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30 Cards in this Set
- Front
- Back
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What are the components of the Health History?
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-Chief Complaint (CC)
-History of Present Illness (HPI) -Past Medical History (PMH) -Family History (FH) -Social History (SH) -Review of Systems (ROH) |
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Describe Chief Complaint (CC).
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reason for seeking care; brief; usually in the patient's own words & the duration of that complaint
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Symptoms
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subjective; what people feel that relate to the problem
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Signs
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objective; observed; found during examination
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Describe History of Present Illness (HPI).
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location, character or quality, severity or quantity, timing, setting, aggravating or relieving factors, associated factors, patient's perception
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Describe Past Medical History (PMH).
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***Keep certain questions applicable to the patient's age/gender
-childhood illnesses -accidents or injuries -obstetric history -allergies -operations -last menstrual period, etc |
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Describe Social History (SH)
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-marital status
-number of children -tobacco use -alcohol use -street drugs, etc |
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ADLs
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(Activities of Daily Living); i.e. dressing, bathing, etc
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IADLs
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(Instrumental Activities of Daily Living); i.e. putting together shopping lists, balancing checkbook, cooking,etc
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Describe Review of Systems (ROS)
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***last step in assessing history
-evaluating health of each body system -verify anything that was overlooked -health promotion **Just ask questions, not a physical exam |
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Infant/Child Health Assessment
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CC from parent
Present Illness-PI PMH -prental care L&D Postnatal -developmental -nutrition -functional assessment(behavior) |
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Older Adult Health History
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f-ocus on ADL's and IADLs
-meds -emotional status-depression -sleep pattern -bowel habits -home safety |
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Assessment Techniques
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-Inspection
-Palpation -Percussion -Auscultation |
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Inspection
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sight
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palpation
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touch
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percussion
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hearing
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auscultation
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hearing through stethoscope
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inspection
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1st and continual
take time evaluate symmetry-alignment of body parts good lighting |
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palpation
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fingertips-lumps,bumps
fingers/thumb dorsal of hand(temperature) ulnar surface (bony of fingers) |
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percussion
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tapping skin
-Tympany -hyperresonance -resonance -dullness -flatness |
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Direct Percussion
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percuss area w/two fingers
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indirect persussion
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using dominant hand to strike
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Tympany
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hollow noise (e.g. stomach)
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hyperresonance
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loud (e.g. lungs)
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Resonance
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medium(lung)
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dullness
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soft, fluid noise(liver/spleen)
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flatness
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soft noise over bones(e.g. thigh muscle, bone, tumor)
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Common Percussion Errors
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-failure to exert firm pressure
-failure to separate hammer finger -snapping from elbow -striking finger pad |
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Points to remember
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organize equipment before exam
step out while patient is undressing hand hygeine before/after standard precautions (wear gloves) |
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Examining Infants/Children
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-work fast
-examine eye,ears,throat LAST -use parent (while assessing) -keep developmental stages in mind |
