Health History- Pt Dx And Eval

Front 1

components of health history

Back 1

1) ID source of data and history
2) CC
3) HPI
4) past MHX (adult, adolescent, childhood, psych)
5) Prev health measures
6) exposures
7) social hx
8) family history
9) ROS

Front 2

ID of data and source of history includes:

Back 2

• Date and Time of Exam
• Data:
• Age
• Gender
• Marital Status
• Occupation
• Source (Informant)
• Who is supplying the information

Front 3

CC includes

Back 3

• reason for visit- written either in patient’s own words or paraphrased/abbreviated (eg. BM’s x 5d – 6x/d)
• “What brings you in here today?”

Front 4

HPI includes

Back 4

• what lead up to this, symptoms, etc, what, when, why, how, etc.

• Allergies “Do you have any allergies?” (if answer yes- “What happens when you take/eat/are around xxxx?”
• Drug allergies
• Food Allergies
• Other

• Medications: What meds is the pt currently taking
• Rx “Are you currently taking any medications? (if yes) “What medications are you taking? Why are you taking them? How often and what time of day? Do you know the dose? Are you taking them consistently? Are you tolerating them well? How long have you been on this? Do you ever miss a dose?
• OTC “Do you take any over the counter drugs or supplements?” (if yes) For what?- same questions as above

Front 5

OPQRSTABCD (OPPQQRSTAABCD)

Back 5

o Onset “When did this start?”
o Provocation/Place “What provokes it? Can you show me where?”
o Quantity/Quality “How many/describe for me”
o Radiation “Does the sensation radiate anywhere?”
o Severity “On a scale of 1 to 10, how bad is it?”
o Time (when and how long) “When does this occur and for how long?”
o Accommodation/Attribution “What helps alleviate it? What do you this caused this?”
o Bad Habits “Do you have any habits you think may be contributing to this?”
o Concerns “What concerns do you have?”
o Disability (how does this disable pt) “Does this hinder you in any way? Are you able to go about your day and participate in your hobbies/activities?”

Front 6

past medical history includes

Back 6

A review of the pts PMHx from HEAD to TOE finding out when, what, how tx
use MSRPs

Front 7

MSRPs

Back 7

• Medical history “Have you had any medical problems in the past? (if yes) What was it, when, how was treated?”
• Surgical history “Have you had any surgeries? (if yes) “What, where, when, and possibly why.”
• emergency Room “Have you ever been to the emergency room? (if yes) Why, when, where, how tx?
• Psych/Pediatrics
o Psych “Have you ever been to counseling for any reason?” (if yes) Why, when, when stopped?
o Peds “As a child did you have any medical problems?” (if yes) What was it, when, how was treated?”
• Supplemental care “Have you ever had any other types of care such as any holistic medications or alternative care practices?”

Front 8

Preventative health includes

Back 8

what is the pt doing for their health
• Vaccines (primary prevention) “Have you been vaccinated? (if yes) For what? When?”
• Physical Exams (Annual Exams, Military Exams) “Do you have annual (or whatever the recommendation is for pts age) physical exams?”
• Exercise “Do you exercise regularly? (if yes) “what do you do for exercise and how often?”
• Diet- encourage people to increase vegan, vegetarian diet bc its shown to be healthier (are vegan and vegetarians using vitamins) “Tell me what you have had to eat in the past 24 hours”
• Screenings (secondary prevention)- mammograms, Papsmears, colonoscopy, self exams- for early detection “Do you get early detection screening tests such as …..”
• Delay or cease progression of disease (tertiary prevention)- like preventing metastasis “Are you XXXX to slow your XXX”
• Safety prevention (seat belts, bike helmets, masks/hoods, etc) “Do you wear a seatbelt, safety gear, etc?”
• Home safety – “Do you have rugs, railings, gates, stairs, lighting, CO detectors, smoke detectors in the house (obviously not asking this all at once) where are meds kept?

Front 9

Exposures includes

Back 9

• Is the pt exposed to anything toxic in their work environment or otherwise? “Are you exposed to anything toxic or hazardous in either your work environment or at home?”

Front 10

social history includes

Back 10

a history of pts social habits/environments
• Adult
• Trying to obtain the following info:
o What is your current living situation?
o Are you sexually active?
o Do you use Protection? Pregnancies can come in here….
o Do you have more than one partner or have they ever? Are you satisfied with their sexual interactions? Is it painful?
o How is it at home?
o What do you do for fun/in your spare time?
o Do you feel comfortable with your level of income? Can talk about mental health here.
o Nutrition: “Tell me what you have had to eat in the past 24 hours”
o sleep habits “How many hours a night do you sleep?”
o What is your daily caffeine, soda intake?
o dieting attempts: Have you ever been on a diet? (if yes) What has and has not worked? Have you gained it back- are they over exercising, etc?
• Substances:
o What are you using, how much, how often, with whom? Is it affecting job? How do you take it? Why do they use it? Have you ever gotten in trouble using? Or gone into therapy/rehab for it? Do you feel you need to now? How do you pay for it?
• ETOH:
• How often, what, with who?

• TOBACCO: Have you ever smoked? Have you ever used tobacco in any other form? With or without filters, chewing, cigars, pipes, etc. Have you tried to stop? Do you want to try and stop again?
o Cigarettes- how many yrs (10 pks (per day) x 2 yrs)? Some write “20 pk yrs”

Front 11

CAGE questions

Back 11

C= cutting down (have you/anyone suggested you cut down) A= annoyed (are you annoyed when people ask)
• G= do you feel guilty
• E= do you have an eye opener?
• If yes to 2 or more questions, then have ETOH problem (alcoholic)

Front 12

risk factors includes

Back 12

• Factors the pt has mentioned that may put them at a heightened risk for illness and/or disease

Front 13

pertinent negatives include

Back 13

• Findings from the interview that are relevant (ex. Pt has stomach cramps but no vomiting)

Front 14

family history included

Back 14

• If pressed for time can put med hx with fam med hx together “do you or anyone in your family have diabetes”
• Find out what happened, when, how are they doing now, etc.
• Do your parents have any health issues? (if deceased how and what age)
• Do your siblings have any health issues?
• Does your PGF have any health issues?
• Does your PGM have any health issues?
• Ask this for MGF, MGM, A, U
• Fam hx could be written as a pedigree (often to see pattern of inheritence)

Front 15

ROS includes

Back 15

General
Skin
HEENT
Neck
Breasts
Respiratory
Cardiovascular
GI
Periph Vascular
Urinary
Genital
Musculoskeletal
Pshychiatric
Neurological
Hematological
Endocrine

Front 16

ROS questions for general

Back 16

• How has your weight been?
• Have you had any weakness, fatigue, or fever?

Front 17

ROS questions for skin

Back 17

• Do you have any rashes, lumps, sores?
• Do you have any itching or dryness?
• Do you have any color changes in your hair or nails?
• Have you noticed and change in the size of moles?

Front 18

ROS ?s for head

Back 18

o Have you had any headaches, dizziness, or lightheadedness?

Front 19

ROS ?s for eyes

Back 19

o How is your vision? Do you have glasses or contact lenses?
o When was your last eye examination?
o Have you had any pain, redness, or excessive tearing in or around your eye?
o Have you had any blurred or double vision?
o Have you seen spots or flashing lights?

Front 20

ROS ?s for ears

Back 20

o How is your hearing?
o Have you had any vertigo or felt like the room was spinning?
o Have you had any ringing in your ears?
o Have your ears hurt at all?
o Have you had any discharge from your ears?
o Do you use a hearing aide (if hearing impaired)

Front 21

ROS ?s for nose/ sinus

Back 21

o How has your sense of smell been?
o Have you had any colds recently or any sinus pain?
o Have you had any nosebleeds?

Front 22

ROS ?s for throat

Back 22

o How are your teeth, gums? Any bleeding?
o Do you wear dentures?
o Have you had a sore tongue or throat or been hoarse lately?

Front 23

ROS ?s for neck

Back 23

• Have you had swollen glands?
• Have you had any neck pain or stiffness?

Front 24

ROS ?s for breasts

Back 24

• Have you noticed any lumps, pain, or discomfort?
• Have you had any nipple discharge?
• Do you do a breast self exam?

Front 25

ROS ?s for respiratory

Back 25

• Have you had a cough recently?
• Have you had any trouble breathing or shortness of breath?

Front 26

ROS ?s for cardiovascular

Back 26

• How has your heart been?
• How has your blood pressure been?
• Have you had any chest pain, palpitations, or swelling?

Front 27

ROS ?s for GI

Back 27

• Have you had a change in bowel habits or stool?
• Have you had any abdominal pain?
• Have you had any trouble swallowing or eating?

Front 28

ROS ?s for perip vascular

Back 28

• Have you had any pain or cramping in your legs?
• Have you had any swelling in your legs or ankles?
• Do you have any swelling with redness?

Front 29

ROS ?s for urinary

Back 29

• Do you have any concerns regarding urination frequency, infrequency?
• Do you have any pain while urinating?
• Is there blood in your urine?
• Do you have any back pain around your kidneys?

Front 30

ROS ?s for genital

Back 30

• Male: Do you have any hernias, pain or discharge from the penis?
• Do you have any scrotal pain or swelling?
• Do you use condoms?
• Are you happy with your sexual activity?
• Female: Is your period regular?
• When was your last menstrual period?
• When did you experience menopause?
• Do you have any vaginal discharge or sores?
• How many times have you been pregnant?/Given birth?
• Have you ever had an abortion?

Front 31

ROS ?s for musculoskeletal

Back 31

• Have you had any muscle or joint pain?
• Had any neck or low back pain?

Front 32

ROS ?s for psychiatric

Back 32

• Have you experienced any nervousness, anxiety, mood swings?

Front 33

ROS ?s for neurological

Back 33

• Have you noticed any changes in speech or attention?
• Have you noticed any changes in memory or judgement?
• Have you had any blackouts, seizures, weakness, or paralysis?
• Have you had any numbness or tingling?

Front 34

ROS ?s for hematological

Back 34

• Have you noticed that you bruise or bleed easily?
• Are you anemic?

Front 35

ROS ?s for Endocrine

Back 35

• Do you have any heat or cold intolerance?
• Do you sweat excessively?
• Are you overly hungry or thirsty?

Front 36

subjective data

Back 36

what the patient tells you (hx, cc, ros)

Front 37

Objective data

Back 37

what is detected during exam/ all PE findings

Front 38

Components of medical interview in sequence

Back 38

o Introduction
o History
o Physical Exam
o Clinical Assessment and Plan Formation
o Oral Presentation
o Documentation

Front 39

psychomotor objective to health history

Back 39

correctly record health history, demonstrate active listening

Front 40

affective objective to health history

Back 40

• demonstrate sensitivity to the patient by using appropriate explanations, transitions, and responses;
• demonstrate interest in the patient by use of appropriate body language.