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14 Cards in this Set
- Front
- Back
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What is the purpose of a health history?
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To collect subjective data (what the person says about him or herself.) the history is then combined with objective data from the physical examination and laboratory studies to form the database.
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What is included in the BIOGRAPHICAL COMPONENT of the Health History?
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Demographic information (Including language and communication needs.)
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What is included in the SOURCE OF HISTORY?
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1. Who provides the subjective information for the health history
2. How reliable is the information? 3. Any special circumstances *ie; the use of an interpreter |
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What is included in the area of REASON FOR SEEKING CARE?
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A brief statement in the person's own words that describes the reason for seeking care. It includes one or possible two signs or symptoms, and their duration. *THIS IS NEVER A MEDICAL DIAGNOSIS*
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What is included in the PRESENT HEALTH OR HISTORY OF PRESENT ILLNESS?
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For the well person, this is a short statement about the general state of health "I am healthy and active."
For the ill person, this is a chronological record of the reason for seeking care from the time the symptom first started until now. Isolate each reason for care separately. |
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What is a good way to remember how to analyze each symptom that your patient reports to you.
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Onset
Location Duration Characteristic Aggrivating Alleviating Radiating Time |
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What is included in the PAST HEALTH section?
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Past health events are important because they may have residual effects on the current health state. Past health includes:
Childhood Illnesses Accidents or Injuries Serious or Chronic Illnesses Hospitalizations Operations Obstetric History Immunizations Last Examination Data Allergies Current Medications |
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What is included in FAMILY HISTORY?
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Consists of a pedigree or genogram, which is a graphic family tree to depict gender, relationship, and age of immediate blood relatives in at least three generations.
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What is included in the FUNCTIONAL ASSESSMENT (Including ADL's)
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This measures a person's self care ability in the areas of general physical health or absence of illness.
Areas to ask about include: Self-Esteem/Self Concept Activities/Exercise Sleep/Rest Nutrition/Elimination Interpersonal relationships/Resources Spiritual Resources Coping and Stress Management Personal Habits Alcohol Ilicit/Street Drugs Environmental Hazards Intiminate partner violence Occupational health |
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What are some factors that would change about the health history when obtaining it from an older adult?
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*FOR PAST HEALTH*
General Health-Health state in the past 5 years Last Examination- Last colonoscopy,mammography Obstetric Status-it is not important to obtain a detailed account of each pregnancy if the person has passed menopause. |
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What happens to a person who has had a BCG shot for TB?
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They always have a positive TB and have to have a chest x-ray
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What are relevant negatives?
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(Reports no uti, nor loss or urine) These are helpful because they save time later on for ruling things out.
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What does CAGE stand for?
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Ever thought you should Cut down?
Ever been Annoyed by criticism? Ever felt Guilty? Ever have an Eyeopener? |
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How do you calculate pack years?
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the amount of packs per day x years smoked.
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