Health History

Purpose of the Health History

• establishes the “subjective.”

• There is NO OBJECTIVE data in the health Hx

• Information is obtained through the Interview process

Reason for seeking care or Chief Complaint

should be one sentence: what is your major healthcare concern today?

History of Present Illness (HPI) or History of Present Health Concern

have patient explain the health problem in as much detail as possible. Use COLDSPA or PQRST

Symptom Analysis: OLD CART Mnemonic

Onset

Location

Duration

Character: patient description of pain

Aggravating factors/ associated factors

Pain Analysis: PQRST

P- provoke/palliative

Q- Quality (sharp, burning, dull, stabbing)

R- Radiation- Does it radiate anywhere?

S- Severity- pain scale (different types of scales)

T- Timing- When does the pain occur? How long does it last?

Personal Health History (Hx) or Past Medical History (PMH)

A. childhood illnesses

B. serious or chronic illnesses

C. Hospitalizations

D. Accidents/ Injuries

E. Operations

F. Blood Transfusions

Obstetric history

Gravida: # of pregnancies

Para: # of pregnancies that have delivered at 20 weeks’ gestation or greater

GTPAL

Gravida: # of pregnancies

Term Gestation: delivery of pregnancy, 38-42 weeks of gestation

Preterm gestation: delivery before 38 weeks

Abortion: termination, spontaneous (miscarriage) or induced

Living: number of living children

ex: G4P2113= pregnant 4 times, 2 term deliveries, 1 preterm delivery, 1 abortion, 3 living

Immunizations: Child

MMR, Varicella, Polio, Hib (Hflu), DTap, Prevnar 13, Flu, Hep A, Hep B, HPV

Adult immunization

• Influenza (annually)

• Tetanus-diphtheria-pertussis (Tdap), then Td every 10 years

  • And with each pregnancy

• Varicella (if no evidence of immunity) (chicken pox)

• Human Papillomavirus (HPV)

  • –protects from external genital warts and cervical cancer

• Zoster (shingles) - age 50- Shingrix – 2 DOSE SERIES

• Measles-mumps-rubella (MMR)- if not received as child or immune

• Meningococcal-at risk (dormitories, military, immunocompromised)

• Pneumococcal (pneumonia) after 65, OR IF immunocompromised

• Hep A- high risk behaviors (IVDU, travel to 3^rd world countries)  

• Hep B-Usually given at birth now- HEALTH CARE WORKERS/ALL

Screening Test

1. TB Surveillance (skin test or blood test)

• skin test (PPD) > 10 mm redness is positive in most cases

2. Blood tests (titers)

• assess immunity

• asses for infection

Health Maintenance Screening

ask when their last health maintenance screening was (mammogram, colonoscopy, etc)

Allergies

NKA= no known allergies

NKDA= no known drug allergies

Current Medications

List drug name, dose, route, frequency, rationale and last dose

family history

• ask the age of family members

• record medical problems

• if the member is healthy, alive, and well

• A genogram is a drawing of a family tree with diseases and death records

Lifestyle and health practices

tobacco:

pack year history = packs per day x number of years smoked

ex: 2 ppd x 10 yrs = 20 pack year history

Review of System (ROS) more subjective data

Go through all body systems and ask specific questions that will help you collect pertinent information.

asking client questions about pertinent specific body system problems/ past problems

Age related considerations

1. child health history

2. adolescent health history

3. older adult: functional assessment- measures the patient’s self care ability

subjective + objective data clinical judgement

• Identify abnormal cues and client strengths   

• using your knowledge of anatomy/physiology, sociology, reference materials 

• Cluster Cues  (combination of subjective and objective)

  • certain clusters of cues support a problem 

• Draw inferences to propose or hypothesize possible clinical judgements

  • hypothesis problems or concerns (as above)

• Identify possible client concerns

  • health concern- (breathing difficulties)

  • risk for a health concern– (risk for decreased gas exchange, hypoxia)

  • opportunity for health promotion - (smoking cessation, medication use, low salt diet)

• validate the concern

  • verbalize what you think the concern is and have patient or family validate