Chapter 4- Health history
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Q: What is the primary purpose of a complete health history?
To collect subjective data reported by the patient, forming a comprehensive database with objective data for accurate diagnosis and care planning.
Q: What does a complete health history provide about the patient?
A holistic view of past and present health status to guide clinical decision-making.
Q: What is the focus of health history for well patients?
Assessing lifestyle factors and encouraging healthy behaviors.
Q: Why is it important to recognize positive health actions in well patients?
It reinforces health maintenance and promotes disease prevention.
Q: What is the focus of health history for ill patients?
A detailed, chronological record of the current health problem, including symptom onset, progression, and context.
Q: Why is a detailed history important for ill patients?
It helps diagnose the current illness, plan treatment, and monitor progress.
Q: How does health history act as a screening tool?
By detecting abnormal symptoms, health problems, and patient concerns.
Q: What additional insights can a health history provide?
Health promotion behaviors, coping skills, strengths, and areas needing intervention.
Q: How many data categories are collected in a health history?
Eight key categories.
Q: What are the eight data categories in health history?
Biographic data, source of history, reason for seeking care, present health/history of present illness, past health events, family history, review of systems, functional assessment.
Q: What is biographic data?
Personal identifiers including name, address, phone number, age, birthdate, birthplace, gender, relationship status, race/ethnicity, occupation, and primary language.
Q: Why is accurate biographic data important?
It facilitates effective communication and care planning.
Q: What is the source of history?
The individual who provides health information, often the patient, sometimes a relative or interpreter.
Q: Why is it important to document the use of an interpreter?
To ensure accuracy, clarity, and include their identification number if used.
Q: What is the reason for seeking care (chief complaint)?
The patient’s description of their main reason for the visit in one or two symptoms or signs along with duration.
Q: Why are the patient’s own words important for the chief complaint?
They guide the initial focus of the assessment.
Q: What information is collected in present health for well patients?
General health status and lifestyle factors.
Q: What information is collected in present health for sick patients?
Chronological symptom analysis including location, character, quantity/severity, timing, setting, aggravating/relieving factors, associated symptoms, and patient perception.
Q: What does the "P" in PQRST stand for?
Provocative/Palliative – what makes the symptom worse or better.
Q: What does the "Q" in PQRST stand for?
Quality/Quantity – how the symptom feels and its severity.
Q: What does the "R" in PQRST stand for?
Region/Radiation – location of the symptom and whether it radiates.
Q: What does the "S" in PQRST stand for?
Severity – how bad the symptom is.
Q: What does the "T" in PQRST stand for?
Timing – when the symptom started and how long it lasts.
Q: What does the patient perception component in PQRST assess?
How the patient interprets or understands their symptom.
Q: What past health events are important to collect?
Childhood illnesses, serious/chronic illnesses, accidents/injuries, hospitalizations, surgeries, obstetric history, immunizations, allergies, current medications.
Q: Why is past health history important?
It helps identify risk factors and patterns influencing current health.
Q: What is the purpose of family history?
To detect genetic risks and guide screening.
Q: What tools can be used to document family history?
Pedigrees or genograms showing gender, relationship, age, and health status over three generations.
Q: Why is family history important?
It highlights hereditary diseases and patterns indicating inherited risks.
Q: What cultural and genetic factors should be considered in health history?
Immigration history, spiritual resources, prohibited procedures or practices, immunization status, nutritional practices, and health perceptions influenced by culture.
Q: Why is understanding cultural and genetic factors important?
It aids in providing culturally sensitive care.
Q: What is the Review of Systems (ROS)?
A systematic head-to-toe evaluation of all body systems to detect additional health issues, omitted data, and health promotion practices.
Q: How is ROS conducted?
Through questions tailored to current complaints and past health.
Q: What is a functional assessment (ADLs)?
Evaluation of the patient’s ability to perform self-care activities and daily living functions.
Q: What areas are assessed in functional assessment?
Self-esteem, activity/exercise, sleep/rest, nutrition/elimination, relationships, spiritual resources, coping/stress, personal habits, environmental hazards, intimate partner violence, occupational health.
Q: Why is functional assessment important?
It informs quality of life and identifies potential psychosocial issues.
Q: What additional areas are assessed in pediatric patients?
Prenatal/perinatal history, childhood illnesses, injuries, hospitalizations, immunizations, medications, developmental milestones, nutritional history, growth patterns, family history, and pediatric-specific review of systems.
Q: What does pediatric functional assessment include?
Environmental safety and role within family/community.
Q: What psychosocial framework is used for adolescents?
HEEADSSS – home, education/employment, eating, activities/peers, drugs, sexuality, suicide/depression, safety.
Q: Why is HEEADSSS important?
It facilitates trust and comprehensive psychosocial assessment of adolescents.
Q: What is the recommended sequence of health history collection?
Biographic data, reason for seeking care, present health/history of present illness, past health history, medication reconciliation, family history, review of systems, functional assessment.
Q: Why is following a sequence in health history important?
It ensures logical flow and comprehensive data collection.
Q: What should be included in adult health history documentation?
Biographic data, source of history, reason for care, history of present illness (PQRST), past health, family history, cultural/genetic factors, review of systems, functional assessment.
Q: How should developmental considerations affect history taking?
Questions and approach should be adapted to age, cultural background, and individual needs.
Q: Why is structured symptom analysis important?
Frameworks like PQRST standardize data collection and improve assessment accuracy.
Q: Why is accurate and complete documentation crucial?
It ensures quality care and effective communication.
Q: What is the primary purpose of a complete health history?
To collect subjective data reported by the patient, which, combined with objective data, forms a comprehensive database for diagnosis and care planning.
Q: What holistic benefit does a complete health history provide?
It gives a view of past and present health to guide clinical decision-making.
Q: How does health history differ for well patients?
Focuses on lifestyle, healthy behaviors, and reinforcing positive health actions.
Q: How does health history differ for ill patients?
Provides a detailed, chronological record of the current health problem, symptoms, and context to aid diagnosis and treatment.
Q: How does health history act as a screening tool?
Detects abnormal symptoms, health problems, patient concerns, coping skills, and health promotion behaviors.
Q: How many key categories are collected in a health history?
Eight.
Q: What are the eight data categories?
Biographic data, source of history, reason for seeking care, present health/history of present illness, past health events, family history, review of systems, functional assessment (ADLs).
Q: What is biographic data?
Personal identifiers like name, age, birthdate, gender, race/ethnicity, occupation, and language.
Q: Why is accurate biographic data important?
It ensures effective communication and appropriate care planning.
Q: Who can provide the source of health history?
Usually the patient, sometimes a relative or interpreter.
Q: Why must the use of an interpreter be documented?
For accuracy, clarity, and to include their identification number.
Q: How should the chief complaint be recorded?
In the patient’s own words, ideally one or two symptoms or signs with duration.
Q: Why are the patient’s words important for the chief complaint?
They guide the initial focus of the assessment.
Q: Patient says, “I’ve had a headache for 3 days.” Which category does this belong to?
Reason for seeking care / chief complaint.
Q: What does PQRST stand for?
Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing, Patient perception.
Q: What question does “Provocative/Palliative” answer?
What makes the symptom worse or better?
Q: What does “Quality/Quantity” assess?
How the symptom feels and how severe it is.
Q: What is “Region/Radiation”?
Location of the symptom and whether it radiates.
Q: What does “Severity” measure?
How bad the symptom is.
Q: What does “Timing” indicate?
Onset, duration, and frequency of the symptom.
Q: What does “Patient perception” assess?
How the patient interprets or understands the symptom.
Q: A patient reports chest pain that radiates to the arm and is worse with activity. Using PQRST, which aspects are identified?
Region/Radiation: arm; Provocative: activity; Quality/Quantity and Severity: described by patient; Timing: during activity; Patient perception: what patient thinks it means.
Q: What past health events are collected?
Childhood illnesses, chronic illnesses, accidents/injuries, hospitalizations, surgeries, obstetric history, immunizations, allergies, medications.
Q: Why is past health history important?
Identifies risk factors and patterns influencing current health.
Q: Why is family history collected?
To detect genetic risks and guide screening.
Q: What tools can document family history?
Pedigrees or genograms showing gender, relationships, age, and health status over three generations.
Q: Patient’s mother had diabetes and father had hypertension. Why is this important?
Identifies hereditary risks and guides preventive care and screening.
Q: What cultural factors are important in health history?
Immigration history, spiritual resources, prohibited procedures, dietary restrictions, immunizations, and health perceptions.
Q: Why are cultural and genetic factors assessed?
To provide culturally sensitive and individualized care.
Q: What is ROS?
A systematic head-to-toe evaluation of all body systems to detect health issues and omitted data.
Q: How is ROS conducted?
Through questions tailored to current complaints and past health.
Q: What is functional assessment?
Evaluation of ability to perform self-care and daily living activities.
Q: What areas are assessed in functional assessment?
Self-esteem, activity/exercise, sleep/rest, nutrition/elimination, relationships, spiritual resources, coping/stress, personal habits, environmental hazards, intimate partner violence, occupational health.
Q: What additional areas are assessed in pediatric health history?
Prenatal/perinatal history, illnesses, injuries, hospitalizations, immunizations, medications, developmental milestones, nutrition, growth patterns, family history, ROS.
Q: What does pediatric functional assessment include?
Environmental safety and role in family/community.
Q: What psychosocial framework is used for adolescents?
HEEADSSS – Home, Education/Employment, Eating, Activities/Peers, Drugs, Sexuality, Suicide/Depression, Safety.
Q: Why is HEEADSSS used?
Facilitates trust and comprehensive psychosocial assessment.
Q: What is the recommended sequence for health history collection?
Biographic data → Reason for care → Present health → Past health → Medication reconciliation → Family history → ROS → Functional assessment.
Q: Why is following a sequence important?
Ensures logical flow and comprehensive data collection.
Q: Why is structured symptom analysis important?
Frameworks like PQRST standardize data collection and improve assessment accuracy.
Q: Why is accurate documentation crucial?
Ensures quality care and effective communication.