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30 Cards in this Set
- Front
- Back
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Components of an Episodic Health History
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1. Date
2. Identifying data 3. Source and reliability 4. Chief concern/ reason for seeking care 5. HPI 6. PMH 7. Family history 8. Psycholsocial history |
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Components of identifying data?
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1 name
2 age 3 date of birth 4 gender 5 occupation and prior occupations (military) |
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Components of HPI?
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1. Location
2 Radiation 3 Duration 4 Timing 5 Setting 6 Quality 7 Quantity 8 alleviating factors 9 aggravating factors 10 associated factors |
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Components of PMH?
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1 Medications
2 Allergies 3 LMP 4 Adult Illnesses |
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Components of Psychosocial History?
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Habits:
1. tobacco 2. ETOH 3. illicit drug use Stress level/ coping |
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How do you ask about the location?
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Can you point to where it hurts?
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How do you ask about the radiation?
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Does it travel anywhere?
Point to where it travels? Does it hurt anywhere else? |
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How do you ask about the duration?
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When did this start?
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How do you ask about the timing?
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Is is constant?
or does it come and go? If it comes and goes, does it usually how long does it stay or does it vary? |
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How do you ask about the setting?
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Are you in a certain place when it occurs? Does it happen the same place each time?
Does it vary with the weather? |
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How do you ask about the quality?
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How does it feel? Is it throbbing, sharp, stabbing, crushing, tingling, burning, like pins and needles?
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How do you ask about the quantity?
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From 1-10 with 10 being worst can you rate it? At its worst? At its best?
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How do you ask about the aggravating factors?
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Have you found that anything makes it worse?
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How do you ask about the alleviating factors?
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Have you found that anything makes it better? Rest, meds, time, position change?
After you do that, how much does the pain go down on a scale of 1-10? |
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How do you ask about the associated factors?
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Have you been feeling any other unusual or uncomfortable feelings since this started? Nausea, vommiting, dizziness, SOB, headache, diarrhea, bleeding, photophobia, phelm, mucous etc....pain, weakness
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How do you ask about the medications?
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1. Drug
2. Dose 3. Route 4. Frequency 5. About how long have you been taking this 6. When was the las t itme you took these? |
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Other questions to ask about meds?
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Any OTC meds, vitamins or herval remedies?
Do you take any other medications in your eyes, ears, nose, skin or anywhere else? Can you tell me what each of your meds are for? Are you taking any birth control pills? Allergies? Do you feel llike your medications help you? Do you have any uncomfortable feelings when you are taking any of yor meds? |
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How do you ask about allergies?
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Are you allergic to any medicaitons?
Foods? Anything in the environment? What happens when you have these allergies? |
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How do you ask about the LMP history?
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When was the first day of your LMP?
Was it a normal period? FMPAL? Catamenia? |
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FMPAL?
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full term, premies, mult birth, abortions, living children
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Catamenia?
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Menarche
length between cycles day of menstrual flow |
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Menopausal women?
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When was your last period?
Have you had any other bleeding since your menopause? |
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How do you ask about other illnesses?
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Have you ever been told that you have anything that should be treated for? Any surgeries? Childhood illnesses?
So your BP been good? Your blood sugars have been OK? No ca, asthma, breathing prob, seizures, SS, mono, valve, rheumatic fever, dx, meningitis or chronic infections? When were you told that you had this problem? (yr) |
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For each of the family member what do you want to ask?
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1 Who are they
2 Age 3 Gender 4 Known dx 5 Age/ Cause of death |
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What do you ask about smoking habits?
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Have you ever used tobacco like cigaretttes, pipes, chewing etc?
If so what form, how often? Are you exposed to 2nd hand smoke? You quit, when did you quit? |
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How do you calculate pack yrs?
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PPDx # yrs smoked -excess 20 pk yr
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ETOH?
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How many drinks do you have to drink to get high?
Do you drink? How much? How often? What type? |
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CAGE?
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Cut down?
(Annoyed) Other people annoyed? (Guilty) Have you felt guilty about it? (Eye Opener) Have you used it as an eye opener? |
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Drugs?
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Have you ever taken recreational /illegal drugs
Are you still taking them? What are you taking? How often? How long? Is there a reason that you started taking them? |
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Stress?
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How would you characterize your stress level?
Have you ever had tough times? What do you do to releive the stress? |
