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Purpose of complete health history
*Gives a subjective data base, helps develop a problem list to identify major pt problems; helps to make dx
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*Reason for seeking care/CC
- ~Usually the 1st section
- R: includes wellness needs; if getting phys exam for school
- CC: problem-illness oriented
- -Usually one sentence stating the problem & its duration
- -If clinic pt ask why you are here today
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*Present Health Status (or HPI)
- -Well pt: pts response to the Q you ask (what is their general health status: moderately, generally, very healthy)
- -Ill pt: Analyze the CC in detail
- -progress chronologically from start of symptom til present
- -use logical order & be concise
- -Pts perception: of what they think is wrong. May give clue to what's going on, to understand pts fears
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*HPI
Symptom Analysis
(Q's to address)
- -Have you ever had these sx before?
- -Did you find out what was wrong?
- -What diagnostic tests were done? Results?
- -How were you treated? Was it effective?
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*HPI
Symptom Analysis
(OLD CART)
- O: Onset (date/time, sudden gradual, predisposing factors)
- L: Location (be specific)
- D: Duration (how long it lasts, frequency, constant/intermittent)
- C:Character (quality, quantity/severity, pt description)
- A: Aggravating factors/Associated factors
- R: Relieving factors (what makes sx better)
- T: Treatment (pts own self treatment, effective?)
- -70-90% all illnesses treated w/ self care
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*Medication List
- *Prescription, OTC, herbal, vitamins, Ca++
- -Drug name, route, dose, frequency, rationale, duration of use
- -Drug interactions (ex: motrin-coumadin)
- -Confusion w/ generic names (same drug class, diff names--should not be on more than 1 drug in 1 class)
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*Medication List
Calcium
- -9/10 girls don't get enough Ca++
- -Achieve peak bone mass by 25
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*Medication list
-Ca ++ needs
- -4-8 yo: 800mg/day
- -11-24 yo: 1200-1500mg/day
- - >25 yo: 1000mg/day
- -postmenopausal & men: 1500mg/day
- -must be taken w/ vit D to be absorbed
- -can't absorb more than 500mg at once
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*Allergies
- *Allergens and rxns
- -Medications
- -Vaccines
- -Foods
- -Animals/insects
- -Seasonal (pollen, grass)
- -Occupational
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*Past Health History (PMH)
- *May effect current health status, or how pt responds to illness
- -Childhood illnesses (date/age of occurrence)
- -Serious or chronic illnesses (date/age, addtl info)
- -Hospitalizations (cause, date, name of hospital, treatment, length of hospitalization)
- -Accidents/Injuries (dates/nature of event & resulting disability
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