202Health History

  1. Purpose of complete health history
    *Gives a subjective data base, helps develop a problem list to identify major pt problems; helps to make dx
  2. *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
  3. *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
  4. *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?
  5. *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
  6. *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)
  7. *Medication List
    • -9/10 girls don't get enough Ca++
    • -Achieve peak bone mass by 25
  8. *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
  9. *Allergies
    • *Allergens and rxns
    • -Medications
    • -Vaccines
    • -Foods
    • -Animals/insects
    • -Seasonal (pollen, grass)
    • -Occupational
  10. *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
Card Set
202Health History
Health History