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74 Cards in this Set
- Front
- Back
Purpose of a Complete Health History |
- Establish Subjective Data - Helps in dveloping a problem list - Helps to establish a diagnosis
*There is no objective data in the health history |
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Biographical Data |
Date, Name, DOB, Birthplace, Sex Marital Status, Race, Ethnic Origin, Religion, primary/secondary language, level of education, occupation, health insurance
Source of info, know who filled it out and impression of the informant's reliability, good or poor historian |
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Reason for seeking care |
- Also known as "chief complaint" or "chief concern" - May focus on illness or wellness needs - One sentence stating the problem and its duration, in quotes - May need to ask what the major concern is for the day, can't necessarily address all problems in one visit |
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Present health status or History of present illness (HPI) |
Well patient - statement of general health
Ill Patient - provide a symptom analysis and describe the characteristics of the symptoms PQRST or OLD CART |
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OLD CART |
Onset Location Duration Character - Quality, Quantity, Patient Description Aggravating Factors/Associated Factors Relieving Factors Treatment |
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PQRST |
P - Provocative/Palliative Q - Quality/Quantity R - Region/Radiation S - Severity scale T - Timing U - Understanding pt's perception |
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HPI - Patient's Perception |
What do they think is wrong? - Fears, denial, misinterpretation
What are your concerns?
How are you affected by the illness? |
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HPI - Symptom Analysis |
Have you ever had these symptoms before?
Did you find out what was wrong?
What diagnostics were done? Results?
How were you treated? Was it effective? *Past history may be very helpful |
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Onset |
Date/Time Sudden/Gradual Predisposing factors, exposure to sick contacts |
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Location |
Point with one finger Where does it radiate? Is it localized? |
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Duration |
How long does it last? How often does it occur? Is it constant or intermittent? If intermittent, does it subside completely between episodes? |
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Character |
Quality - sharp, dull, throbbing, vise-like, pressure, bright red blood on tissue, black sticky, tar-like stools Quantity/Severity - Blood (saturated pads), pain (scale 0-10), ability to do ADLs Patient description - In quotes |
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Aggravating favtors |
What makes it worse? Bending forward, lifting, walking upstairs, running, eating spicy or fatty foods |
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Associated Factors |
Chest pain - nausea, vomiting, diaphoresis, dyspnea, left arm pain Dysuria - shaking, chills, fever |
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Relieving factors |
What makes the symptoms better? |
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Treatment |
What has the patient tried at home? Was it effective?
* 70-90% of all illness are treated first with self-care |
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Past health history or Past medical history (PMH) |
May affect current health status
May affect hos the patient responds to the illness
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PMH - Childhood illness |
List illness and date/age of occurrece includes:
measles, mumps, rubella, diptheria, pertussis, polio, rheumatic fever, varicella |
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PMH - Serious or Chronic illnesses |
Illness and date of occurrence, details should be identified in ROS |
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PMH - Hospitalizations |
List dates, causes, hospital, treatment, and length |
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PMH - Accidents/Injuries |
Dates, nature of event/circumstances, resulting disability
Burns, fractures, laceractions, loss of consciousness, penetrating wounds, etc. |
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PMH - Operations |
List procedure, indications for procedure, date, sequela |
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PMH - Blood transfusions |
Help in identification of infectious disease transmission |
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PMH - Obstetric History |
Gravida (# of pregnancies) Para (carrying pregnancy to 500 gm wt or 20 weeks gestation, regardless of survival) Still Birth (loss of baby after 20 weeks gestation) Abortion (loss of baby before 20 weeks gestation) (Spontaneous/SAB, Induced/TAB - Therapeutic) Multiple births - one para Deliveries - dates, delivery, sex, wt, problems |
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PMH - Immunizations |
List dates or yr of immunizations Advers reactions If immunizations not appropriate in particular patient, document "not applicable"
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Immunizations - Tetanus/Diptheria, TDAP |
Tetanus/Diptheria (Td) - Every 10 yrs TDAP (with pertussis) - give once before age 65 instead of Td, may need booster after 65 yrs if high risk, frequent contact with kids younger than 12 mo |
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Immunizations - MMR |
Given as an adult if not received as a child or if they were never infected |
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Immunizations - Hep B |
Given if at risk, health care workers
May be a sexually transmitted disease
Three series immunizations |
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Immunizations - Influenza |
Annually given for all ages |
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Immunizations - Zostavax |
Single dose vaccine for herpes zoster prophylaxis, indicated for adults older than 50 yo
For shingles, people who previously had chicken pox are at risk |
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Immunizations - Health care worker |
Hep B
Influenza
MMR - if not immune
Varicella - if not immune |
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Immunizations - Adolescents |
Hep B for all (3 series), first shot today, then one month later, then six months later |
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Immunizations - Childhood |
DPT Tdap MMR Polio Hflu (HIB) Varicella Hep A is now recommended at 12-23 mo |
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Immunizations - Hep A |
If not previously given in childhood
Series of 2 injections given 6 mo apart
Given to at risk: foreign travel, men having sex with men (MSM)
There is a combo for Hep A and B, "twinrix," given in 3 part series |
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Immunizations - Gardisil |
For men and women
Protects against viral strains of HPV that causes external genital warts (EGW) and cervical cancer |
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Immunizations - Meningococcal |
Given to college freshman living in dorms or military recruits
High risk individuals, ie. s/p splenectomy |
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Immunizations - Pneumococcal |
Polysaccharide vaccine (PPSV 23) - given at age 65 and other high risk individuals (may be given at an earlier age)
Pneumococcal Conjugate 12-Valent Vaccine (PCV 13) - given in addition to PPSV 23 for those with immuno-compromising conditions |
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Immunizations - PPSV 23, over 65 |
All people over 65, don't need revaccine Under 65: chonic CV disease (CHF, CM), chronic pulm disease (COPD), DM, ETOH, chonic liver disease (cirrhosis), CRF, nephrotic syndrome, CSF leaks, cochlear implants, functional or anatomic asplenia (splenectomy, sickle cell disease), immuno compromised disease (HIV) Under 65 - if received 1-2 doses prior to 65, single revaccination at 65 if earlier dose >5yrs REvaccinate 5 yrs after first dose in |
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Immunizations - PPSV 23, under 65 |
Chronic CV disease (CHF, CM), chronic pulm disease (COPD), DM, ETOH, chonic liver disease (cirrhosis), CRF, nephrotic syndrome, CSF leaks, cochlear implants, functional or anatomic asplenia (splenectomy, sickle cell disease), immuno compromised disease (HIV). Revaccinate if received 1-2 doses prior to 65, single dose at 65 if earlier dose >5yrs prior. Revaccinate 5 yrs after first dose in CRF, nephrotic syndrome, functional or anatomic asplenia, immuno-compromised conditions |
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Immunizations - PCV 13 |
Indicated for adults 19 yrs or older with immuno-compromising conditions such as CRF, nephrotic syndrome, functional or anatomic asplenia, CSF leaks, cochlear implant. If no prior doses of PPSV 23 or PCV 13: give PCV 13 followed by PPSV 23 at least 8 weeks later If previously received PPSV 2: given PCV within the last dose of PPSV 23 |
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Screening Tests |
Identify date and whether the person is immune or shows evidence of disease Blood titers: assess for immunity or infection (MMR, varicella), (Hep A/B; HAV/HBV), assess for infection (Hep C/HCV, RPR/Syphillus, HIV), |
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Lead Poisoning |
Assess for lead poisoning in children (found in paint until 1978, glazes of old pottery/china, ceramics produced in countries outside of US, UK, France) Avoid dishes from Mexico, China, Hong Kong, India, Italy Poisons the RBC, interferes with iron uptake, may cause anemia/metal retardation in kids |
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TB Surveillance - Purified protein derivative |
Skin Test - PPD Positive PPD indicates TB infection, not differentiated between activ and inactive/latent If positive PPD, CXR done to see if evidence of active TB. May also need induced sputum cultures for AFB
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TB Surveillance - PPD, positive value |
Positive >5mm induration with associated risks: sick contacts, clinical suspicion, abnormal CXR, HIV Positive >10 mm induration with risks: foreign-born, medically underserved, low-income, high risk ethnic minorities, IVD use, homeless, residents of long term care, healthcare workers, persons with medical conditions with high TB risk (kidney failure, DM) Positive >15mm induration low risk patient not living in LA with no risk factors |
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TB Surveillance - Quantiferon |
Approved in 2005 Doesn't distinguish between active or latent Eliminates false positives from BCG vaccine (vaccine given in 3rd orld country as TB vaccine) |
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Health Care Maintenance |
Dates and results of screening exams |
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Screening - Blood pressure |
BP< 120/80: Every 2 yrs SBP 120-139/DBP 80-90: Every yr |
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Screening - Lipids |
20 yrs or older: Every 5 yrs |
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Screening - Diabetes |
Sustained BP> 130/80: screen with FPG or 2 hr post-load plasma, or hemoglobin A1c |
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Screening - Colorectal Cancer |
50-75 yrs: FOBT every year, or sigmoidoscopy every 5 yrs plus FOBT every 3 yrs or colonoscopy every 10 yrs |
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Screening - Abdominal Aortic Aneurysm |
65-75 yr old men who have ever smoked: one time ultrasound |
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Screening - Hepatitis C (HCV) |
Adults born between 1945-1965: one time blood test |
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Screening - Prostate Cancer |
Most men 50 yrs or older, or African Americans and other high risk men at 45 yrs old:
Discuss pros/cons of screening with PSA/rectal exam annually |
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Screening - Cervical Cancer |
21-29 yrs: Pap every 3 yrs 30-65 yrs: Pap every 3 yrs with HPV screen every 5 yrs |
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Screening - Chlamydia |
< 25 yrs old: Annually if they are at risk |
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Screening - Osteoporosis |
65 yrs old: baseline, then follow-up as indicated |
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Screening - Mammograms |
50-74 yrs old: Every 2 yrs |
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Screening - Vision |
40-64 yrs old: Comprehensive eye exam with glaucoma screening every 2-4 yrs
65 and older: comprehensive eye exam with glaucoma screening every 1-2 yrs |
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Screening - Dental |
Yearly exam and twice a year cleaning |
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Allergies |
List meds, vaccines, foods, animals/insects, seasonal/pollens, occupational, etc.
Allergens and reactions: some people list allergens that don't have a true allergic reaction
Histamine response: itching, rash, throat swelling, trouble breathing - reintroducing allegen can intensify reaction |
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Current Medications |
Perscriptions, OTC, herbal, vitamins, calcium
List name, dose, route, frequency, rationale/indication, duration of use
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OTC meds are not harmless |
NSAIDS: GI Bleed Pseudoephedrine: HTN Antihistamines: drowsiness, fall risk Drug interactions: Coumadin, ASA Confusion with generic and trade names - patients should not be on 2 drugs of same class |
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Calcium |
Achieving peak bone mass before age 25 can decrease risk of osteoporosis
Age specific needs (both sexes): 4-8 yrs: 800 mg/day 11-24 yrs: 1200-1500 mg/day over 25 yrs: 1000 mg/day Post menopausal and men: 1500 mg/day
Multiple doses because body can't absorb more than 500 mg at a time, take with Vit D 400 units/15 min sun to increase absorption
One glass of milk = 300 mg
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Family History |
Genogram/Family Pedigree Age of members, age when illness occurs, age and cause of death or document A&W (alive and well) Attention to cancer, heart disease, Alzheimer's, thyroid, obesity, vision/hearing loss, birth defects, blood disorders, genetic diseases, substance abuse |
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Personal/Social History - Tobacco |
Tobacco (cigarettes, cigars, pipe, smokeless) - never smoked, current smoker, previous smoker
pack year history = ppd x yrs smoked ie. 2ppd x 15 yrs = 30 pack yr history |
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Personal/Social history - ETOH |
Type, amount, frequency, duration
Never document "social drinker," be very specific |
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Personal/Social History |
Habits - Past and present Drug abuse (type, amount, frequency, duration) Sleep (Quantity, quality, problems) Exercise (type, frequency, duration) Housing - members and relationships, marital history, children, h/o domestic violence, describe support systems. Occupational history - jobs for past 5 yrs, satisfaction, stress, hrs worked per week Economic status, financial concerns, social services |
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Review of Systems |
*No physical exam findings Dates of onset, treatment, response to treatment Sequela: unexpected response
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Review of Systems includes: |
General overall health, skin, hair, nails, head, neck, eyes, ears, nose, sinuses, mouth, throat, breasts, lungs, thorax, heart, peripheral vascular system, gastrointestinal, urinary, musculoskeletal, neurologic, psychological, endocrine, hemtologic, female, male, sexual healing |
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Problem list |
*No new info, just supported from previous info collected, not documented in narrative form Past resolved problems Chronic unresolved problems Acute problems (6 weeks or less in duration) Risk Assessment (potential or high risk problems) - famly hx, risk factors, health promotion behaviors (ETOH, smoking, calcium intake, dentition, noise exposure, exercise, pap smears, immunizations, pap smears, prostate exams, testicular/breast self exams, seat bet use, sun protection, helmet use) |
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Age Related Considerations - Child health history |
Adapted to include specific info for age and developmental stages Data mostly obtained from adult Parental concerns Prenatal data: mother's health status, l&d, postnatal problems, mother smoking, small birth wt, ETOH abuse, difficult delivery How child manifests behavior/symptoms Coping ability Parent's health problems Current developmental tasks: gross motor, fine motor, language, social skills Past developmental milestones: were events on the normal growth and development schedule ROS: birthmarks, see blackboard, congenital heart problems, immunizations |
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Age Related Considerations - Adolescent |
Use pediatric data base until ages 12-14, then use adult health history Parents may or may not bepresent depending on age of child |
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Age Relted Considerations - Older Adult |
May understate symptoms, fail to mention fatigue, decreased activity tolerance (CHF) Polypharmacy: consider drug-drug interaction, numerous side-effects ROS: dentures, dry skin, decreased sensation in feet, appetite changes, elder abuse, hearing and vision loss Functional assessment: self-care abilities |
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Cultural Considerations |
Different ethnic groups view health differently, may affecy request for pain meds, health may be defined as good appetite, feeling strong, absence of disease |