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27 Cards in this Set
- Front
- Back
- 3rd side (hint)
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In an adult health history what is the purpose to obtain? |
Subjective data |
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What else might you be obtaining in an adult health history? |
Biographic data, source of resource, who is providing the information |
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Reason for seeking care |
Brief statement in the patient’s own words |
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A subjective sensation |
Symptom |
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An objective abnormality that can be detected on physical exam or their diagnostic testing |
Sign |
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Present health or history of present illness |
Location Character quality Quantity or severity Timing Setting Aggravating/relieving factors Associate factors Patient’s perception |
OPQRST |
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Past health |
Childhood illnesses Accident/injury‘s Serious or chronic illnesses Hospitalizations Operation/surgeries Obstetric history Immunizations Last exam dates Allergies Current medications |
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And accurate family history highlights what? |
Diseases and conditions for which particular patients may be at increased risk for |
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It’s a good idea to have a patient fill information when? |
Prior to the appointment |
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Record the medical condition of each relative and significant health data such as |
Age and cause of death, twinning, tobacco use, heavy EtOH use |
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Evaluate the past and present health state of |
Each body system |
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Double check in case any significant data was omitted |
In the present illness section |
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Evaluate |
Health promotion practices |
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The order of the examination should be |
Head to toe |
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Review overall health state |
Present weight gain or loss, fatigue, weakness, chills, fever, sweats, night sweats |
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Functional assessment ADL’s |
Self-esteem/concept Activity/exercise Sleep/rest Nutrition/elimination Interpersonal relationships Spiritual resources Coping and stress management Personal habits Alcohol consumption Elicit or street drug use Environmental hazards Partner violence Occupational health |
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Cage assessment questions |
Have you ever thought you should cut down on your drinking? Have you ever been annoyed at criticism for your drinking? Have you ever felt guilty about your drinking? Do you drink in the morning ( an eye opener)? |
If a person answers yes totwo or more questions, you should suspect EtOH abuse and continue with substance abuse assessment |
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In children, the health history is adapted to include information specific for |
The age and development stage the child |
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What might a health history include in a child? |
Mom’s Health during pregnancy, labor and delivery, the perinatal period and the family unit |
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Children past health |
Prenatal status Labor and delivery Post natal status Childhood illness Serious accidents or injuries Serious or chronic illnesses Operation/hospitalizations Immunizations Allergies Medications |
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What are common true food allergies in children? |
Cows milk Eggs Peanuts Tree nuts Soybean Fish |
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Development history – what should you look and grills in a child? |
Height and weight at birth in at one years old, two years old, five years old, and 10 years old. Also look for tooth Eruption and loss |
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Milestones and developmental history for children |
Holding head up, sitting up alone, rolling over, walking, saying first word, potty training. How does this compare the siblings and peers |
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In nutritional history, the younger the child the more what? |
Detailed and specific the data should be |
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Questions in nutritional history for children mostly babies? |
Breast or bottle fed, introduction to solid foods, any issues?Colic or diarrhea |
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The door minimizes adolescent stress because it moves from expected unless there any questions to those that are more personal |
Headsss |
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What does headsss stand for? |
H - Home environment E - education and employment E- eating A - Peer related activities D - drugs S - sexuality S - suicide/depression S - safety |
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