Chapter 4: The Complete Health History

ENTIRELY SUBJECTIVE!!*affirm what the person is doing right   -for well person, used to assess his or her lifestyle   -for ill person, includes a detailed and chronologic record of the health problem.   -a screening for abnormal symptoms.

1. Biographic Data2. Reason for seeking care3. Present health or history of present illness4. Past history5. Family history 6. Review of systems*******************7. Functional assess of ADL's

Record time and date for interview1. Biographic DataName, address, phone #, age, birthday, birthplace, gender, martial status, race, ethnic origin, occupation. Primary language/authorized representative. 

Source of History*record who furnishes the data, seems reliable?

Reason for Seeking Care*brief statement in patient's own words that describes the reason for the visit.*think of it as title*it states one or two S/S and their duration.*some people self-diagnose, avoid it by asking questions about symptoms.*for multiple symptoms, as patient which one prompted him or her to seek care.

Present Health to History of Present Illness*a chronological record of the reason for seeking care, from the time the symptom first appear until now.*isolate each reason for care.*summary of any symptom:   1. Location...ask person to point to the location. If it's pain, note the precise site. Head pain is vague, use "pain behind the eyes" instead. Localized site to radiating? Superficial or deep?   2. Character or Quality....specific descriptive terms such as burning, sharp, dull aching, gnawing, throbbing, shooting. Use similes. Does blood in stool look like sticky tar?   3. Quantity or Severity....attempt to quantify the sign to symptom, such as "profuse menstrual flow soaking five pads an hour." Use pain scale.   4. Timing...(onset, duration, frequency)..when did the symptom first appear? Give specific date and time.Was is steady? intermittent?    5. Setting...where was the person or what were they doing when the symptom started?   6. Aggravating or Relieving Factors...what makes the pain worse?   7. Associated Factors...is this primary symptoms associated with others? May be side effect of medication.    8. Patient's Perception...find out the meaning of the symptom by asking how it affects daily activities. ****************************************************PQRTSUP: Provocative or Palliative. what brings it on? Makes is better or worse?Q: Quality or Quantity. how does it look, feel, sound? how intense/severe is it?R: Region or Radiation. Where is it? Does is spread anywhere?S: Severity Scale. How bad is it? on a scale of 1 to 10?T: Timing. Onset. when did it first occur? Duration? Frequency? U: Understand Patient's Perception

Past Health*past health events are important because they may have a residual effect.*childhood illnesses*serious or chronic illnesses*hospitalizations*operations*obstetric hx*immunizations*last exam sate*allergies*current medications

Family Hx* will highlight those diseases and conditions for which a particular patient may be at increased risk.

Review of Symptoms*purpose is to evaluate the past and present health state of each body system, to double-check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices. *history should be about patient statements or subjective data!!!*head-to-toe; is present illness section covered one section, you don't need to do it again.

Functional Assessment (ADLs)*measures self-care ability 

New Page