What is the in the organization of a health history (8)?
- 1) biographical data
- 2) reasons for seeking care
- 3) Present health status or history of present illness
- 4)previous medical history
- 5) Family hisotry
- 6)personal and social history
- 7)Review of systems (ROS)
- 8) Problem List
Purpose of health history? (3 )
- Establishes subjective database
- Helps develop a problem list
- Helps establish a diagnosis
What is NOT included in the health history?
List of inforamtion included in biographical data?
- Date of Interview
- Clients name
- Marital Status
- Ethnic origin
- Language (Primary and Secondary)
- Level of Education
- Health insurance
- Source of information (reliability)
What is usually "a short sentence provided by the pt stating the problem and its duration"
Reason for seeking Care/ Chief Complaint
What part of the health history involves a pt voicing their perceptions or concerns with what they feel is wrong?
Present Health Staus or History of Present Illness (HPI)
What mnemonic devices are used for Present Health Status?
OLDCART or PQRST
What does OLD CART stand for?
- Aggravating/Associated factors
- Relieving Factors
What does PQRST stand for?
- Severity Scale
What questions should be asked in a symptom analysis?
- Have you had symptoms before?
- Did you find out what was wrong?
- What diagnostic tests were done? Results?
- Were you treated? was it effective?
What information is included in "Onset"? (3)
- Date and time
- sudden vs gradual
- Any predisposing factors? (sick contacts)
What information is included in "Location"? (2)
- 1) Location of problem
- 2) localized vs radiate
What information is included in "Duration"? (3)
- How long does it last?
- How frequent is problem?
- Is problem constant or intermittent?
What information is included in "Character" of Present illness? (3)
- Quality (sharp, dull, throbbing)
- Quantity/Severity (quantifiable measurements)
- Pt description (feels like an elephant is sitting on my chest)
What is an Aggravating Factor?
Something that makes pain/ present illness worse
What is a Relieving Factor?
Something that makes the symptoms better.
What questions should be asked for "Treatment"?
- What has the patient tried?
- What was the effect of the treatment?
Why is it important to collect a past health history or past medical history (PMH)? (2)
- It may affect current health status
- It may affect how pt responds to illness
What information is asked in a PMH? (12)
- 1) childhood illness
- 2)Serious or chronic illness
- 3) hospitalization
- 4) Accidents injuries
- 5) Operations
- 6) Blood Transfusions
- 7) Obstetric History
- 8) Immunization
- 9)Screening tests
- 10) Healthcare maintenance
- 11) Allergies
- 12) Current Medications
List of several common childhood illnesses
- rheumatic fever
- scarlet fever
- varicella (chicken pox)
What information is needed about past hospitalizations? (5)
- Name of hospital
- reason for hospitalization
- length of stay
What information regarding accidents/ injuries should be recorded? (3)
- Nature of accident?
- Any resulting disability
What information regarding an operation is needed? (4)
- What procedure was done?
- Reason for procedure?
- Date/ age
- sequela (complications)
Why is blood fusion history important?
It may help in the identification of infectious disease transmission
What is gravida?
The number of pregnancies a woman has had
What is "Para"?
carrying a pregnancy to a 500g weight or 20 weeks gestation (regardless of survival)
What is "Still-birth"?
loss of baby after 20 weeks gestation
What is an abortion?
loss of baby before 20 weeks gestation
What is another name for a "spontaneous abortion"?
What is another name for an induced abortion?
How are multiple births classified?
e.g.- one pregnancy with twins = G1P1 (twins)
What information is recorded for a woman's delivery history? (6)
- Type of delivery
- condition of infant
Besides the date, what other information may need to be recorded involving a persons immunization record?
- Any adverse reactions?
- If an immunization is "not applicable" due to age or situation
How often i a tetanus shot given
Every 10 years
Who is given Zostavax (vaccine for herpes zoster prophylxis)?
adults >60 yrs
What immunizations do healthcare workers need?
- Hep B
- Influenza (annual)
- MMR (if not immune)
- Varicella (if not immune)
How many injections are given in the Hep B series?
3- today, 1 month, 6 months
What are the common vaccines for children?
- Hflu( HIB)
- Hep A
Gardisil helps protect against?
HPV that causes external genital warts, and cervical cancer
available to young men an women
What populations are encouraged to receive meningococcal vaccine? (3)
- college freshman in dorms
- Military recruits
- high risk individuals (eg after splenectomy)
Blood tests (titers) are a screening test that asses for what? (3)
- Assess for immunity or infection (MMR, varicella)
- Assess for infection (HCV, HIV, Syphilis/RPR)
- Assess for lead poisoning
The two types of Tests for TB Surveillance?
What does PPD stand for?
Purified protein derivative
What is another name for inactive TB?
Latent TB infection (LTBI)
What is done if a TB test is positive?
A chest x-ray is done to see of there is evidence of active TB
What is a disadvantage of a Blood test for PPD?
It does not differentiate between active TB and LTBI
What is an advantage of a TB blood test?
It eliminates false positives from the BCG vaccine
Health care Maintenance include what exams? Name a few
- Eye exam
- chest x-ray
- Lipid panel
- Physical exam
- PAP smear
How should health care maintenance exams be recorded in the health history?
Write date and the results, or indicate if "never done"
What is NKA?
No known allergies
What is NKDA?
No known drug allergies
Name common allergens (6)
- SEasonal (pollen)
How should allergies be recorded?
The allergen and type of reaction
Besides prescriptions, what else is considered 'current medications'?
What information is needed for current medications?
- Drug name,
- route frequency
- duration of usage
Why is it important to list OTC as part of current medications? (3)
- Not all OTC drugs are harmless
- There may be drug interactions with their prescriptions
- Pt may be confused with generic and trade name (Motrin and Ibuprofen)
What is the name of the diagram for a family history?
genogram (family pedigree)
What is documented in a genogram?
- The age of family members
- age which illness occurred
- age of death and cause
- medical problems
- If family member is alive and well (A&W)
What is included in a persons social history? (4)
- Hosuing/living situation
- Occupational Hisotry
- Economic Staus
What type of information may be recorded under habits?
- Tobacco use
- Drug use
- Sleep habits
How is pack year history equated?
Packs per day x number of years smoked
2 ppd x 10 years = 20 pk year hx
What information is needed regarding alcohol consumption? (4)
- Type of alcohol
Why is the term "social drinker" not used?
Social drinker means different things to different people. it is not quantifiable
What information regarding sleep is recorded? (3)
What is recorded under "Housing and Living Situations"?
- List of household members and their relationships
- marital history
- pattern and quality of relationships
- h/o of domestic violence
- description of support systems
What is recorded for a persons occupational history?
- List of jobs for past 5 years
- Level of job satisfaction
- level of job stress (physical and mental)
- current number of hours worked per week
What is usually discussed in the economic status portion of the health history?
- Any financial concerns by the pt.
- Need or use of social services
What is detailed in the Review of Systems portion of the health history?
Any positive findings (date of onset, treatment, response to treatment, sequela)
What is written in the Problems List? (4)
- List of past resolved problems
- List of chronic unresolved problems
- List of acute problems
- Risk assessment (list of potential or high risk problems)
In a child health history who is data usually obtained from?
The parent, but include child when appropriate.
What is included in a childs health history that is not in an adults?
- Parental concerns
- Prenatal, L&D, postnatal problems
- parents coping ability
- developmental skils/milestones
At around what age is the health history taken changed from pediatric to adult?
12- 14 years of age
What considerations need to be taken into affect with older adults and their health history?
- They may underestimate their symptoms
- May be taking many drugs (potential drug interation)
- Their ability to take care of themselves or live independently
- tailor questions related to problems of aging