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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
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Purpose of health history? (3 )
- Establishes subjective database
- Helps develop a problem list
- Helps establish a diagnosis
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What is NOT included in the health history?
Objective data
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List of inforamtion included in biographical data?
- Date of Interview
- Clients name
- DOB
- Birthplace
- Sex
- Marital Status
- Race
- Ethnic origin
- Religion
- Language (Primary and Secondary)
- Level of Education
- Occupation
- Health insurance
- Source of information (reliability)
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What is usually "a short sentence provided by the pt stating the problem and its duration"
Reason for seeking Care/ Chief Complaint
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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)
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What mnemonic devices are used for Present Health Status?
OLDCART or PQRST
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What does OLD CART stand for?
- Onset
- Location
- Duration
- Character
- Aggravating/Associated factors
- Relieving Factors
- Treatment
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What does PQRST stand for?
- Palliative
- Quality/Quantity
- Region/Radiation
- Severity Scale
- Timing
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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?
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What information is included in "Onset"? (3)
- Date and time
- sudden vs gradual
- Any predisposing factors? (sick contacts)
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What information is included in "Location"? (2)
- 1) Location of problem
- 2) localized vs radiate
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What information is included in "Duration"? (3)
- How long does it last?
- How frequent is problem?
- Is problem constant or intermittent?
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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)
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What is an Aggravating Factor?
Something that makes pain/ present illness worse
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What is a Relieving Factor?
Something that makes the symptoms better.
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What questions should be asked for "Treatment"?
- What has the patient tried?
- What was the effect of the treatment?
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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
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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
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List of several common childhood illnesses
- Measles
- Mumps
- rubella
- Diphtheria
- Pertussis
- Polio
- rheumatic fever
- scarlet fever
- varicella (chicken pox)
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What information is needed about past hospitalizations? (5)
- Date
- Name of hospital
- reason for hospitalization
- treatment
- length of stay
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What information regarding accidents/ injuries should be recorded? (3)
- Date
- Nature of accident?
- Any resulting disability
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What information regarding an operation is needed? (4)
- What procedure was done?
- Reason for procedure?
- Date/ age
- sequela (complications)
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Why is blood fusion history important?
It may help in the identification of infectious disease transmission
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What is gravida?
The number of pregnancies a woman has had
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What is "Para"?
carrying a pregnancy to a 500g weight or 20 weeks gestation (regardless of survival)
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What is "Still-birth"?
loss of baby after 20 weeks gestation
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What is an abortion?
loss of baby before 20 weeks gestation
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What is another name for a "spontaneous abortion"?
miscarriage
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What is another name for an induced abortion?
Therapeutic abortion
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How are multiple births classified?
One para
e.g.- one pregnancy with twins = G1P1 (twins)
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What information is recorded for a woman's delivery history? (6)
- Date
- Type of delivery
- Sex
- Birthweight
- condition of infant
- complcations
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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
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How often i a tetanus shot given
Every 10 years
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Who is given Zostavax (vaccine for herpes zoster prophylxis)?
adults >60 yrs
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What immunizations do healthcare workers need?
- Hep B
- Influenza (annual)
- MMR (if not immune)
- Varicella (if not immune)
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How many injections are given in the Hep B series?
3- today, 1 month, 6 months
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What are the common vaccines for children?
- DPT
- Tdap
- MMR
- Polio
- Hflu( HIB)
- Varicella
- Hep A
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Gardisil helps protect against?
HPV that causes external genital warts, and cervical cancer
available to young men an women
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What populations are encouraged to receive meningococcal vaccine? (3)
- college freshman in dorms
- Military recruits
- high risk individuals (eg after splenectomy)
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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
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The two types of Tests for TB Surveillance?
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What does PPD stand for?
Purified protein derivative
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What is another name for inactive TB?
Latent TB infection (LTBI)
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What is done if a TB test is positive?
A chest x-ray is done to see of there is evidence of active TB
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What is a disadvantage of a Blood test for PPD?
It does not differentiate between active TB and LTBI
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What is an advantage of a TB blood test?
It eliminates false positives from the BCG vaccine
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Health care Maintenance include what exams? Name a few
- Eye exam
- Hearing
- Dental
- mammogram
- chest x-ray
- ECG
- Lipid panel
- Physical exam
- PAP smear
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How should health care maintenance exams be recorded in the health history?
Write date and the results, or indicate if "never done"
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What is NKA?
No known allergies
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What is NKDA?
No known drug allergies
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Name common allergens (6)
- Medication
- Vaccines
- Foods
- Animals/insects
- SEasonal (pollen)
- occupationa
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How should allergies be recorded?
The allergen and type of reaction
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Besides prescriptions, what else is considered 'current medications'?
- OTC
- herbals
- vitamins
- calcium
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What information is needed for current medications?
- Drug name,
- dose
- route frequency
- rationale
- duration of usage
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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)
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What is the name of the diagram for a family history?
genogram (family pedigree)
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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)
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What is included in a persons social history? (4)
- Habits
- Hosuing/living situation
- Occupational Hisotry
- Economic Staus
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What type of information may be recorded under habits?
- Tobacco use
- Alcohol
- Drug use
- Sleep habits
- Exercise
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How is pack year history equated?
Packs per day x number of years smoked
2 ppd x 10 years = 20 pk year hx
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What information is needed regarding alcohol consumption? (4)
- Type of alcohol
- Amount
- frequency
- duration
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Why is the term "social drinker" not used?
Social drinker means different things to different people. it is not quantifiable
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What information regarding sleep is recorded? (3)
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What is recorded under "Housing and Living Situations"?
- List of household members and their relationships
- marital history
- children
- pattern and quality of relationships
- h/o of domestic violence
- description of support systems
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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
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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
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What is detailed in the Review of Systems portion of the health history?
Any positive findings (date of onset, treatment, response to treatment, sequela)
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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)
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In a child health history who is data usually obtained from?
The parent, but include child when appropriate.
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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
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At around what age is the health history taken changed from pediatric to adult?
12- 14 years of age
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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
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