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What is the purpse of the complete health history?
- - established the subjective data base
- - helps in developing in a problem list
- - helps to establish a diagnosis
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What is the organization of the health history?
- 1. biographical data
- 2. reason for seeking care or chief complaint (CC)
- 3. Present health Status or History of Present Illness (HPI)
- - OLD CART
- 4. Previous Medical History
- a. Childhood illnesses
- b. serious or chronic illnesses
- c. hospitalizations
- d. accidents or injuries
- e. operations
- f. blood transfusions
- g. obstetric history
- h. immunizations
- i. screening tests
- j. health care maintenance
- k. allergies
- l. current medications
- 5. Family History
- 6. Personal and social history
- 7. Reveiw of System (ROS)
- 8. Problem list
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What is "Reason for Seeking Care or Chief Complaint (CC)" entail?
- - may focus on illness or wellness needs (e.g. routine physical exam or sore throat)
- - usually one sentence stating problem and its duration
- - for clinic patients, ask why you are here today (you may need to focus on the most important problem)
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What does Present Health Status or History of Present illness entail?
- - well pt (short statement of general health)
- - ill pt
- -provide a symptom analysis and describe the characterisitics of the symptoms (OLDCART, PQRST)
- - pt's perception
- - what do you think is wrong?
- - What are your concerns?
- - how are you affected by the illness, etc.
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What are type of questions you can ask for symptom analysis?
- 1. have you ever had these symptoms before
- 2. Did you find out what was wrong?
- 3. What diagnostic tests were done? What were the results?
- 4. How were you treated? Was the treatment effective?
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What does OLDCART stand for?
- O Onset
- - date/time
- - sudden/gradual
- - predisposing factors (e.g., exposure to "sick contacts")
- L Location
- - point with one finger
- - Where does the pain radiate?
- D Duration
- - how long does it last?
- - Frequency (How often does it occur?)
- -Constant/intermitten (if intermittent, does it subside completely between episodes?)
- C Character
- A Aggravating Factors/Associated Factors
- R Relieving factors
- T treatment
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What does Character from OLDCART entail?
- Quality
- - e.g. sharp, dull throbbing, vise-like, pressure, etc.
- - e.g. bright red blood on tissue; black, sticky, tar-like stools
- Quantity/Severity (Quantify measurments when possible)
- - e.g. blood (saturated 2 pad per hour)
- - e.g. pain (scale [e.g. 0=no pain and 10=severe pain)
- - ask regarding ability to do activities of daily living (ADL)
- patient description- "it feels like an elephant is sitting on my chest"
- - "This is the worst headache I've every had"
- -
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What are the Aggravating Factors/Associated Factors of OLDCART?
- - Aggravating factors (What makes the pain worse?)
- -e.g. bending forward, lifting, walking up stairs, running
- - e.g. eating (any food-fatty food-spicy food)
- -Associated Factors
- -e.g. chest pain (nausea, vomiting, diaphoresis, dyspnea and L arm pain) r/o MI
- - e.g. dysuria (shaking chills and fever)- r/o infection
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What are the relieving factors of OLDCART?
What makes the symptoms better? (e.g. position)
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What does the Treatment part of OLDCART mean?
- What has the pt tried; what was the effect
- - 70-90% of all illnesses are treated first with self-care
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Past health history or past medical history may affect what?
- - may affect current health status
- - may affect how the pt responds to illness
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What would you include for childhood illnesses?
List the illnesses and date [or age] of occurrence; additional details should be identified in the review of systems.
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What would you include for serious or chronic illnesses?
"list" the illnesses and date [or age] or occurence; additional details should be identified in the Review of Systems
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What would accident/Injuries include and some examples?
- Dates, nature of event and resulting disability
- - burns
- - fractures
- - lacerations
- - loss of consciousness
- - penetrating wounds
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How would you describe Operations?
- List procedure
- indication for procedure (if unclear), date [or age]
- e.g. hysterectomy for uterine fibroids, age 35, complicated by incisional wound infection
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What would you include for blood transfusions any why is it important to note?
- Note the dates.
- - may help in the identification of infectious disease transmission.
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What would you include in Obstetric History?
- 1. gravida (number of pregnancies)
- 2. Para (carrying a pregnancy to a 500 g weight or 20 wks gestation, regardless of survival.
- 3. Still birth (loss of baby after 20 weeks gestation)
- 4. Abortion (loss of baby before 20 weeks gestation)
- - spontaneous (SAB)= miscarriage
- - Induced (TAB)= therapeutic AB
- 5. Multiple births (twins,etc.) are counted as one para
- - e.g. one pregnancy with twins= G1P1
- 6. sample documentation
- P2G1SAB1
- 7. Deliveries (dates, type of delivery, sex, birthweight, condition of infant, complications)
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What would you include for immunizations?
List all dates (if known) or year of last immunization and adverse reactions
- some immunizations may not be appropriate due the person's age or situation "not applicable"
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Adult immunizations could include:
- 1. tetanus-diptheria (Td) every 10 years
- 2. Tdap-give one time instead if Td if <65 yo and never received
- 3. MMR if susceptible
- 4. Hep B if at risk
- 5. Influenza-annually for age 50 and over
- 6. Zostavax- single dose vaccine for herpes zoster prophylaxis (indicated for adults > 60 yo)
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Health care workers immunizations should include:
- 1. Hepatitis B (if not previously received)
- 2. Influenza-annual (ethical responsibility; protect your pts)
- 3. MMR if not immune
- 4. Varicella if not immune
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Adolescent immunizations would include:
Hep B series for all (3 injections)- today, in one month, in six months
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Some common childhood immunizations include:
- DPt, Tdap, MMR, Polio. Hflu [HIB], varicella
- - hep A is now recommended 12-23 months old
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How is Hep A shot given and who is it given to?
- -series of 2 injections given 6 months apart
- -given for those at risk (e.g. foreign travel, MSM)
- - there is also a combo immunization for Hep A and Hep B
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Why is the meningococcal shot given and who is it given to?
- - college freshman living in dorms or military recruits
- - other high risk individuals (e.g. after splenectomy)
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Who is the Pneumococcal Polysaccharide Vaccine given to?
age 65 and other high risk individuals
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What do screening tests include and what are some of the types?
- Include the dates and results
- 1) blood tests (titers)
- -assess immunity or infection
- - assess for infection (HCV, RPR, HIV)
- - assess for lead poisoning in children
- 2) TB Surveillance (by skin test or blood test)
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What do TB skin tests indicate?
- - Positive PPD indicates TB infection, but does not differentiate between active TB and inactive TB
- - Inactive TB is called latent TB infection (LTBI)
- - If a PPD is positive, then a chest XRAY is done to see if there is evidence of active TB.
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What would you include for health care maintenance and what are some examples?
- - list the dates and results of the last exam or indicate "never done"
- 1. eye exam
- 2. hearing test
- 3. dental exam
- 4. mammogram
- 5. chest x-ray
- 6. ECG
- 7. Lipid panel (cholesterol, LDL, HDL, triglycerides)
- 8. Physical exam
- 9. PAP smear
- 10. Other (rectal exam, prostate exam, occult blood test, sigmoidoscopy, colonoscopy)
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What would you include for allergies and name some examples.
- (allergens and reactions
- NKA= no known allergies
- NKDA= no known drug allergies
- 1. Medications
- 2. Vaccines
- 3. Foods
- 4. Animals/insects
- 5. Seasonal (pollens, etc.)
- 6. Occupational
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What would you include for current medications?
Preceiption, OTC, herbal, vitamins, calcium
- 1. Drug name
- 2. dose
- 3. route
- 4. frequency
- 5. rationale and duration of use
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Why would you include prescription and over the counter (OTC) drugs?
- - not all OTC drugs are harmless
- - drug interactions (Coumadin and ASA)
- - Confusion with generic and trade names (pt may not know that Motrin and Ibuprofen are the same, therefore may be taking both)
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Why would you include calcium?
- -achieving peak bone mass before age 25 can decrease the risk of osteoporosis.
- - 9 out of 10 teenage girls fail to consume adequate calcium
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What are the age specific calcium needs for both sexes?
- 4-8 yo: 800 mg/day
- 11-24 yo: 1200-1500 mg/day
- > 25 yo: 1000 mg/day
- postmenopausal & men >65 1500 mg/day
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Why do you take a family history and what type of medical problems do you record?
- - identify age of family members, age at which an illness occurred, age of death and cause of death
- - if family member is healthy without illness, document as alive and well
- - record medical problems such as cancer, heart disease, diabetes, asthma, mental illness, high blood pressure, stroke, kidney disease, alzheimer's disease, thyroid disease, obesity, vision/hearing loss, birth defects, blood disorders, genetic diseases, substance abuse, etc
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What types of personal and social history would you consider?
- 1. habits (past and present)
- 2. Housing and living situation
- 3. Occupational history
- 4. Economic status
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What type of habits would you discuss?
- 1. Tobacco (cigarettes, cigars, pipe, smokeless; indicate if never
- smoked, current smoker, or date of cessation; document pack year
- cigarette history if applicable.
- - pack year history= ppd x # of years smoked
- 2. Alcohol (type, amount, frequency, duration): don't record as social drinker
- 3. Drug Abuse (type, amount, frequency, duration)
- 4. Sleep (quantity, quality, problems)
- 5. exercise (type, frequency, duration)
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What does housing and living situation entail?
- -list household members and relationships, marital history and children
- - describe the pattern and quality of family relationships/interactions and h/o domestic violence. Describe support systems.
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What would you factor in for occupational history?
- - list you jobs for the past 5 years and the dates for each
- - describe you level of current job satisfaction and job stress (physical and mental)
- - current number of hours per week
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What is considered in the review of systems?
- 1. general overall health
- 2. skin, hair and nails
- 3. head and neck
- 4. eyes
- 5. ears
- 6. nose and sinuses
- 7. mouth and throat
- 8. breast
- 9. heart and peripheral vascular
- 10. gastrointestinal
- 11. urinary
- 12. musculoskeletal
- 13. neurologic
- 14. psychological
- 15. endocrine
- 16. hematologic
- 17. female
- 18. male
- 19. sexual health
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What would your problem list include?
- 1. list past resolved problems
- 2. List chronic unresolved problems
- 3. List acute problems (current problems of less than 6 weeks duration)
- 4. Risk assessment (list potential or high risk) problems)
- - i.e. increased risk of osteoporosis related to inadequate calcium intake
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Describe the child health history?
- 1. most data obtained from the adult, but include the child when appropriate (indicate the source of info (parent?)
- 2. Parental concerns
- 3. Prenatal data (mother's health status), labor and delivery and postnatal problems
- - mother smoking (smaller birth wt)
- - ETOH abuse (fetal alcohol syndrome)
- - difficult delivery (effect on mental development)
- 4. ask parents who the child manifests symptoms (e.g. earache)-behavior?
- 5. Ask regarding parent's coping ability (may affect the child)
- 6. Ask regarding parent's health problems (genetic predisposition, e.g. asthma)
- 7. Current developmental tasks (infants and yound children)
- - gross motor, fine motor, lanuage, social skills
- 8. past health included developmental milestones (growth, toilet training, etc)- were these events on the normal growth and development schedule?
- 9. Review of Systems
- - birthmarks, ability to see the blackboard at school, problems, immunizations
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What are some adolescent health history considerations?
- - use the pediatric data base until age 12-14, then use the adult health history
- - parents may or may not be present during history taking depending on the age of the child
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What are some older adult considerations?
- 1. may understate their symptoms (may think its part of getting old) e.g. may fail to mention fatigue and decreased activity tolerance which may be an early sign of CHF
- 2. Polypharmacy (consider potential drug-drug interactions and numerous side effects)
- 3. Review of Systems
- - dentures, dry skin, decreased sensation in feet, appetite changes, elder abuse, hearing and vision loss, etc.
- 4. functional assessment-measures the pt's self-care ability and ability to live independently
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