Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
12 Cards in this Set
- Front
- Back
|
What should be included in Identifying Data
|
Date and Time of History: time is important in hospital/emergent situations
Age, gender, occupation, marital status Source of history (patient, family member) Source of referral |
|
|
What are the components of Adult Health History
|
Identifying Data
Reliability Chief Complaints Present Illness Past History Family History Personal and Social History Review of Systoms |
|
|
What causes reliability to vary?
|
Patient's mood, trust and memory
|
|
|
What is included in present illness
|
Amplifies Chief Complaint: describes how each symptom developed
Includes patient thoughts and feelings about illness Pertinent positives and negatives Include medications, allergies and habits of smoking/alcohol |
|
|
What is included in past history?
|
Childhood illnesses
Adult illnesses with dates in 4 categories: medical/surgical/ob-gyn/psychiatric Health maintenance practices (shots, screening, home safety, lifestyle) |
|
|
What is included in family history?
|
Outline/diagram age and health or cause of death
Documents presence or absence of specific family illnesses (HTN, CAD) |
|
|
What is the personal/social history?
|
Education level, family of origin, current household, personal interests and lifestyle
|
|
|
What is the Review of Symptoms?
|
Documents presence or absence of common symptoms related to each major body system
|
|
|
What are the seven attributes to assessing present illness?
|
1. Location
2. Quality 3. Quantity or severity 4. timing, including onset/duration/frequency 5. setting in which it occurs 6. factors that have aggravated or relieved symptom 7. associated manifestations |
|
|
What section does medications, allergies, tobacco use and alcohol/drug Hx go?
|
Present Illness
|
|
|
What 4 areas are important according to Adult Illness in Past History?
|
1. Medical: illnesses such as DM, HTN, asthma, hospitalizations, sexual partners/past
2. Surgical: dates, indications, types 3. OB/GYN: OB Hx, menstral Hx, methods of contraception, sexual function 4. Psychiatric: illness and time frame, Dx, hospitalizations, Tx |
|
|
What is included in Personal and Social History (detailed)
|
Personality, interests, support sources, coping style, strengths, fears, occupation, last year of schooling, home situation, significant others, sources of stress, military service, job Hx, financial situation, leisure activities, religious affiliation, spiritual beliefs, ADL's, exercise, diet, food intake, usee of coffe/tea/caffeinated beverages, safety measures (seatbelts, helpmets, sunblock etc), alternative helath care practices
|
