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57 Cards in this Set
- Front
- Back
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The Health History
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Biographical data
Reason for seeking care Current health or history of current illness past health history (immunizations, diseases) Family history Review of systems Functional assessment or ADLs |
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Biographical Data
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Name, source of info, reliablilty
Address and phone number Age and birth date Birthplace sex Marital status Ethnic origin Occupation—usual and present Primary language Source of information |
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Reason for Seeking Care
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Also known as, “Chief Complaint”
This is a brief description as to why the client is here Not medical diagnosis Technically not “recheck of diabetes” In quotes, subjective |
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Current Health or History of Current Illness
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Also known as, History of Present Illness (HPI) – subjective, from the patient
Characteristics of symptom location Character or quality Quantity or severity timing setting – where were you when it started? Aggravating or relieving factors associated factors Patient’s perception |
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Past Health
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Childhood illnesses
accidents or injuries serious or chronic illnesses hospitalizations - when operations – when (date or age) OB history (GPAT) REVIEW immunizations – what immunizations and year; childhood and flu, etc. last exam date - allergies – medications and latex current medications – name, route, frequency, why |
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Family History
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Age – of family members
Health or cause of death of blood relatives – age and why Health of close family members Family history of various conditions – back to grandparents Family tree (genogram) |
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General overall health state
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Unexplained weight loss/gain, fevers, fatigue, weakness
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Skin
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History y of eczema, psoriasis, new lesions, discoloration of skin, excessively dry or sweaty skin
Health Promotion: sunscreen |
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Hair
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Thinning, texture changes
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Head
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History of head trauma or migraines; Frequent headaches, lightheadedness, dizziness
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Eyes
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History of glaucoma or cataracts; Changes in vision, blurred or double vision, eye pain, redness, excessive watering or discharge from eyes
Health Promotion: date of last eye exam, sunglasses |
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Ears
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Difficulties hearing, tinnitus, earaches, frequent ear infections
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Nose and sinuses
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Nasal congestion or drainage, sinus pain or tenderness, epistaxis, allergies, decreased sense of smell
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Mouth and throat
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Lesions or sores, pain, dryness, bleeding gums, toothache, dysphagia, hoarseness
Health Promotion |
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Neck
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Pain, masses or swelling
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breast
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History of breast cancer, fibrocystic breasts; Pain, masses, nipple discharge, rash
Health Promotion |
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Axilla
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Pain or tenderness, masses, swelling, rash
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Respiratory system
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History of asthma, COPD, bronchitis, RSV, TB; Cough, shortness or breath, wheezing, chest pain with breathing, hemoptysis, sputum
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Cardiovascular system
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History of CAD, hyperlipidemia, hypertension, heart murmur; chest pains, heart palpitations, swelling, dyspnea on exertion
Health Promotion |
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Peripheral vascular system
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Numbness or tingling of the extremities, varicose veins
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Gastrointestinal system
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N/V, diarrhea, constipation, pain, heartburn, appetite, dysphagia, flatulence, frequency of BM’s, blood in stools, or black stools, hemorrhoids
Health Promotion |
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Urinary system
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Urinary frequency, urgency, dysuria, hematuria, hesitancy, polyuria, oliguria, nocturia, flank pain, low back pain
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Genital system
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Testicular or penile pain, pelvic pain, genital sores or lesions, penile or vaginal discharge, hernia, menstrual history, vaginal itching, menopausal symptoms
Health Promotion |
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Sexual health
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History of STI’s, dyspareunia, erection problems
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Musculoskeletal system
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History of arthritis; Joint pain, stiffness, or swelling, muscle aches, cramps weakness, gait problems, back pain
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Neurologic system
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History of seizures, strokes, blacking out, or fainting; Headaches, dizziness, weakness, tremor, coordination problems, numbness or tingling
Mental health: Depression symptoms, hallucinations |
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Hematologic system
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History of anemia, bleeding or clotting disorders, blood transfusions; Unusual bleeding, excessive bruising
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Endocrine system
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History of diabetes or thyroid problems; diabetic symptoms, intolerance to heat or cold, excessive sweating, changes in skin texture, loss of hair, weight loss/gain, tremors
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functional assessment
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1. Self-esteem, self-concept – education, financial status/concerns
2. Activity/exercise – what and how much, or who helps with ADLs 3. Sleep/rest – hours, naps, sleeping aids 4. Nutrition/elimination – 24 hour recall, frequency/difficulty 5. Interpersonal relationships/resources – support system 6. Spiritual resources – church, religion 7. Coping and stress management – how is stress managed |
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personal habits
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Personal habits
Tobacco Alcohol Alcohol: Cage test Have you ever thought you should Cut down your drinking? Have you ever been Annoyed by criticism of your drinking? Have you ever felt Guilty about your drinking? Do you drink in the morning? (i.e., an Eye opener?) Street drugs |
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functional assessment - hazards
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Environment/hazards – where you live, transportation (Seatbelt?)
Occupational health – where do you work, what do you do? Intimate partner violence – have partner step out |
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Perception of Health
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How do you define health?
How do you view your situation now? What are your concerns/goals? What do you think will happen in the future? What do you expect from your health care providers? |
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inspection
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do not rush
Compare patient’s right side with left side use good lighting Obtain adequate exposure (of the patient) Ex: need to look at chest, not just listen to heart Will include instruments in many body systems |
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Palpation
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Purpose:
Use different parts of the hands Light vs. deep palpation Light – nodules, little tumors, cysts, crepitus Deep – organs, liver, spleen |
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Characteristics Assessed by Palpation
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texture
Temperature – back of the end moisture Organ location and size swelling Vibration or pulsation (thrill, pulse) Rigidity or spasticity crepitation (Snap, crackle, pop) presence of lumps or masses Presence of tenderness or pain |
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Uses for particular parts of the hand upon palpation
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Fingertips
Best for fine tactile discrimination A grasping action of the fingers and thumb Detects the position, shape, and consistency of an organ or mass The dorsa (backs) of hands and fingers Evaluating temperature b/c the skin here is thinner Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand Vibrations |
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Percussion
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Purpose
Helps determine position, size, density and other characteristics of an organ via palpable vibration Types of percussion Indirect – using one finger to hit the other Direct – over back, kidneys, sinus (ulnar aspect of fist |
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Characteristics of percussion notes
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Resonant: Loud, low, hollow sound (drumlike)
Example: normal over normal lung tissue Hyperresonant: Very low and very loud booming sound (extra air) Example: COPD, emphysema – over inflation of the lungs Tympany: Loud, high pitched sound Example: over abdomen Dull: Thud – no air Example: bones, organs, lung tissue collapsed (Atelectisis) Flatness: Extremely dull |
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Auscultation
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Fit and quality of stethoscope
Eliminate confusing artifacts – quiet environment Diaphragm vs. Bell Diaphragm Use: High-pitched sounds Examples: bowel sounds, normal heart sounds Bell Use: Low-pitched sounds Examples: heart murmur, bruit |
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general survey - Physical appearance
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age – match how they look
sex Level of consciousness skin color – pale, jaundice Facial features – grimace, symetrical |
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Body structure - general survey
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Stature – how are they sit/standing
nutrition Symmetry Position Body build, contour |
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Mobility - general survey
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gait
Range of motion |
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Behavior - general survey
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Facial expression
Mood and affect speech – slurred, clear dress – dressed/groomed Personal hygiene – psychiatric disorders |
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pulse- techniques
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Do not push too hard
Pulses bilaterally Count beats over 30 seconds |
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pulse - rate
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Normal rate for age group
Bradycardia Tachycardia |
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Rhythm - pulse
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Regular or irregular?
Tachy, brady Irregularly irregular – atrial fibrilation |
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pulse - Force
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0 to 3+
Bounding – fluid overload Thready – not enough fluid, blood loss |
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Elasticity - pulse
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straight
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Respirations
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Technique of measurement
Normal rate for age group Adult 12-20 Infant 30-40 Preschooler 23-30 Ratio of pulse rate to respiratory rate should be approximately 4:1 |
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Blood pressure
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Defined: force of blood against arterial walls
Systolic pressure Maximum pressure against the artery during left ventricular contraction Diastolic pressure pressure between contractions Pulse pressure - difference |
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Influences on blood pressure
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age
race – African Americans higher weight emotions sex – females lower until menopause diurnal rhythm – lower in the am, highest in late afternoon exercise – should go back down within 5-10 minutes after exercising stress |
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Factors
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Cardiac output – volume of blood
Vascular resistance – vasoconstriction, vasodilation Volume of blood – hemorrhage, dehydration Viscosity Elasticity of arterial walls – loss causes higher blood pressure |
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Oxygen Saturation
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What is oxygen saturation?
a measure of the how much oxygen the blood is carrying as a percentage of the maximum it could carry Oxygen saturation is measured by a pulse oximeter a device that estimates oxygen saturation of hemoglobin in blood |
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Special Age-Related Variations: Infants and Children
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Measurement of height (lying down), weight, head and chest circumference
plot on growth chart, watch for changes/deviations Skipping or two lines at a time are a cause for concern |
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pain
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The 5th Vital Sign - standard at each visit
subjective |
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Sources of Pain
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Visceral pain – organs, appendicitis, gallbladder
Deep somatic pain - joint pain, tendons, ligaments, muscles, bones Cutaneous pain – skin surface, abrasion Referred pain – radiates from one area to another; shoulder pain from gallbladder |
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Types of Pain
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Acute pain
short term self-limiting Follows a predictable trajectory Dissipates after injury heals Chronic pain 6 months or longer Types are malignant (cancer related) and nonmalignant Does not stop when injury heals |
