RLE 4

Cards (56)

  • The purpose of health history is to collect subjective data, which is what the patient says about themselves.
  • The health history is combined with objective data from the physical examination and laboratory studies to form the data base.
  • The health history provides a detailed picture of the patient’s past and present health.
  • The components of health history are biographic data, reasons for seeking care/chief complaint, history, past health history, family health history, current medication, lifestyle, developmental level and psychosocial history.
  • Biographic data in the health history includes name, address and contact number, age and birthdate, sex, marital status, race, ethnic origin, occupation, and language and communication needs.
  • Students can prepare index cards or half-sheets of paper to write feedback to the following questions: "What was the most useful or the most meaningful thing you have learned this session?" and "What question(s) do you have as we end this session?".
  • While gathering data for the family history portion of the health history, it's important to ask about suicide, number of siblings, family ethnicity, and religion.
  • Students can ask questions and debate among themselves.
  • The instructor will rationalize the answers to the students during the face to face interaction.
  • The instructor will mark the session as finished and track progress in a tracker.
  • The instructor will ask questions and debate among students.
  • Students can mark the session as finished and track progress in a tracker.
  • Students can write the correct answer and correct/additional ratio in the space provided.
  • The chief complaint is a brief spontaneous statement in the patient’s own words that describes the reason for the visit, stating one or two signs and symptoms and their duration.
  • The chief complaint is not a diagnostic statement and should not be translated into terms of a medical diagnosis.
  • Document who accomplishes the information in the health history (patient or next of kin), judge how reliable the data seems and how willing the patient to communicate, and note any special circumstances, such as use of interpreter.
  • For well clients, the present health or history of present illness is a short statement about general state of health.
  • For ill patients, the present health or history of present illness is a chronological record of the reason for seeking care, from the time the symptom first started until now.
  • The final summary of any symptoms should include the following critical characteristics using the mnemonic PQRSTU to help remember all the points and organize questions sequences.
  • Past health events may have residual effects on the current state of health.
  • Previous experience with illness may give clue on how the patient responds to illness and to the significance of illness for them.
  • Childhood illnesses include measles, mumps, rubella, chicken pox, pertussis, primary complex, and accident or injuries.
  • Serious or chronic illnesses include DM, hypertension, heart diseases, cancer and seizure disorders.
  • Immunization Hepa B vaccine, MMR, DPT, HPV, Flu vaccine, TT, Hib vaccine
  • Timing Onset: exactly when did it first occur? Duration: how long did it last? Frequency: how often does it occur?
  • Region/ Radiation Where is it? Does it spread anywhere?
  • Operations Type of surgery, date and name of the surgeon, name of the health care facility and how the patient recuperated
  • Current medications/ medication reconciliation Note all prescription and OTC medications and herbal supplements, ask specifically for vitamins, birth control pills, ASA, and anticoagulants / blood thinners
  • Multiple Choice: 1 Past history is an example of a Review of systems.
  • Endocrine Check for Understanding (25 minutes) You will answer and rationalize.
  • Quality/ Quantity How does it look, feel, sound? How intense or severe is it?
  • Provocation/ Palliative What brings it on? What were you doing when you first notice it? What makes it better? Worse?
  • Providing the patient with a printed history to complete and then comparing the data provided is most appropriate to verify the reliability of the information provided by the patient during the interview.
  • Understanding Patient’s Perception of the Problem What do you think it means?
  • Hospitalization Cause, name of the hospital, how the condition was treated, how long the person was hospitalized and name of the primary health care provider
  • Allergies (drugs, food and contact agent) Rash, itching, runny nose, watery eyes, difficulty of breathing
  • Last examination date Physical, dental, visual, hearing ECG, CXR
  • Severity Scale How bad is it, on the scale of 0 - 10; Is it getting better, worse, staying the same?
  • General Overall Health Status Skin Head, Eyes, Ears, Nose, Throat (HEENT) Neck Breasts Respiratory Cardiovascular Gastrointestinal Peripheral Vascular Urinary Reproductive Musculoskeletal Psychiatric Neurologic Hematologic
  • Family History Ask about the age and health or age and cause of death of blood relatives, such as grandparents, siblings.