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.
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PQRTSU

P: 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

	Criado por ciciullan quase 11 anos atrás

Health Assessment Notas sobre Chapter 4: The Complete Health History , criado por ciciullan em 23-01-2014.