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What is the purpse of the complete health history?
- - established the subjective data base
- - helps in developing in a problem list
- - helps to establish a diagnosis
What is the organization of the health history?
- 1. biographical data
- 2. reason for seeking care or chief complaint (CC)
- 3. Present health Status or History of Present Illness (HPI)
- - OLD CART
- 4. Previous Medical History
- a. Childhood illnesses
- b. serious or chronic illnesses
- c. hospitalizations
- d. accidents or injuries
- e. operations
- f. blood transfusions
- g. obstetric history
- h. immunizations
- i. screening tests
- j. health care maintenance
- k. allergies
- l. current medications
- 5. Family History
- 6. Personal and social history
- 7. Reveiw of System (ROS)
- 8. Problem list
What is "Reason for Seeking Care or Chief Complaint (CC)" entail?
- - may focus on illness or wellness needs (e.g. routine physical exam or sore throat)
- - usually one sentence stating problem and its duration
- - for clinic patients, ask why you are here today (you may need to focus on the most important problem)
What does Present Health Status or History of Present illness entail?
- - well pt (short statement of general health)
- - ill pt
- -provide a symptom analysis and describe the characterisitics of the symptoms (OLDCART, PQRST)
- - pt's perception
- - what do you think is wrong?
- - What are your concerns?
- - how are you affected by the illness, etc.
What are type of questions you can ask for symptom analysis?
- 1. have you ever had these symptoms before
- 2. Did you find out what was wrong?
- 3. What diagnostic tests were done? What were the results?
- 4. How were you treated? Was the treatment effective?
What does OLDCART stand for?
- O Onset
- - date/time
- - sudden/gradual
- - predisposing factors (e.g., exposure to "sick contacts")
- L Location
- - point with one finger
- - Where does the pain radiate?
- D Duration
- - how long does it last?
- - Frequency (How often does it occur?)
- -Constant/intermitten (if intermittent, does it subside completely between episodes?)
- C Character
- A Aggravating Factors/Associated Factors
- R Relieving factors
- T treatment
What does Character from OLDCART entail?
- - e.g. sharp, dull throbbing, vise-like, pressure, etc.
- - e.g. bright red blood on tissue; black, sticky, tar-like stools
- Quantity/Severity (Quantify measurments when possible)
- - e.g. blood (saturated 2 pad per hour)
- - e.g. pain (scale [e.g. 0=no pain and 10=severe pain)
- - ask regarding ability to do activities of daily living (ADL)
- patient description- "it feels like an elephant is sitting on my chest"
- - "This is the worst headache I've every had"
What are the Aggravating Factors/Associated Factors of OLDCART?
- - Aggravating factors (What makes the pain worse?)
- -e.g. bending forward, lifting, walking up stairs, running
- - e.g. eating (any food-fatty food-spicy food)
- -Associated Factors
- -e.g. chest pain (nausea, vomiting, diaphoresis, dyspnea and L arm pain) r/o MI
- - e.g. dysuria (shaking chills and fever)- r/o infection
What are the relieving factors of OLDCART?
What makes the symptoms better? (e.g. position)
What does the Treatment part of OLDCART mean?
- What has the pt tried; what was the effect
- - 70-90% of all illnesses are treated first with self-care
Past health history or past medical history may affect what?
- - may affect current health status
- - may affect how the pt responds to illness
What would you include for childhood illnesses?
List the illnesses and date [or age] of occurrence; additional details should be identified in the review of systems.
What would you include for serious or chronic illnesses?
"list" the illnesses and date [or age] or occurence; additional details should be identified in the Review of Systems
What would accident/Injuries include and some examples?
- Dates, nature of event and resulting disability
- - burns
- - fractures
- - lacerations
- - loss of consciousness
- - penetrating wounds
How would you describe Operations?
- List procedure
- indication for procedure (if unclear), date [or age]
- e.g. hysterectomy for uterine fibroids, age 35, complicated by incisional wound infection
What would you include for blood transfusions any why is it important to note?
- Note the dates.
- - may help in the identification of infectious disease transmission.
What would you include in Obstetric History?
- 1. gravida (number of pregnancies)
- 2. Para (carrying a pregnancy to a 500 g weight or 20 wks gestation, regardless of survival.
- 3. Still birth (loss of baby after 20 weeks gestation)
- 4. Abortion (loss of baby before 20 weeks gestation)
- - spontaneous (SAB)= miscarriage
- - Induced (TAB)= therapeutic AB
- 5. Multiple births (twins,etc.) are counted as one para
- - e.g. one pregnancy with twins= G1P1
- 6. sample documentation
- 7. Deliveries (dates, type of delivery, sex, birthweight, condition of infant, complications)
What would you include for immunizations?
List all dates (if known) or year of last immunization and adverse reactions
- some immunizations may not be appropriate due the person's age or situation "not applicable"
Adult immunizations could include:
- 1. tetanus-diptheria (Td) every 10 years
- 2. Tdap-give one time instead if Td if <65 yo and never received
- 3. MMR if susceptible
- 4. Hep B if at risk
- 5. Influenza-annually for age 50 and over
- 6. Zostavax- single dose vaccine for herpes zoster prophylaxis (indicated for adults > 60 yo)
Health care workers immunizations should include:
- 1. Hepatitis B (if not previously received)
- 2. Influenza-annual (ethical responsibility; protect your pts)
- 3. MMR if not immune
- 4. Varicella if not immune
Adolescent immunizations would include:
Hep B series for all (3 injections)- today, in one month, in six months
Some common childhood immunizations include:
- DPt, Tdap, MMR, Polio. Hflu [HIB], varicella
- - hep A is now recommended 12-23 months old
How is Hep A shot given and who is it given to?
- -series of 2 injections given 6 months apart
- -given for those at risk (e.g. foreign travel, MSM)
- - there is also a combo immunization for Hep A and Hep B
Why is the meningococcal shot given and who is it given to?
- - college freshman living in dorms or military recruits
- - other high risk individuals (e.g. after splenectomy)
Who is the Pneumococcal Polysaccharide Vaccine given to?
age 65 and other high risk individuals
What do screening tests include and what are some of the types?
- Include the dates and results
- 1) blood tests (titers)
- -assess immunity or infection
- - assess for infection (HCV, RPR, HIV)
- - assess for lead poisoning in children
- 2) TB Surveillance (by skin test or blood test)
What do TB skin tests indicate?
- - Positive PPD indicates TB infection, but does not differentiate between active TB and inactive TB
- - Inactive TB is called latent TB infection (LTBI)
- - If a PPD is positive, then a chest XRAY is done to see if there is evidence of active TB.
What would you include for health care maintenance and what are some examples?
- - list the dates and results of the last exam or indicate "never done"
- 1. eye exam
- 2. hearing test
- 3. dental exam
- 4. mammogram
- 5. chest x-ray
- 6. ECG
- 7. Lipid panel (cholesterol, LDL, HDL, triglycerides)
- 8. Physical exam
- 9. PAP smear
- 10. Other (rectal exam, prostate exam, occult blood test, sigmoidoscopy, colonoscopy)
What would you include for allergies and name some examples.
- (allergens and reactions
- NKA= no known allergies
- NKDA= no known drug allergies
- 1. Medications
- 2. Vaccines
- 3. Foods
- 4. Animals/insects
- 5. Seasonal (pollens, etc.)
- 6. Occupational
What would you include for current medications?
Preceiption, OTC, herbal, vitamins, calcium
- 1. Drug name
- 2. dose
- 3. route
- 4. frequency
- 5. rationale and duration of use
Why would you include prescription and over the counter (OTC) drugs?
- - not all OTC drugs are harmless
- - drug interactions (Coumadin and ASA)
- - Confusion with generic and trade names (pt may not know that Motrin and Ibuprofen are the same, therefore may be taking both)
Why would you include calcium?
- -achieving peak bone mass before age 25 can decrease the risk of osteoporosis.
- - 9 out of 10 teenage girls fail to consume adequate calcium
What are the age specific calcium needs for both sexes?
- 4-8 yo: 800 mg/day
- 11-24 yo: 1200-1500 mg/day
- > 25 yo: 1000 mg/day
- postmenopausal & men >65 1500 mg/day
Why do you take a family history and what type of medical problems do you record?
- - identify age of family members, age at which an illness occurred, age of death and cause of death
- - if family member is healthy without illness, document as alive and well
- - record medical problems such as cancer, heart disease, diabetes, asthma, mental illness, high blood pressure, stroke, kidney disease, alzheimer's disease, thyroid disease, obesity, vision/hearing loss, birth defects, blood disorders, genetic diseases, substance abuse, etc
What types of personal and social history would you consider?
- 1. habits (past and present)
- 2. Housing and living situation
- 3. Occupational history
- 4. Economic status
What type of habits would you discuss?
- 1. Tobacco (cigarettes, cigars, pipe, smokeless; indicate if never
- smoked, current smoker, or date of cessation; document pack year
- cigarette history if applicable.
- - pack year history= ppd x # of years smoked
- 2. Alcohol (type, amount, frequency, duration): don't record as social drinker
- 3. Drug Abuse (type, amount, frequency, duration)
- 4. Sleep (quantity, quality, problems)
- 5. exercise (type, frequency, duration)
What does housing and living situation entail?
- -list household members and relationships, marital history and children
- - describe the pattern and quality of family relationships/interactions and h/o domestic violence. Describe support systems.
What would you factor in for occupational history?
- - list you jobs for the past 5 years and the dates for each
- - describe you level of current job satisfaction and job stress (physical and mental)
- - current number of hours per week
What is considered in the review of systems?
- 1. general overall health
- 2. skin, hair and nails
- 3. head and neck
- 4. eyes
- 5. ears
- 6. nose and sinuses
- 7. mouth and throat
- 8. breast
- 9. heart and peripheral vascular
- 10. gastrointestinal
- 11. urinary
- 12. musculoskeletal
- 13. neurologic
- 14. psychological
- 15. endocrine
- 16. hematologic
- 17. female
- 18. male
- 19. sexual health
What would your problem list include?
- 1. list past resolved problems
- 2. List chronic unresolved problems
- 3. List acute problems (current problems of less than 6 weeks duration)
- 4. Risk assessment (list potential or high risk) problems)
- - i.e. increased risk of osteoporosis related to inadequate calcium intake
Describe the child health history?
- 1. most data obtained from the adult, but include the child when appropriate (indicate the source of info (parent?)
- 2. Parental concerns
- 3. Prenatal data (mother's health status), labor and delivery and postnatal problems
- - mother smoking (smaller birth wt)
- - ETOH abuse (fetal alcohol syndrome)
- - difficult delivery (effect on mental development)
- 4. ask parents who the child manifests symptoms (e.g. earache)-behavior?
- 5. Ask regarding parent's coping ability (may affect the child)
- 6. Ask regarding parent's health problems (genetic predisposition, e.g. asthma)
- 7. Current developmental tasks (infants and yound children)
- - gross motor, fine motor, lanuage, social skills
- 8. past health included developmental milestones (growth, toilet training, etc)- were these events on the normal growth and development schedule?
- 9. Review of Systems
- - birthmarks, ability to see the blackboard at school, problems, immunizations
What are some adolescent health history considerations?
- - use the pediatric data base until age 12-14, then use the adult health history
- - parents may or may not be present during history taking depending on the age of the child
What are some older adult considerations?
- 1. may understate their symptoms (may think its part of getting old) e.g. may fail to mention fatigue and decreased activity tolerance which may be an early sign of CHF
- 2. Polypharmacy (consider potential drug-drug interactions and numerous side effects)
- 3. Review of Systems
- - dentures, dry skin, decreased sensation in feet, appetite changes, elder abuse, hearing and vision loss, etc.
- 4. functional assessment-measures the pt's self-care ability and ability to live independently