriasis
- Eczema -- connected with allergies & ear infections
- Pruritis (itching)
- Bruising
- Amnt of sun exposure, tanning
- Hair and nails:
- Recent loss
- Change in texture
- Color, brittleness
- Breast:
- Pain
- Lumps
- Nipple discharge
- Surgery
- Last mammogram
- Axilla:
- Tenderness
- Lump
- Swelling
- Rash
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In PMH, what to ask under "ortho/musculoskeletal?"
- Fractures
- Joint swelling, pain, stiffness
- Tenderness
- Arthritis (Distinguish RA from OA)
- Gout
- Lupus
- Spine Scoliosis/Lordosis (head & ass)/Kyphosis
- Osteopenia/Osteoporosis
- Limited ROM
- Cramps, muscle pain
- Weakness
- Gait issues (cane, walker, WC)
- Coordination
- Back pain, disc disease
- Accidents
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In PMH, what to ask under "cancer?"
Any hx of cancer besides what has already been discussed
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In PMH, what to ask under "Childhood?"
- Measles, mumps, rubella
- Chicken pox
- Meningitis
- Polio
- Rheumatic fever/heart disease
- Whooping cough (pertussis)
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In PMH, what to ask under "Hospitalizations?"
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What to ask under PSH?
- Any rxn to anesthesia and type
- Dental: caps, crowns, dentures, plates
- Difficulty swallowing
- Complications post-op
- Commonly forgotten: tonsillectomy, appendectomy, C/S
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What to ask under Meds?
- Rx: Name, dose, frequency, time last taken (have them bring in their meds!!)
- OTC
- Herbs
- Alternative healing methods practiced
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What to ask under Allergies?
- DEF:
- Drugs
- Environmental
- Foods
- & Latex!
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What to ask under Family Hx?
- Do genogram of 3 generations:
- Immediate family -- parents and siblings
- Extended family -- grandparents, aunts, uncles
- Indicate A&W, or deceased and age of death
- Include: genetic disorders, blood dyscrasias, arthritis, psych disorders, suicide, sub abuse
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What are the Social Hx categories?
- HEADS:
- Home
- Education/Exercise/Employment
- Activities/Abuse
- Diet/Drugs
- Safety/Sex/Spirituality/Stress/Suicide
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What to ask under Social Hx -- "Home?"
- Who live with? Alone
- Feel safe at home?
- Safety:
- Fire alarm
- Radon detector
- CO detector
- Fire extinguisher in kitchen
- Scatter rugs (elderly)
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What to ask under Social Hx -- "Education/Exercise/Employment?"
- Education:
- Year education completed (want 8th grade to understand pt educ. lit.)
- Disabilities: learning or otherwise
- Exercise:
- Type of exercise (cardio, weights, yoga, pilates, walking...)
- Intensity
- Amount per week
- Affected by any physical conditions?
- Enjoy it?
- Employment:
- Location
- Type of work
- Length
- Exposure to toxins
- Affecting or affected by health conditions?
- Retired?
- Financial situation?
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What to ask under Social Hx -- "Activities/Abuse?"
- Hobbies:
- What do you do for fun? What activity do you enjoy?
- Alcohol:
- Cutting down?
- Annoyed when asked?
- Guilty?
- Eye opener?
- Tobacco/Smoking:
- Pipe, cigar, chewing
- Cigarettes: pack years
- Caffeine Intake:
- Coffee
- Tea
- Soda
- Chocolate
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What to ask under Social Hx -- "Diet/Drugs?"
- Vegetarian / Vegan
- 24 hr recall
- "Recreational" or "street drugs"
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What to ask under Social Hx -- "Safety/Sex/Spirituality/Stress/Suicide?"
- Safety:
- Helmets, Seat belts, Car seats
- Guns in house
- Sunblock
- Domestic violence
- Sex:
- Active? Tell me a little about hx.
- Sleep with men, women, trans, all?
- Protection/Condoms
- Type - vag interc, oral, anal -- penetrator/penetrated?
- STI hx, STI testing
- Birth control?
- Problems with sexual function, libido, orgasm?
- Pregnancy intentions/testing
- Spirituality:
- Faith/belief system
- Coping with health/illness
- Stress:
- Economic
- Family
- Legal - Living will, Power of attorney
- Suicide:
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What about ROS?
- 1. General
- 2. Neuro
- 3. Psychiatric
- 4. Vision
- 5. Ears, Nose, Throat
- 6. Neck
- 7. Endocrine
- 8. CV
- 9. Hematological
- 10. Respiratory
- 11. GI
- 12. GU
- 13. Genitals (Men); 13. GYN (Women)
- 14. Skin
- 15. Ortho/Musculoskeletal
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What to ask under RHM?
- Mammogram
- SBE: self breast exam
- STE: self testicular exam
- Colonoscopy
- Labs: Lipid, TSH, CBC, glucose
- Urinalysis
- Pap
- Dental: dentist, hygiene
- Last Skin Exam
- Last Physical
- Last Eye Exam
- Last PPD
- Last Tetanus (need Q10 years)
- Last EKG/heart test
- Immunizations
- Screening tests (DEXA scan)
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What 3 questions to ask at the end?
- Have I addressed all of your concerns?
- Do you have anything to add?
- Do you have any questions?
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What to Review?
- Note + and -
- Discuss risk factors
- Review RHM
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