Complete Health History

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Author:
meganfrances
ID:
16147
Filename:
Complete Health History
Updated:
2010-04-25 17:56:49
Tags:
nursing health history physical assessment
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Flashcards for memorizing how to take a complete health history
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  1. What are the overarching categories/areas to ask about in the health hx?
    • I. Identifying Data
    • II. CC
    • III. HPI
    • IV. PMH
    • V. PSH
    • VI. Meds
    • VII. Allergies
    • VIII. Family Hx
    • IX. Social Hx
    • X. ROS
    • XI RHM
    • Have I addressed all of your concerns? Do you have anything to add? Do you have any questions?
    • Review
  2. What systems to ask about as part of PMH?
    • 1. General
    • 2. Neuro
    • 3. Psych
    • 4. Vision
    • 5. Ears, Nose, Throat
    • 6. Neck
    • 7. Endocrine
    • 8. CV
    • 9. Hematological
    • 10. Respiratory
    • 11. GI
    • 12. GU
    • 13. Genitals (men); GYN (women)
    • 14. Skin
    • 15. Ortho/musculoskeletal
    • 16. Cancer (if not covered elsewhere)
    • 17. Childhood
    • 18. Hospitalizations
  3. In PMH, what to ask under "General?"
    • Usual State of health
    • Energy level - weakness/fatigue
    • Appetite changes
    • Wt gain/loss/BMI
    • Fever/chills/night sweats
    • Pain
  4. In PMH, what to ask under "Neuro?"
    • HA/migraines
    • Seizures
    • Tremors
    • CVA/TIA (mini-stroke)
    • Stroke
    • Gait disturbance
    • Parkinsons Disease
    • Myasthenia Gravis
    • Memory changes
    • Disorientation
    • Paralysis
    • Lyme
    • Bells palsy
    • IF DM -- neuropathy
    • Syncope or pre-syncope
    • Dizziness
    • Head injuries
    • Any FH of Parkinsons, MG, Lyme, neuropathies
  5. In PMH, what to ask under "Psychiatric?"
    • Nervousness
    • Anxiety
    • Stress
    • Depression
    • Hallucinations: see or hear things that others don't see or hear?
    • Mood changes
  6. In PMH, what to ask under "Vision?"
    • Acuity
    • Blind spots
    • 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
    • Eye pain
    • Redness, swelling
    • Photophobia
    • Glaucoma, cataracts
  7. In PMH, what to ask under "ENT?"
    • E:
    • Earaches
    • Discharge
    • Tinnitus
    • Vertigo
    • Tubes?
    • Hearing loss, exposure to noise, aids
    • N:
    • Deviated septum
    • Epistaxis (nose bleed)
    • Loss of smell (anosmia)
    • Chronic congestion, sinus infections, gum pain
    • Altered smell or taste
    • T:
    • Mouth pain
    • Daily dental care
    • Bleeding gums, lesions
    • Hoarseness, voice change
    • Sore throat
    • Odynophagia (painful swallowing)
    • Dysphagia (difficulty swallowing)
  8. In PMH, what to ask under "Neck?"
    • Neck discomfort
    • Limited ROM
    • Neck lumps or swelling
    • Goiter
  9. In PMH, what to ask under "Endocrine?"
    • **Diabetes
    • **Hyper/Hypothyroid
    • ==> Hot / cold intolerance
    • ==> Hair changes/distribution
  10. In PMH, what to ask under "CV?"
    • BP/HTN
    • Dyslipidemia, TGs
    • MI (heart attack)/Angina/Chest Pain
    • CAD
    • CHF
    • Congenital defects
    • Murmurs, arrhythmias
    • SOB/dyspnea
    • Cyanosis
    • Edema
    • Varicose veins
    • Claudication (limping)
    • Ulcers (venous/arterial)
    • Mitral valve problem/Rheumatic fever
    • DVT
  11. In PMH, what to ask under "Hematological?"
    • Bleeding/bruising tendency
    • Radiation exposure
  12. In PMH, what to ask under "Respiratory?"
    • COPD:
    • *Asthma
    • *Emphysema
    • *Chronic bronchitis
    • Smoking hx (pack-yrs)
    • Cough: if productive ==> color, amnt, consistency
    • Last PPD/TB
    • Asbestosis: MUST ask carpenters, plumbers, pipe fitters, navy
    • PE
    • PND/orthopnea (#pillows)
    • Wheezing, SOB
    • Pneumonia
    • Fractured ribs
    • Cystic fibrosis
    • Pain with breathing
    • Hemoptysis
    • Last CXR
  13. In PMH, what to ask under "GI?"
    • N/V/D
    • GERD
    • Appearance of output (melena, blood)
    • Heartburn, indigestion
    • Jaundice
    • Colitis
    • BMs/Constipation
    • Bloating/gas
    • Incontinence
    • Hemorrhoids
    • Ulcers
    • Hepatitis
  14. In PMH, what to ask under "GU?"
    • Burning
    • Color of urine
    • Urgency, frequency
    • Nocturia
    • Dysuria
    • Polyuria, Oliguria
    • Narrowed stream
    • Difficulty voiding completely
    • Incontinence
    • Flank pain, kidney stones
    • Hx of UTIs
    • Last PSA (men)
  15. In PMH, what to ask under "Genitals (Men)?"
    • Penile or testicular pain
    • STIs
    • Itch
    • Sores of lesions
    • Discharge
    • Lumps
    • Hernia
    • Rash
    • Erectile function/libido
  16. In PMH, what to ask under "GYN (Women)?"
    • Sexual function/libido
    • Menstrual hx
    • Age of menarche
    • LMP
    • Duration
    • Amenorrhea
    • Menorrhagia
    • Premenstrual pain
    • Spotting
    • Vaginal itch, recurrent/chronic infections
    • Menopause
    • Post-menopausal bleeding
    • Last GYN and Pap
    • STIs
    • Pregnancies:
    • # pregnancies
    • # births
    • # live children
  17. In PMH, what to ask under "Dermatology?"
    • Skin cancer
    • Mole changes
    • Pigment changes
    • Lesions
    • Rashes
    • Scars
    • Psoriasis
    • Eczema -- connected with allergies & ear infections
    • Pruritis (itching)
    • Bruising
    • Amnt of sun exposure, tanning
    • Hair and nails:
    • Recent loss
    • Change in texture
    • Color, brittleness
    • Breast:
    • Pain
    • Lumps
    • Nipple discharge
    • Surgery
    • Last mammogram
    • Axilla:
    • Tenderness
    • Lump
    • Swelling
    • Rash
  18. In PMH, what to ask under "ortho/musculoskeletal?"
    • Fractures
    • Joint swelling, pain, stiffness
    • Tenderness
    • Arthritis (Distinguish RA from OA)
    • Gout
    • Lupus
    • Spine Scoliosis/Lordosis (head & ass)/Kyphosis
    • Osteopenia/Osteoporosis
    • Limited ROM
    • Cramps, muscle pain
    • Weakness
    • Gait issues (cane, walker, WC)
    • Coordination
    • Back pain, disc disease
    • Accidents
  19. In PMH, what to ask under "cancer?"
    Any hx of cancer besides what has already been discussed
  20. In PMH, what to ask under "Childhood?"
    • Measles, mumps, rubella
    • Chicken pox
    • Meningitis
    • Polio
    • Rheumatic fever/heart disease
    • Whooping cough (pertussis)
  21. In PMH, what to ask under "Hospitalizations?"
    • Year
    • Reason
    • Complications
  22. What to ask under PSH?
    • Any rxn to anesthesia and type
    • Dental: caps, crowns, dentures, plates
    • Difficulty swallowing
    • Complications post-op
    • Commonly forgotten: tonsillectomy, appendectomy, C/S
  23. What to ask under Meds?
    • Rx: Name, dose, frequency, time last taken (have them bring in their meds!!)
    • OTC
    • Herbs
    • Alternative healing methods practiced
  24. What to ask under Allergies?
    • DEF:
    • Drugs
    • Environmental
    • Foods
    • & Latex!
  25. 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
    • Include: genetic disorders, blood dyscrasias, arthritis, psych disorders, suicide, sub abuse
  26. What are the Social Hx categories?
    • HEADS:
    • Home
    • Education/Exercise/Employment
    • Activities/Abuse
    • Diet/Drugs
    • Safety/Sex/Spirituality/Stress/Suicide
  27. What to ask under Social Hx -- "Home?"
    • Who live with? Alone
    • Feel safe at home?
    • Safety:
    • Fire alarm
    • Radon detector
    • CO detector
    • Fire extinguisher in kitchen
    • Scatter rugs (elderly)
  28. What to ask under Social Hx -- "Education/Exercise/Employment?"
    • Education:
    • Year education completed (want 8th grade to understand pt educ. lit.)
    • Disabilities: learning or otherwise
    • Exercise:
    • Type of exercise (cardio, weights, yoga, pilates, walking...)
    • Intensity
    • Amount per week
    • Affected by any physical conditions?
    • Enjoy it?
    • Employment:
    • Location
    • Type of work
    • Length
    • Exposure to toxins
    • Affecting or affected by health conditions?
    • Retired?
    • Financial situation?
  29. What to ask under Social Hx -- "Activities/Abuse?"
    • Hobbies:
    • What do you do for fun? What activity do you enjoy?
    • Alcohol:
    • Cutting down?
    • Annoyed when asked?
    • Guilty?
    • Eye opener?
    • Tobacco/Smoking:
    • Pipe, cigar, chewing
    • Cigarettes: pack years
    • Caffeine Intake:
    • Coffee
    • Tea
    • Soda
    • Chocolate
  30. What to ask under Social Hx -- "Diet/Drugs?"
    • Vegetarian / Vegan
    • 24 hr recall
    • "Recreational" or "street drugs"
  31. What to ask under Social Hx -- "Safety/Sex/Spirituality/Stress/Suicide?"
    • Safety:
    • Helmets, Seat belts, Car seats
    • Guns in house
    • Sunblock
    • Domestic violence
    • Sex:
    • Active? Tell me a little about hx.
    • Sleep with men, women, trans, all?
    • Protection/Condoms
    • Type - vag interc, oral, anal -- penetrator/penetrated?
    • STI hx, STI testing
    • Birth control?
    • Problems with sexual function, libido, orgasm?
    • Pregnancy intentions/testing
    • Spirituality:
    • Faith/belief system
    • Coping with health/illness
    • Stress:
    • Economic
    • Family
    • Legal - Living will, Power of attorney
    • Suicide:
  32. What about ROS?
    • 1. General
    • 2. Neuro
    • 3. Psychiatric
    • 4. Vision
    • 5. Ears, Nose, Throat
    • 6. Neck
    • 7. Endocrine
    • 8. CV
    • 9. Hematological
    • 10. Respiratory
    • 11. GI
    • 12. GU
    • 13. Genitals (Men); 13. GYN (Women)
    • 14. Skin
    • 15. Ortho/Musculoskeletal
  33. What to ask under RHM?
    • Mammogram
    • SBE: self breast exam
    • STE: self testicular exam
    • Colonoscopy
    • Labs: Lipid, TSH, CBC, glucose
    • Urinalysis
    • Pap
    • Dental: dentist, hygiene
    • Last Skin Exam
    • Last Physical
    • Last Eye Exam
    • Last PPD
    • Last Tetanus (need Q10 years)
    • Last EKG/heart test
    • Immunizations
    • Screening tests (DEXA scan)
  34. 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?
  35. What to Review?
    • Note + and -
    • Discuss risk factors
    • Review RHM

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