complete health history

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

The Complete Health HistoryThe Complete Health History

Chapter 4Chapter 4


Chapter 4: The Complete Health HistoryChapter 4: The Complete Health History

The Health History: AdultThe Health History: Adult

1.1. Biographical dataBiographical data

2.2. Source of historySource of history

3.3. Reason for seeking careReason for seeking care

4.4. Present health or history of present illnessPresent health or history of present illness

5.5. Past healthPast health

6.6. Family historyFamily history

7.7. Review of systemsReview of systems

8.8. Functional assessment including activities of Functional assessment including activities of daily living (ADLs)daily living (ADLs)

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The Health History: Adult (cont.)The Health History: Adult (cont.)

Biographical dataBiographical data NameName Address and phone numberAddress and phone number Age and birth dateAge and birth date BirthplaceBirthplace SexSex Marital statusMarital status RaceRace Ethnic originEthnic origin Occupation: usual and presentOccupation: usual and present

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Source of historySource of history Record who furnishes information, usually the Record who furnishes information, usually the

person, although source may be relative or friend person, although source may be relative or friend Judge reliability of informant and how willing he or Judge reliability of informant and how willing he or

she is to communicate she is to communicate • A reliable person always gives same answers when A reliable person always gives same answers when

questions are rephrased or are repeated later in questions are rephrased or are repeated later in interviewinterview

Note any special circumstances, such as use of Note any special circumstances, such as use of interpreterinterpreter

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Reason for seeking careReason for seeking care Brief spontaneous statement in person’s own Brief spontaneous statement in person’s own

words describing reason for visitwords describing reason for visit Symptom: subjective sensation person feels from Symptom: subjective sensation person feels from

disorderdisorder• What person says is reason for seeking care is recorded What person says is reason for seeking care is recorded

and enclosed in quotation marks to indicate person’s and enclosed in quotation marks to indicate person’s exact wordsexact words

Sign: objective abnormality that can be detected Sign: objective abnormality that can be detected on physical examination or in laboratory reportson physical examination or in laboratory reports

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The Health HistoryThe Health History: : Adult (cont.)Adult (cont.)

Present health or history of present illnessPresent health or history of present illness LocationLocation Character or qualityCharacter or quality Quantity or severityQuantity or severity TimingTiming SettingSetting Aggravating or relieving factorsAggravating or relieving factors Associated factorsAssociated factors Patient’s perceptionPatient’s perception

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It may be helpful to organize same question It may be helpful to organize same question sequence into a mnemonic, PQRSTU, to help sequence into a mnemonic, PQRSTU, to help remember all pointsremember all points P = Provocative or palliativeP = Provocative or palliative Q = Quality or quantityQ = Quality or quantity R = Region or radiationR = Region or radiation S = Severity scale: 1 to 10S = Severity scale: 1 to 10 T = Timing or onsetT = Timing or onset U = Understand patient’s perception of problemU = Understand patient’s perception of problem

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The Health HistoryThe Health History: : Adult (cont.)Adult (cont.)

Past HealthPast Health

Childhood illnessesChildhood illnesses Accidents or injuriesAccidents or injuries Serious or chronic Serious or chronic

illnessesillnesses HospitalizationsHospitalizations OperationsOperations

Obstetric historyObstetric history ImmunizationsImmunizations Last examination dateLast examination date AllergiesAllergies Current medicationsCurrent medications

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Family historyFamily history Age and health or cause of death of relativesAge and health or cause of death of relatives Health of close family members Health of close family members Family history of various conditions such as heart Family history of various conditions such as heart

disease, high blood pressure, stroke, diabetes, disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and illness, seizure disorder, kidney disease, and tuberculosistuberculosis

Family tree (genogram) to show this information Family tree (genogram) to show this information clearly and conciselyclearly and concisely

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Family tree Family tree or genogramor genogram

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Cross-cultural careCross-cultural care Additional questions for new immigrantsAdditional questions for new immigrants

• Biographical dataBiographical data

• Spiritual resource and religion: assess if certain Spiritual resource and religion: assess if certain procedures cannot be doneprocedures cannot be done

• Past health: what immunizations, if anyPast health: what immunizations, if any

• Health perceptionHealth perception How does person describe health and illnessHow does person describe health and illness How does person see problems he or she is now How does person see problems he or she is now

experiencingexperiencing

• Nutrition: taboo foods or food combinationsNutrition: taboo foods or food combinations

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Review of systemsReview of systems General overall health General overall health

statestate SkinSkin HairHair HeadHead EyesEyes EarsEars Nose and SinusesNose and Sinuses Mouth and ThroatMouth and Throat

NeckNeck BreastBreast AxillaAxilla Respiratory systemRespiratory system CardiovascularCardiovascular Peripheral vascularPeripheral vascular GastrointestinalGastrointestinal Urinary systemUrinary system

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Review of systems (cont.) Review of systems (cont.) Male genital systemMale genital system Female genital systemFemale genital system Sexual healthSexual health Musculoskeletal systemMusculoskeletal system Neurologic systemNeurologic system Hematologic systemHematologic system Endocrine systemEndocrine system

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Functional assessment, including ADLsFunctional assessment, including ADLs Self-esteem, self-conceptSelf-esteem, self-concept Activity and exerciseActivity and exercise Sleep and restSleep and rest Nutrition and eliminationNutrition and elimination Interpersonal relationships and resourcesInterpersonal relationships and resources Spiritual resourcesSpiritual resources Coping and stress managementCoping and stress management

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Functional assessment, including ADLs Functional assessment, including ADLs (cont.)(cont.) Personal habitsPersonal habits AlcoholAlcohol CAGE testCAGE test

• Have you ever thought you should Have you ever thought you should CCut down your ut down your drinking?drinking?

• Have you ever been Have you ever been AAnnoyed by criticism of your nnoyed by criticism of your drinking?drinking?

• Have you ever felt Have you ever felt GGuilty about your drinking?uilty about your drinking?

• Do you drink in the morning, an Do you drink in the morning, an EEye opener?ye opener?

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Functional assessment, including ADLs Functional assessment, including ADLs (cont.)(cont.) Illicit or street drugsIllicit or street drugs Environment and work hazardsEnvironment and work hazards Intimate partner violenceIntimate partner violence Occupational healthOccupational health

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Perception of healthPerception of health Ask questions such as: Ask questions such as:

• How do you define health?How do you define health?

• How do you view your situation now?How do you view your situation now?

• What are your concerns?What are your concerns?

• What do you think will happen in the future?What do you think will happen in the future?

• What are your health goals?What are your health goals?

• What do you expect from us as nurses, physicians, or What do you expect from us as nurses, physicians, or other health care providers?other health care providers?

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Developmental CareDevelopmental Care

ChildrenChildren Health history adapted to include information Health history adapted to include information

specific for age and developmental stage of specific for age and developmental stage of childchild Biographic dataBiographic data Source of historySource of history

• Person providing information and relation to childPerson providing information and relation to child

• Your impression of reliability of informationYour impression of reliability of information

• Any special circumstances, e.g., use of an interpreterAny special circumstances, e.g., use of an interpreter

Reason for seeking careReason for seeking care

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Developmental Care (cont.)Developmental Care (cont.)

Children: history of present IllnessChildren: history of present Illness Severity of pain: note effect on usual behavior, e.g., Severity of pain: note effect on usual behavior, e.g.,

does it stop child from playing?does it stop child from playing? Associated factors, such as relation to activity, eating, Associated factors, such as relation to activity, eating,

and body positionand body position Parent’s intuitive sense of problem often accurate; Parent’s intuitive sense of problem often accurate;

even if proven otherwise, this gives an idea of even if proven otherwise, this gives an idea of parent’s area of concernparent’s area of concern

Parent’s coping ability and reaction of other family Parent’s coping ability and reaction of other family members to child’s symptoms or illnessmembers to child’s symptoms or illness

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Children: past healthChildren: past health Prenatal statusPrenatal status Labor and deliveryLabor and delivery Postnatal statusPostnatal status Childhood illnessesChildhood illnesses Serious accidents or injuries Serious accidents or injuries Serious or chronic illnessesSerious or chronic illnesses Operations or hospitalizationsOperations or hospitalizations Immunizations and allergiesImmunizations and allergies MedicationsMedications

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Children: developmental historyChildren: developmental history GrowthGrowth MilestonesMilestones Current development for children 1 month through Current development for children 1 month through

preschoolpreschool School-age childSchool-age child

Nutritional historyNutritional history Family historyFamily history

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Children: review of systemsChildren: review of systems GeneralGeneral SkinSkin HeadHead EyesEyes EarsEars Nose and sinusesNose and sinuses Mouth and throatMouth and throat NeckNeck

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Children: review of systems (cont.)Children: review of systems (cont.) BreastsBreasts Respiratory systemRespiratory system Cardiovascular systemCardiovascular system Gastrointestinal systemGastrointestinal system Urinary systemUrinary system Male genital systemMale genital system Female genital systemFemale genital system Sexual healthSexual health

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Children: review of systems (cont.)Children: review of systems (cont.) Musculoskeletal systemMusculoskeletal system Neurologic systemNeurologic system Hematologic systemsHematologic systems Endocrine systemEndocrine system

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Children: functional assessment, including Children: functional assessment, including ADLsADLs Interpersonal relationshipsInterpersonal relationships Activity and restActivity and rest Economic statusEconomic status Home environmentHome environment Environmental hazardsEnvironmental hazards Coping and stress managementCoping and stress management HabitsHabits Health promotionHealth promotion

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Adolescent: HEEADSSS psychosocial interviewAdolescent: HEEADSSS psychosocial interview

Method of interviewing Method of interviewing focuses on assessment of focuses on assessment of Home environment, Home environment, Education and Education and employment, Eating, peer-employment, Eating, peer-related Activities, Drugs, related Activities, Drugs, Sexuality, Suicide and Sexuality, Suicide and depression, and Safety depression, and Safety from injury and violencefrom injury and violence

HomeHome Education and Education and

employmentemployment EatingEating ActivitiesActivities DrugsDrugs SexualitySexuality Suicide and depressionSuicide and depression SafetySafety

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Older adultOlder adult Includes same format described for younger adult, Includes same format described for younger adult,

plus additional questionsplus additional questions• These questions address ways in which ADLs are These questions address ways in which ADLs are

affected by normal aging processes or by effects of affected by normal aging processes or by effects of chronic illness or disabilitychronic illness or disability

• No specific age at which to ask these additional No specific age at which to ask these additional questions; use them when it seems appropriatequestions; use them when it seems appropriate

• Important to recognize positive health measures: what Important to recognize positive health measures: what they are doing to help themselves stay wellthey are doing to help themselves stay well

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Older adult (cont.)Older adult (cont.) Older people have spent a lifetime with traditional Older people have spent a lifetime with traditional

health care that searches only for pathology and health care that searches only for pathology and what is wrong with their healthwhat is wrong with their health

May be pleasant surprise to have a health May be pleasant surprise to have a health professional affirm things they are doing right and professional affirm things they are doing right and note health strengthsnote health strengths

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Older adult: reason for seeking careOlder adult: reason for seeking care May take time to figure out why older person has May take time to figure out why older person has

come for an examinationcome for an examination• Aging person may shrug off symptoms as evidence of Aging person may shrug off symptoms as evidence of

growing old and be unsure whether it is worth mentioninggrowing old and be unsure whether it is worth mentioning

• Some older people have a conservative philosophy Some older people have a conservative philosophy toward their health status and come for care only when toward their health status and come for care only when something is seriously wrongsomething is seriously wrong

• Older person may have many chronic problems, such as Older person may have many chronic problems, such as diabetes, hypertension, or constipationdiabetes, hypertension, or constipation

• Final statement should be person’s reason for seeking Final statement should be person’s reason for seeking care, not your assumption of problemcare, not your assumption of problem

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Older adult: past healthOlder adult: past health General health in past 5 yearsGeneral health in past 5 years Accidents or injuries, serious or chronic illnesses, Accidents or injuries, serious or chronic illnesses,

hospitalizations, operationshospitalizations, operations Last examinationLast examination Obstetric statusObstetric status

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Older adult: past health (cont.)Older adult: past health (cont.) Current MedicationsCurrent Medications

• Also consider following issues:Also consider following issues: Some older persons take large number of drugs prescribed Some older persons take large number of drugs prescribed

by different physiciansby different physicians Person may not know drug name or purposePerson may not know drug name or purpose

– Ask person to bring in drug to be identifiedAsk person to bring in drug to be identified When person is unable to afford drug, he or she may When person is unable to afford drug, he or she may

decrease dosage or not refill immediatelydecrease dosage or not refill immediately Travel to pharmacy may present a problemTravel to pharmacy may present a problem May use over-the-counter medications for self-treatmentMay use over-the-counter medications for self-treatment Some share medications with neighbors or friendsSome share medications with neighbors or friends

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Older adult: family historyOlder adult: family history Not as useful in predicting which familial diseases Not as useful in predicting which familial diseases

person may contract, because most of those will person may contract, because most of those will have occurred at an earlier agehave occurred at an earlier age

Useful to assess which diseases or causes of Useful to assess which diseases or causes of death of relatives person has experienceddeath of relatives person has experienced

Also describes person’s existing social networkAlso describes person’s existing social network

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Older adult: review of systemsOlder adult: review of systems GeneralGeneral SkinSkin EyesEyes EarsEars MouthMouth Respiratory systemRespiratory system Cardiovascular systemCardiovascular system

Peripheral vascular Peripheral vascular systemsystem

Urinary systemUrinary system Sexual healthSexual health Musculoskeletal systemMusculoskeletal system Neurologic systemNeurologic system

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Older adult: functional assessment including Older adult: functional assessment including ADLsADLs Self-concept, self-esteemSelf-concept, self-esteem OccupationOccupation Activity and exerciseActivity and exercise Sleep and restSleep and rest Nutrition and eliminationNutrition and elimination Interpersonal relationships and resourcesInterpersonal relationships and resources Coping and stress managementCoping and stress management Environment and home safety hazardsEnvironment and home safety hazards

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complete health history

Healthcare

derived items

imprint of elsevier

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