Complete Health History
Card Set Information
Complete Health History
nursing health history physical assessment
Flashcards for memorizing how to take a complete health history
What are the overarching categories/areas to ask about in the health hx?
I. Identifying Data
VIII. Family Hx
IX. Social Hx
Have I addressed all of your concerns? Do you have anything to add? Do you have any questions?
What systems to ask about as part of PMH?
5. Ears, Nose, Throat
13. Genitals (men); GYN (women)
16. Cancer (if not covered elsewhere)
In PMH, what to ask under "General?"
Usual State of health
Energy level - weakness/fatigue
In PMH, what to ask under "Neuro?"
IF DM -- neuropathy
Syncope or pre-syncope
Any FH of Parkinsons, MG, Lyme, neuropathies
In PMH, what to ask under "Psychiatric?"
: see or hear things that others don't see or hear?
In PMH, what to ask under "Vision?"
Blurred vision (worry about macular degeneration)
Diplopia (double vision)
Eye discharge, watering
Dry eyes & constant tearing (tearing often s/s of dry eyes)
Corrective wear -- contacts, glasses
In PMH, what to ask under "ENT?"
Hearing loss, exposure to noise, aids
Epistaxis (nose bleed)
Loss of smell (anosmia)
Chronic congestion, sinus infections, gum pain
Altered smell or taste
Daily dental care
Bleeding gums, lesions
Hoarseness, voice change
Odynophagia (painful swallowing)
Dysphagia (difficulty swallowing)
In PMH, what to ask under "Neck?"
Neck lumps or swelling
In PMH, what to ask under "Endocrine?"
==> Hot / cold intolerance
==> Hair changes/distribution
In PMH, what to ask under "CV?"
MI (heart attack)/Angina/Chest Pain
Mitral valve problem/Rheumatic fever
In PMH, what to ask under "Hematological?"
In PMH, what to ask under "Respiratory?"
Smoking hx (pack-yrs)
: if productive ==> color, amnt, consistency
: MUST ask carpenters, plumbers, pipe fitters, navy
Pain with breathing
In PMH, what to ask under "GI?"
Appearance of output (melena, blood)
In PMH, what to ask under "GU?"
Color of urine
Difficulty voiding completely
Flank pain, kidney stones
Hx of UTIs
Last PSA (men)
In PMH, what to ask under "Genitals (Men)?"
Penile or testicular pain
Sores of lesions
In PMH, what to ask under "GYN (Women)?"
Age of menarche
Vaginal itch, recurrent/chronic infections
Last GYN and Pap
# live children
In PMH, what to ask under "Dermatology?"
Eczema -- connected with allergies & ear infections
Amnt of sun exposure, tanning
Hair and nails:
Change in texture
In PMH, what to ask under "ortho/musculoskeletal?"
Joint swelling, pain, stiffness
Arthritis (Distinguish RA from OA)
Spine Scoliosis/Lordosis (head & ass)/Kyphosis
Cramps, muscle pain
Gait issues (cane, walker, WC)
Back pain, disc disease
In PMH, what to ask under "cancer?"
Any hx of cancer besides what has already been discussed
In PMH, what to ask under "Childhood?"
Measles, mumps, rubella
Rheumatic fever/heart disease
Whooping cough (pertussis)
In PMH, what to ask under "Hospitalizations?"
What to ask under PSH?
Any rxn to anesthesia and type
: caps, crowns, dentures, plates
: tonsillectomy, appendectomy, C/S
What to ask under Meds?
: Name, dose, frequency, time last taken (have them bring in their meds!!)
Alternative healing methods practiced
What to ask under Allergies?
What to ask under Family Hx?
Do genogram of 3 generations:
Immediate family -- parents and siblings
Extended family -- grandparents, aunts, uncles
Indicate A&W, or deceased and age of death
: genetic disorders, blood dyscrasias, arthritis, psych disorders, suicide, sub abuse
What are the Social Hx categories?
What to ask under Social Hx -- "Home?"
Who live with? Alone
Feel safe at home?
Fire extinguisher in kitchen
Scatter rugs (elderly)
What to ask under Social Hx -- "Education/Exercise/Employment?"
Year education completed (want 8th grade to understand pt educ. lit.)
: learning or otherwise
Type of exercise (cardio, weights, yoga, pilates, walking...)
Amount per week
Affected by any physical conditions?
Type of work
Exposure to toxins
Affecting or affected by health conditions?
What to ask under Social Hx -- "Activities/Abuse?"
What do you do for fun? What activity do you enjoy?
Annoyed when asked?
Pipe, cigar, chewing
: pack years
What to ask under Social Hx -- "Diet/Drugs?"
Vegetarian / Vegan
24 hr recall
"Recreational" or "street drugs"
What to ask under Social Hx -- "Safety/Sex/Spirituality/Stress/Suicide?"
Helmets, Seat belts, Car seats
Guns in house
Active? Tell me a little about hx.
Sleep with men, women, trans, all?
Type - vag interc, oral, anal -- penetrator/penetrated?
STI hx, STI testing
Problems with sexual function, libido, orgasm?
Coping with health/illness
Legal - Living will, Power of attorney
What about ROS?
5. Ears, Nose, Throat
13. Genitals (Men); 13. GYN (Women)
What to ask under RHM?
: self breast exam
: self testicular exam
: Lipid, TSH, CBC, glucose
: dentist, hygiene
Last Skin Exam
Last Eye Exam
Last Tetanus (need Q10 years)
Last EKG/heart test
Screening tests (DEXA scan)
What 3 questions to ask at the end?
Have I addressed all of your concerns?
Do you have anything to add?
Do you have any questions?
What to Review?
Note + and -
Discuss risk factors