Advanced Health Assessment Exam 1

Front 1

Purpose of a Complete Health History

Back 1

- Establish Subjective Data

- Helps in dveloping a problem list

- Helps to establish a diagnosis

*There is no objective data in the health history

Front 2

Biographical Data

Back 2

Date, Name, DOB, Birthplace, Sex

Marital Status, Race, Ethnic Origin, Religion, primary/secondary language, level of education, occupation, health insurance

Source of info, know who filled it out and impression of the informant's reliability, good or poor historian

Front 3

Reason for seeking care

Back 3

- Also known as "chief complaint" or "chief concern"

- May focus on illness or wellness needs

- One sentence stating the problem and its duration, in quotes

- May need to ask what the major concern is for the day, can't necessarily address all problems in one visit

Front 4

Present health status or History of present illness (HPI)

Back 4

Well patient - statement of general health

Ill Patient - provide a symptom analysis and describe the characteristics of the symptoms PQRST or OLD CART

Front 5

OLD CART

Back 5

Onset

Location

Duration

Character - Quality, Quantity, Patient Description

Aggravating Factors/Associated Factors

Relieving Factors

Treatment

Front 6

PQRST

Back 6

P - Provocative/Palliative

Q - Quality/Quantity

R - Region/Radiation

S - Severity scale

T - Timing

U - Understanding pt's perception

Front 7

HPI - Patient's Perception

Back 7

What do they think is wrong?

- Fears, denial, misinterpretation

What are your concerns?

How are you affected by the illness?

Front 8

HPI - Symptom Analysis

Back 8

Have you ever had these symptoms before?

Did you find out what was wrong?

What diagnostics were done? Results?

How were you treated? Was it effective?

*Past history may be very helpful

Front 9

Onset

Back 9

Date/Time

Sudden/Gradual

Predisposing factors, exposure to sick contacts

Front 10

Location

Back 10

Point with one finger

Where does it radiate?

Is it localized?

Front 11

Duration

Back 11

How long does it last?

How often does it occur?

Is it constant or intermittent?

If intermittent, does it subside completely between episodes?

Front 12

Character

Back 12

Quality - sharp, dull, throbbing, vise-like, pressure, bright red blood on tissue, black sticky, tar-like stools

Quantity/Severity - Blood (saturated pads), pain (scale 0-10), ability to do ADLs

Patient description - In quotes

Front 13

Aggravating favtors

Back 13

What makes it worse?

Bending forward, lifting, walking upstairs, running, eating spicy or fatty foods

Front 14

Associated Factors

Back 14

Chest pain - nausea, vomiting, diaphoresis, dyspnea, left arm pain

Dysuria - shaking, chills, fever

Front 15

Relieving factors

Back 15

What makes the symptoms better?

Front 16

Treatment

Back 16

What has the patient tried at home?

Was it effective?

* 70-90% of all illness are treated first with self-care

Front 17

Past health history or Past medical history (PMH)

Back 17

May affect current health status

May affect hos the patient responds to the illness

Front 18

PMH - Childhood illness

Back 18

List illness and date/age of occurrece includes:

measles, mumps, rubella, diptheria, pertussis, polio, rheumatic fever, varicella

Front 19

PMH - Serious or Chronic illnesses

Back 19

Illness and date of occurrence, details should be identified in ROS

Front 20

PMH - Hospitalizations

Back 20

List dates, causes, hospital, treatment, and length

Front 21

PMH - Accidents/Injuries

Back 21

Dates, nature of event/circumstances, resulting disability

Burns, fractures, laceractions, loss of consciousness, penetrating wounds, etc.

Front 22

PMH - Operations

Back 22

List procedure, indications for procedure, date, sequela

Front 23

PMH - Blood transfusions

Back 23

Help in identification of infectious disease transmission

Front 24

PMH - Obstetric History

Back 24

Gravida (# of pregnancies)

Para (carrying pregnancy to 500 gm wt or 20 weeks gestation, regardless of survival)

Still Birth (loss of baby after 20 weeks gestation)

Abortion (loss of baby before 20 weeks gestation)

(Spontaneous/SAB, Induced/TAB - Therapeutic)

Multiple births - one para

Deliveries - dates, delivery, sex, wt, problems

Front 25

PMH - Immunizations

Back 25

List dates or yr of immunizations

Advers reactions

If immunizations not appropriate in particular patient, document "not applicable"

Front 26

Immunizations - Tetanus/Diptheria, TDAP

Back 26

Tetanus/Diptheria (Td) - Every 10 yrs

TDAP (with pertussis) - give once before age 65 instead of Td, may need booster after 65 yrs if high risk, frequent contact with kids younger than 12 mo

Front 27

Immunizations - MMR

Back 27

Given as an adult if not received as a child or if they were never infected

Front 28

Immunizations - Hep B

Back 28

Given if at risk, health care workers

May be a sexually transmitted disease

Three series immunizations

Front 29

Immunizations - Influenza

Back 29

Annually given for all ages

Front 30

Immunizations - Zostavax

Back 30

Single dose vaccine for herpes zoster prophylaxis, indicated for adults older than 50 yo

For shingles, people who previously had chicken pox are at risk

Front 31

Immunizations - Health care worker

Back 31

Hep B

Influenza

MMR - if not immune

Varicella - if not immune

Front 32

Immunizations - Adolescents

Back 32

Hep B for all (3 series), first shot today, then one month later, then six months later

Front 33

Immunizations - Childhood

Back 33

DPT

Tdap

MMR

Polio

Hflu (HIB)

Varicella

Hep A is now recommended at 12-23 mo

Front 34

Immunizations - Hep A

Back 34

If not previously given in childhood

Series of 2 injections given 6 mo apart

Given to at risk: foreign travel, men having sex with men (MSM)

There is a combo for Hep A and B, "twinrix," given in 3 part series

Front 35

Immunizations - Gardisil

Back 35

For men and women

Protects against viral strains of HPV that causes external genital warts (EGW) and cervical cancer

Front 36

Immunizations - Meningococcal

Back 36

Given to college freshman living in dorms or military recruits

High risk individuals, ie. s/p splenectomy

Front 37

Immunizations - Pneumococcal

Back 37

Polysaccharide vaccine (PPSV 23) - given at age 65 and other high risk individuals (may be given at an earlier age)

Pneumococcal Conjugate 12-Valent Vaccine (PCV 13) - given in addition to PPSV 23 for those with immuno-compromising conditions

Front 38

Immunizations - PPSV 23, over 65

Back 38

All people over 65, don't need revaccine

Under 65: chonic CV disease (CHF, CM), chronic pulm disease (COPD), DM, ETOH, chonic liver disease (cirrhosis), CRF, nephrotic syndrome, CSF leaks, cochlear implants, functional or anatomic asplenia (splenectomy, sickle cell disease), immuno compromised disease (HIV)

Under 65 - if received 1-2 doses prior to 65, single revaccination at 65 if earlier dose >5yrs

REvaccinate 5 yrs after first dose in

Front 39

Immunizations - PPSV 23, under 65

Back 39

Chronic CV disease (CHF, CM), chronic pulm disease (COPD), DM, ETOH, chonic liver disease (cirrhosis), CRF, nephrotic syndrome, CSF leaks, cochlear implants, functional or anatomic asplenia (splenectomy, sickle cell disease), immuno compromised disease (HIV). Revaccinate if received 1-2 doses prior to 65, single dose at 65 if earlier dose >5yrs prior.

Revaccinate 5 yrs after first dose in CRF, nephrotic syndrome, functional or anatomic asplenia, immuno-compromised conditions

Front 40

Immunizations - PCV 13

Back 40

Indicated for adults 19 yrs or older with immuno-compromising conditions such as CRF, nephrotic syndrome, functional or anatomic asplenia, CSF leaks, cochlear implant.

If no prior doses of PPSV 23 or PCV 13: give PCV 13 followed by PPSV 23 at least 8 weeks later

If previously received PPSV 2: given PCV within the last dose of PPSV 23

Front 41

Screening Tests

Back 41

Identify date and whether the person is immune or shows evidence of disease

Blood titers: assess for immunity or infection (MMR, varicella), (Hep A/B; HAV/HBV), assess for infection (Hep C/HCV, RPR/Syphillus, HIV),

Front 42

Lead Poisoning

Back 42

Assess for lead poisoning in children (found in paint until 1978, glazes of old pottery/china, ceramics produced in countries outside of US, UK, France)

Avoid dishes from Mexico, China, Hong Kong, India, Italy

Poisons the RBC, interferes with iron uptake, may cause anemia/metal retardation in kids

Front 43

TB Surveillance - Purified protein derivative

Back 43

Skin Test - PPD

Positive PPD indicates TB infection, not differentiated between activ and inactive/latent

If positive PPD, CXR done to see if evidence of active TB. May also need induced sputum cultures for AFB

Front 44

TB Surveillance - PPD, positive value

Back 44

Positive >5mm induration with associated risks: sick contacts, clinical suspicion, abnormal CXR, HIV

Positive >10 mm induration with risks: foreign-born, medically underserved, low-income, high risk ethnic minorities, IVD use, homeless, residents of long term care, healthcare workers, persons with medical conditions with high TB risk (kidney failure, DM)

Positive >15mm induration low risk patient not living in LA with no risk factors

Front 45

TB Surveillance - Quantiferon

Back 45

Approved in 2005

Doesn't distinguish between active or latent

Eliminates false positives from BCG vaccine (vaccine given in 3rd orld country as TB vaccine)

Front 46

Health Care Maintenance

Back 46

Dates and results of screening exams

Front 47

Screening - Blood pressure

Back 47

BP< 120/80: Every 2 yrs

SBP 120-139/DBP 80-90: Every yr

Front 48

Screening - Lipids

Back 48

20 yrs or older: Every 5 yrs

Front 49

Screening - Diabetes

Back 49

Sustained BP> 130/80: screen with FPG or 2 hr post-load plasma, or hemoglobin A1c

Front 50

Screening - Colorectal Cancer

Back 50

50-75 yrs: FOBT every year, or sigmoidoscopy every 5 yrs plus FOBT every 3 yrs or colonoscopy every 10 yrs

Front 51

Screening - Abdominal Aortic Aneurysm

Back 51

65-75 yr old men who have ever smoked: one time ultrasound

Front 52

Screening - Hepatitis C (HCV)

Back 52

Adults born between 1945-1965: one time blood test

Front 53

Screening - Prostate Cancer

Back 53

Most men 50 yrs or older, or African Americans and other high risk men at 45 yrs old:

Discuss pros/cons of screening with PSA/rectal exam annually

Front 54

Screening - Cervical Cancer

Back 54

21-29 yrs: Pap every 3 yrs

30-65 yrs: Pap every 3 yrs with HPV screen every 5 yrs

Front 55

Screening - Chlamydia

Back 55

< 25 yrs old: Annually if they are at risk

Front 56

Screening - Osteoporosis

Back 56

65 yrs old: baseline, then follow-up as indicated

Front 57

Screening - Mammograms

Back 57

50-74 yrs old: Every 2 yrs

Front 58

Screening - Vision

Back 58

40-64 yrs old: Comprehensive eye exam with glaucoma screening every 2-4 yrs

65 and older: comprehensive eye exam with glaucoma screening every 1-2 yrs

Front 59

Screening - Dental

Back 59

Yearly exam and twice a year cleaning

Front 60

Allergies

Back 60

List meds, vaccines, foods, animals/insects, seasonal/pollens, occupational, etc.

Allergens and reactions: some people list allergens that don't have a true allergic reaction

Histamine response: itching, rash, throat swelling, trouble breathing - reintroducing allegen can intensify reaction

Front 61

Current Medications

Back 61

Perscriptions, OTC, herbal, vitamins, calcium

List name, dose, route, frequency, rationale/indication, duration of use

Front 62

OTC meds are not harmless

Back 62

NSAIDS: GI Bleed

Pseudoephedrine: HTN

Antihistamines: drowsiness, fall risk

Drug interactions: Coumadin, ASA

Confusion with generic and trade names - patients should not be on 2 drugs of same class

Front 63

Calcium

Back 63

Achieving peak bone mass before age 25 can decrease risk of osteoporosis

Age specific needs (both sexes):

4-8 yrs: 800 mg/day

11-24 yrs: 1200-1500 mg/day

over 25 yrs: 1000 mg/day

Post menopausal and men: 1500 mg/day

Multiple doses because body can't absorb more than 500 mg at a time, take with Vit D 400 units/15 min sun to increase absorption

One glass of milk = 300 mg

Front 64

Family History

Back 64

Genogram/Family Pedigree

Age of members, age when illness occurs, age and cause of death or document A&W (alive and well)

Attention to cancer, heart disease, Alzheimer's, thyroid, obesity, vision/hearing loss, birth defects, blood disorders, genetic diseases, substance abuse

Front 65

Personal/Social History - Tobacco

Back 65

Tobacco (cigarettes, cigars, pipe, smokeless) - never smoked, current smoker, previous smoker

pack year history = ppd x yrs smoked

ie. 2ppd x 15 yrs = 30 pack yr history

Front 66

Personal/Social history - ETOH

Back 66

Type, amount, frequency, duration

Never document "social drinker," be very specific

Front 67

Personal/Social History

Back 67

Habits - Past and present

Drug abuse (type, amount, frequency, duration)

Sleep (Quantity, quality, problems)

Exercise (type, frequency, duration)

Housing - members and relationships, marital history, children, h/o domestic violence, describe support systems.

Occupational history - jobs for past 5 yrs, satisfaction, stress, hrs worked per week

Economic status, financial concerns, social services

Front 68

Review of Systems

Back 68

*No physical exam findings

Dates of onset, treatment, response to treatment

Sequela: unexpected response

Front 69

Review of Systems includes:

Back 69

General overall health, skin, hair, nails, head, neck, eyes, ears, nose, sinuses, mouth, throat, breasts, lungs, thorax, heart, peripheral vascular system, gastrointestinal, urinary, musculoskeletal, neurologic, psychological, endocrine, hemtologic, female, male, sexual healing

Front 70

Problem list

Back 70

*No new info, just supported from previous info collected, not documented in narrative form

Past resolved problems

Chronic unresolved problems

Acute problems (6 weeks or less in duration)

Risk Assessment (potential or high risk problems) - famly hx, risk factors, health promotion behaviors (ETOH, smoking, calcium intake, dentition, noise exposure, exercise, pap smears, immunizations, pap smears, prostate exams, testicular/breast self exams, seat bet use, sun protection, helmet use)

Front 71

Age Related Considerations - Child health history

Back 71

Adapted to include specific info for age and developmental stages

Data mostly obtained from adult

Parental concerns

Prenatal data: mother's health status, l&d, postnatal problems, mother smoking, small birth wt, ETOH abuse, difficult delivery

How child manifests behavior/symptoms

Coping ability

Parent's health problems

Current developmental tasks: gross motor, fine motor, language, social skills

Past developmental milestones: were events on the normal growth and development schedule

ROS: birthmarks, see blackboard, congenital heart problems, immunizations

Front 72

Age Related Considerations - Adolescent

Back 72

Use pediatric data base until ages 12-14, then use adult health history

Parents may or may not bepresent depending on age of child

Front 73

Age Relted Considerations - Older Adult

Back 73

May understate symptoms, fail to mention fatigue, decreased activity tolerance (CHF)

Polypharmacy: consider drug-drug interaction, numerous side-effects

ROS: dentures, dry skin, decreased sensation in feet, appetite changes, elder abuse, hearing and vision loss

Functional assessment: self-care abilities

Front 74

Cultural Considerations

Back 74

Different ethnic groups view health differently, may affecy request for pain meds, health may be defined as good appetite, feeling strong, absence of disease