Essay on The complete health history – Flashcards
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* collect subjective data * combing subjective data w/ objective data from the physical exam & diagnostic tests, you create a database to make a judgement about the person's health status * 8 categories
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Purpose of complete health history
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health history includes a detailed, chronological record of the health problem
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Sick patients
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* a screening tool for abnormal symptoms, health problems, & concerns * records the patient's responses to health problems
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All patients
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* patient's name * address * date of birth * language & communication needs
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Biographic data
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* usually the patient * may be someone else, such as relative or interpreter
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Source of history
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* formerly known as chief of complaint * in patient's own words, briefly describe the reason for visit * write this in quotes
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Reason for seeking care
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* well person- briefly note the general state of health * sick person- chronologically record the reason for seeking care
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Present health or history of present illness
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* when a patient reports a symptom * PQRSTU
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Symptom analysis
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provocative or palliative
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P
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quality or quantity
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Q
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region or radiation
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R
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severity scale
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S
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timing
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T
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understanding the patient's perception of the problem
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U
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illnesses, injuries, hospitalizations, allergies, & current medications
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Past health events
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* to help detect health risks for the patient * draw a pedigree or genogram
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Family history
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* to evaluate the past & present health of each body system, double check for significant data, & assess health promotion practice * for each body system, assess for symptoms & health promoting behaviors
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Review of systems
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Include activities of daily living Example: bathing dressing, toileting, eating, walking, housekeeping, shopping, cooking
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Functional assessment
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* obtained for each health history category * may vary from one setting to another * address all categories before making a diagnosis or judgement about the patient's health status
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Depth of information
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* use same structure as adult * make some modifications: a prenatal & perinatal history, the parent's description of the present problem, any childhood illnesses or accidents, immunization data, a developmental overview, and a nutritional history
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Child's health history
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consider child's environment & his/her function or role in the environment
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Assessing child's functional ability
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* ask additional questions * for example: explore changes in activities of daily living that may result from the aging process or chronic illness
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Older adult's health history
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* may be more important to an older adult than the actual disease diagnosis or pathology * be sure to record the person's reason for seeking care, not your assumption of the problem
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Impact or burden of a disease
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useful because it addresses: * basic & instrumental activities of daily living * functional assessment * physical, social, psychologic, demographic, financial, & legal issues
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Comprehensive older person's evaluation
