Taking history Health History Complete Health History Biographic by MikeJenny

VIEWS: 20 PAGES: 8

									                                                                              Health History
                                                              • Usually refers to subjective data
                                                              • Not just past events, but also current
               Taking a history                                 symptoms and situations
                                                              • Several different models
                                                                  – Medical
                                                                  – Several nursing models
                                                              • Several different structures
                                                                  – History and Physical (H&P)
                                                                  – Functional Health Patterns
                                                                  – PBA Neuman Assessment
                                                     Week 2




        Complete Health History                                        Biographic information
•   Biographical Information                                  •   DOB
•   Source and Reliability                                    •   Gender
•   Reason for Seeking Care                                   •   Race
•   Present Health or History of Present Illness
                                                              •   Ethnicity
•   Past Health
                                                                  – ASK!!! DO NOT TRUST YOUR EYES!!!!!!
•   Family History
•   Functional Assessment
•   Perception of Health
•   Review of Systems




          Source and reliability                                        Source and reliability
• Jane Brown accompanied by mother and sister                 • Never leave the term “poor historian”
• Patient claims he does not snore, but wife says he does.      unqualified.
• Patient’s wife scheduled appt and does most of talking.
                                                                  – “When asked about recent injuries, patient
• Patient’s mother answers questions directed to patient.
                                                                    starts relating about an accident fifteen years
• Patient says that he has no allergies, but when asked
  about his rhinorrhea, states that his hay fever is acting
                                                                    ago.”
  up.                                                             – “When asked about completing physical
• Patient states he has never been told he has diabetes.            therapy, patient says yes, but chart indicates
  Chart indicates that he has been referred to diabetic             that PT was completed three years ago.”
  education twice, been given handouts three times, and is
  currently taking metformin.




                                                                                                                      1
              Reason for Seeking Care
         Chief Complaint/Presenting Problem           History of Present Illness
•   “Chest Pain for 2 hours”                    •   Location
•   “Feeling dizzy” after standing up           •   Quality or Character
•   “Follow up” is not a CC                     •   Quantity or Severity
•   “Three month F/U” is not a CC.              •   Duration
•   “3 mo F/U High Blood Pressure” is a CC.     •   Setting
•   “F/U N/O Diabetes 2” is a CC                •   Context
                                                •   Modifying factors
                                                •   Associated signs and symptoms




     Past Medical History (PMH)                                       PMH
• General State of Health                       • Substance use/abuse
• Past illnesses
                                                    – Smoking/Tobacco
• Chronic Illnesses
• Injuries and treatments – lingering effects       – Alcohol
• Hospitalizations – including psychiatric            • CAGE screening
• Surgeries – procedure, date, hospital,            – Recreational drugs
  surgeon                                       • Exercise
• Active/Chronic Problems
• Allergies                                     • Nutrition
    – Environmental                             • Sleep Pattern
    – Food
    – Drugs – See medication history below




                    Medication Hx                              Medication Hx
• Current medications                           • Allergies/ADR’s
    –   Dose                                        – Drug
    –   Frequency                                   – Reaction
    –   Reason
                                                    – Manifestation
    –   Adherence
                                                      • Treatment
• Vitamins                                            • Date
    – Herbal remedies/health supplements              • Repetitions
    – Past medication
         • Dose
         • Reason for taking
         • Reason for d/c




                                                                                    2
                    Allergies                               Health Maintenance
• True allergies are inappropriate immune        • Health Promotion – Primary Prevention
  responses                                      • Disease Detection – Secondary
• Hypersensitivity reactions                       Prevention
    – Type I: Vasoactive response                • Disease Prevention – Primary/Secondary
    – Type II – cytotoxic – humoral antibodies     Prevention
    – Type III – immune complex – activates
      complement
    – Type IV – Cell mediated




           Health Maintenance                                 Environmental Hx
•   Immunizations                                •   Occupation
•   Frequency of physicals or routine care       •   Nature of Work
•   Gynecological exams – Frequency and last     •   Work setting – sun, office building
                                                 •   Exposure to hazardous materials and loud
•   Eye                                              noises
•   Cholesterol                                  •   Hobbies
•   Self breast and testicular exams             •   Work related symptoms
•   Seat belts, bike helmets                     •   Travel history
•   Efforts to change                            •   Living near farms, mines, shipyards, factories
    – Cutting back on Tobacco/Alcohol
    – Diets




                                                       Psychosocial and Spiritual
                Family history
                                                               History
• Health status                                  •   “Tell me about yourself”
• Diseases                                       •   Upbringing
• Hereditary and environmental factors           •   Marital status, roommates
                                                 •   Perceptions of healthcare
                                                 •   Perceptions of and satisfaction with life
                                                 •   How has illness impacted life
                                                 •   Religious beliefs, practices
                                                 •   Prayer or meditation




                                                                                                      3
                        Sexual Hx                                        Sexual Hx
• Sexual drive as an indicator of overall                •   Risk behaviors
  health                                                 •   Sexual orientation
• Perception of sexuality                                •   Abuse/Rape
• Frequency and nature of sexual activity                •   Number of pregnancies, terminations
• Age of first experience                                •   Trying to become pregnant
• Sexual problems – anorgasmia,                          •   LMP
  decreased libido, dyspareunia                          •   Menopause
• STDs




                        Key points                                 Review of Systems
• Don’t write down the chief complaint until the         • A ROS is an inventory of body systems
  patient is done talking                                  obtained through a series of questions
• Open ended questions                                     seeking to identify signs and/or symptoms
• Leading questions – e.g. “How much alcohol               which the patient may be experiencing or
  would you say you drink in a week?”                      has experienced. (Medicare Guidelines,
• “How do you take…?”                                      1997)
• Bring all meds and bottles to visit
• Embarrassment on your part leads to
  embarrassment on the patients part.




                          Systems                                        ROS rules
•   Constitutional symptoms (e.g., fever, weight loss)
•   Eyes
                                                         • A system review should include all
•   Ears, Nose, Mouth, Throat                              questions pertinent to that system
•   Cardiovascular
•   Respiratory
                                                         • Complete ROS – asks about all systems
•   Gastrointestinal                                     • Problem pertinent ROS
•   Genitourinary
•   Musculoskeletal                                      • An initial visit should include a complete
•   Integumentary (skin and/or breast)                     ROS
•   Neurological
•   Psychiatric                                          • At least once a year, complete ROS
•   Endocrine                                              update
•   Hematologic/Lymphatic
•   Allergic/Immunologic




                                                                                                        4
                Constitutional                                                   Eyes
•   Usual state of health   • Fatigue                   •   Eye glasses/contacts   •   Photophobia
•   Fever                   • Sweats                    •   Current Vision         •   Unusual sensations
•   Chills                  • Exposure to radiation     •   Changes in vision      •   Redness
•   Usual Weight              or pollutants             •   Double vision          •   Discharge
•   Changes in weight       • Sleeping habits           •   Excessive tearing      •   Infections
•   Weakness                • Snoring                   •   Dryness                •   Hx of glaucoma
                            • Sleep apnea               •   Pain                   •   Cataracts
                                                        •   Last eye exam          •   Injuries




                        Ears                                                     Nose
•   Hearing impairment                                  •   Epistaxis              •   Congestion
•   Use of hearing aid                                  •   Infections             •   History of injury
                                                        •   Discharge              •   Septal deviation
•   Discharge
                                                        •   Frequency of colds     •   Sinus infections
•   Lightheadedness
                                                        •   Nasal obstruction      •   Hay fever
•   Pain
•   Tinnitus
•   Infections
•   Surgeries




               Mouth & Throat                                              Respiratory
• Dentition                 •   Foul taste (dysgusia)   •   Pain                   •   Asthma
• Last dental               •   Hoarseness              •   Cough                  •   Bronchitis
  appointment               •   Voice changes           •   Pleurisy               •   Hemoptysis
• Condition of gums         •   Postnasal drip          •   Dyspnea                •   Wheezing
• Bleeding gums             •   Thrush                  •   SOB                    •   Last CXR
• Frequent sore gums                                    •   Sputum                 •   Last PPD
• Burning of tongue                                     •   Tuberculosis           •   Hx of BCG (bacilli
  (dysglossia)                                                                         Calmetter-Guerin)
                                                                                       vaccine




                                                                                                            5
           Cardiovascular (CV)                                    Gastrointestinal (GI)
•   Chest pain             • Last ECG                  •   Appetite                 • Reflux, waterbrash
•   HTN                    • Other heart tests –       •   Excessive hunger           (gurp)
•   Palpitations             stress, echo, etc.
                                                       •   Excessive thirst         • Swallowing (dysphagia)
•   DOE                    • Claudication
                                                       •   Nausea                   • Abd pain
•   Orthopnea              • Peripheral/dependent
                             edema                     •   Vomiting                 • Change in stool color,
•   Paroxysmal Nocturnal
    Dyspnea                • Varicose veins            •   Diarrhea (NVD)             caliber, consistency
•   Hx of MI               • Thrombophlebitis          •   Constipation             • Frequency of bowel
•   Rheumatic fever        • Coolness of extremities                                  movements (BM)
                                                       •   Dyspepsia
•   Heart murmur           • Loss of leg/toe hair                                   • Change in bowel habits
                           • Discoloration of          •   Heartburn
•   Valve problems                                                                  • Hematemesis
                             extremities
                           • Ulcers




           Gastrointestinal cont                           Genitourinary (GU) – General
•   Rectal bleeding        •   Hemorrhoids, fissures   • Frequency                  •   Proteinuria
•   Hematochezia           •   Infections              • Urgency                    •   Nephrolithiasis
•   Melena                 •   Jaundice                • Difficulty starting        •   Infections
•   Laxative use           •   Rectal pain               stream                     •   Bed-wetting
•   Antacid use            •   Previous abdominal      • Incontinence               •   Nocturia
•   Excessive belching         x-rays                  • Polyuria                   •   Flank pain
•   Food intolerance       •   Hepatitis               • Oliguria                   •   Hx of retention
•   Halitosis              •   Liver disease           • Dysuria                    •   Urine color, odor
•   Change in abd size     •   Gallbladder disease     • Hematuria
                           •   Pancreatic problems




                  GU – Male                                            GU – Female
•   Penile lesions         • Frequency of              • Lesions on external        • Ability to enjoy sexual
                             intercourse                 genitalia                    relations
•   Discharge
                           • Ability to enjoy sexual   • Itching                    • Fertility problems
•   ED
                             relations                 • Discharge/odor             • Hernias
•   Pain
                                                       • Last Pap smear and         • Hx of STDs and Tx
•   Scrotal masses         • Fertility problems
                                                         result                     • Hx of diethylstilbestrol
•   Hernias                • Prostate problems         • Dyspareunia                  exposure
                           • Hx of STD and Tx          • Frequency of intercourse   • Age at menarche
                                                       • Contraceptive method –
                                                         current and past, why
                                                         stop




                                                                                                                 6
           GU – Female cont.                                  Integumentary/Breast
• Interval between         • Complications of       •   Rashes                  • Hx of previous skin
  periods                    pregnancy              •   Itching                   disorders
• Duration of periods      • Description of labor   •   Hives                   • Lumps
• Amount of flow           • Number of living       •   Easily bruised          • Lesions
• LMP                        children               •   Hx eczema               • Use of hair dye
• Bleeding between         • Breastfeeding          •   Dryness                 • Breast lumps
  periods                  • Menstrual pain         •   Changes in skin color   • Breast discharge
• Number of pregnancies    • Age at menopause       •   Changes nail texture      (galactorrhea)
• Number of terminations   • Menopausal symptoms    •   Changes hair texture    • Breast pain/tenderness
• Term deliveries          • Post menopausal                                    • Mammogram, self-
                             bleeding                                             exam




                Neurological                                           Psychiatric
•   Syncope                • Memory loss            •   Memory loss
•   Vertigo                • Loss of coordination
                                                    •   Psychiatric disorders
•   Equilibrium            • Seizures
•   Blackouts              • Speech disorders       •   Mood changes
•   Paralysis              • Ataxia                 •   Nervousness
•   Hx of CVA, TIA         • Apraxia
                                                    •   Behavioral changes
•   Paresthesia            • Loss of
•   Neuropathy               consciousness          •   Hallucinations
•   Tremors                • Head injuries          •   Confusion
•   Tics                   • Disorientation
                                                    •   Depression




                     Endocrine                             Hematological/Lymphatic
•   Polydipsia                                      • Local or general lymph node enlargement
•   Polyuria                                          or tenderness
•   Polyphagia                                      • Hx of anemia
•   Asthenia                                        • Bleeding tendencies
•   Hormone therapy                                 • Blood transfusions and possible reactions
•   Steroid use
                                                    • Edema
•   Growth, secondary sexual development
•   Intolerance to heat or cold
•   Thyroid problems




                                                                                                           7
          Allergic/Immunologic                      Depression cluster: SIGECAPS
•   Food, drug, insect reactions                    •   Sleep
•   Allergy tx                                      •   Interest
•   Immunosuppressive therapy                       •   Guilt
•   Immunologic d/o                                 •   Energy
    – Cancer                                        •   Concentration
    – Rheumatism                                    •   Appetite
    – SLE
                                                    •   Psychosomatic symptoms
                                                    •   Suicidal/homicidal ideation




         Anticholinergic cluster
• Altered Level of       • Hyperthermia (hot,
  Consciousness            Dry Skin)
• Hallucinations         • Dry Mouth
• Delirium               • Mydriasis with blurred
• Coma                     vision
• Seizures               • Decreased bowel
• Tachycardia              sounds
• Hypertension           • Constipation
                         • Urinary retention




                                                                                      8

								
To top