Fundamentals EXAM 1 (health history)

Comprehensive info on all patient medical history including why they're being seen

Health history

Parts of a health history are

Biographical data, chief complaint, present illness, past health history, family history

In a health history, name, address, age, gender, marital status, occupation, and ethnic origin are all part of the

Biographical datA

In Health history, problem in the patients exact words (ex- "i have a headache" is part of the

Chief complaint

In health history, location, quality, severity, duration, timing, modifying risk factors, associated signs and symptoms are part of what portion

Present illness

In health history, immunizations, childhood illness (serious), adult illness (serious), injuries, hospitalization, surgical and diagnostic procedures are part of the

Past health history

In health history, parents, siblings, children, spouse health information is part of the

Family history

During a health history you will need to do a review of ___________ with the patient (yes or no questions) ex: eyes, cardiovascular, stomach

Systems

Past life events related to health (ex abuse, failure, med history, education, occupation etc) is all a part of the

Patient profile

Use the ________ __________ method when collecting data on a health history chief complaint

OLD CART

A pain scale is a part of ___________ data

Subjective

If someone says they are nauseated that is _______ data

Subjective

If you see your patient throw up that is _______ data

Objective

When you ask a patient when the chief complaint started that is the ______ portion of (OLD CART)

Onset

When you ask a patient where they feel their pain that is the _______ portion of OLD CART

Location

When you ask a patient how long it goes on when it happens that is the ______ portion of OLD CART

Duration

When you ask a patient how it feels when it happens that is the _______ portion of OLD CART

Character

When you ask a patient if any other symptoms come along with their chief complaint that is the ______ potion of OLD CART

Associated manifestation

When you ask a patient if anything makes their chief complaint better or worse that is the ______ portion of OLD CART

Relieving/exacerbating

When you ask a patient have they been seen for their chief complaint before that is the _______ portion of OLD CART

Treatment