Health History Flashcards

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Questions and Answers

What is the purpose of collecting the complete health history? (Select all that apply)

Establishes the subjective database (correct)

Helps in developing a problem list (correct)

Helps to establish a diagnosis (correct)

None of the above

Is there any objective data included in the health history?

False

In what order is the health history organized?

Biographical data, 2. Reason for seeking care (CC), 3. Present health status (HPI), 4. Previous medical history, 5. Family history, 6. Personal and social history, 7. Review of systems (ROS), 8. Problem list

How should the nurse obtain information on the patient's present health status?

By using the OLD CART mnemonic. Signup and view all the answers

What is included in the previous medical history section of the health history?

<ol> <li>Childhood illnesses, 2. Serious or chronic illnesses, 3. Hospitalizations, 4. Accidents or injuries, 5. Operations, 6. Blood transfusions, 7. Obstetric history, 8. Immunizations, 9. Screening tests, 10. Health care maintenance, 11. Allergies, 12. Current medications</li> </ol> Signup and view all the answers

What is included in the biographical data section of the health history?

<ol> <li>Date of interview, 2. Client's full name, 3. Client's DOB, 4. Birthplace, 5. Sex, 6. Marital status, 7. Race, 8. Ethnic origin, 9. Religion, 10. Primary language, 11. Secondary languages, 12. Highest level of education, 13. Occupation, 14. Health insurance, 15. Source of information, 16. Reliability of information</li> </ol> Signup and view all the answers

What may the chief complaint section focus on?

Illness or wellness needs (e.g., routine physical exam or sore throat). Signup and view all the answers

What does the chief complaint section include?

One sentence stating the problem and its duration (e.g., I have chest pain whenever I smoke a cigarette). Signup and view all the answers

How should the chief complaint section be handled for clinic patients?

Ask the patient why they are here today, focusing on the most important problem. Signup and view all the answers

What should be included in the present health status section for a well patient?

A short statement of their general health. Signup and view all the answers

What should be included in the present health status section for an ill patient?

Provide a symptom analysis and describe the characteristics of the symptom. Signup and view all the answers

What does the PQRSTU mnemonic stand for?

P - provocative or palliative; Q - quality or quantity; R - region or radiation; S - severity scale; T - timing; U - understand the patient's perception. Signup and view all the answers

How should the nurse address the patient's perception of her present health status?

Ask the patient what she thinks is wrong, her concerns, and how she is affected by the illness. Signup and view all the answers

What questions should the nurse ask when completing a past history before a symptom analysis?

<ol> <li>Have you ever had these symptoms before? 2. Did you find out what was wrong? 3. What diagnostic tests were done? What were the results? 4. How were you treated? Was the treatment effective?</li> </ol> Signup and view all the answers

What mnemonic should be used to do a symptom analysis in the HPI section, and what does it stand for?

OLD CART; O - Onset; L - Location; D - Duration; C - Character; A - Aggravating factors/associated factors; R - Relieving factors; T - Treatment. Signup and view all the answers

What should the nurse ask regarding the O in the OLD CART mnemonic?

<ol> <li>The date/time the symptom started; 2. If it started suddenly or gradually; 3. Any predisposing factors.</li> </ol> Signup and view all the answers

What should the nurse ask regarding the L in the OLD CART mnemonic?

<ol> <li>Have the patient point to where the symptom is located; 2. Ask if the pain radiates or is localized.</li> </ol> Signup and view all the answers

What should the nurse ask regarding the D in the OLD CART mnemonic?

<ol> <li>How long the symptoms usually last; 2. Frequency of the symptoms; 3. If it is constant or intermittent.</li> </ol> Signup and view all the answers

What should the nurse ask regarding the C in the OLD CART mnemonic?

<ol> <li>About the quality of the symptoms (e.g., sharp, dull, throbbing); 2. About the quantity/severity of the symptoms.</li> </ol> Signup and view all the answers

What should the nurse ask regarding the A in the OLD CART mnemonic?

<ol> <li>What makes the symptoms worse? 2. Any secondary symptoms associated with the main symptom.</li> </ol> Signup and view all the answers

What should the nurse ask regarding the R in the OLD CART mnemonic?

What makes the symptom better? Signup and view all the answers

What should the nurse ask regarding the T in the OLD CART mnemonic?

What treatment has the patient tried, and what was the effect? Signup and view all the answers

What is the importance of the past health history or past medical history (PMH) section?

It may affect the current health status and how the patient responds to illness. Signup and view all the answers

Study Notes

Health History Collection

Collecting a complete health history establishes a subjective database essential for diagnosis and problem list development.
Objective data is not included in the health history.

Health History Organization

Organized in a specific sequence: biographical data, chief complaint, present health status, previous medical history, family history, personal/social history, review of systems, and problem list.

Chief Complaint

Captures patient's primary reason for seeking care, which could relate to illness or wellness (e.g., routine check-up).
The chief complaint section includes a concise statement of the problem and its duration (e.g., "I have chest pain when smoking").

Present Health Status

For well patients, the section should provide a brief overview of their general health.
For ill patients, it requires a symptom analysis detailing the characteristics of their condition.

Mnemonics for Symptom Analysis

OLD CART is utilized for analyzing present health status:
- O: Onset
- L: Location
- D: Duration
- C: Character
- A: Aggravating/associated factors
- R: Relieving factors
- T: Treatment details
PQRSTU is another mnemonic focusing on the provocative, quality, region, severity, timing, and understanding patient perception.

Patient Perception and History

Nurses should explore the patient's perception of their health, including concerns and interpretations of their symptoms.
Past history questions should address previous symptoms, diagnostic tests, and treatment efficacy.

Biographical Data Section

Includes crucial personal information such as name, date of birth, birthplace, sex, marital status, race, ethnicity, religion, languages spoken, education level, occupation, health insurance, and reliability of the information provided.

Previous Medical History

Encompasses childhood illnesses, serious/chronic illnesses, hospitalizations, surgeries, blood transfusions, obstetric history, immunizations, allergies, current medications, and screening tests.

Gathering Information on Symptoms

For each aspect of the OLD CART mnemonic, specific inquiries should be made to pinpoint symptom details:
- Onset (O): Inquire about the start time, suddenness, and any predisposing factors.
- Location (L): Have the patient indicate the location and whether pain radiates.
- Duration (D): Ask about the typical length and frequency of symptoms, noting if they are constant or intermittent.
- Character (C): Gather detailed descriptions regarding the quality and severity of symptoms.
- Aggravating/Associated (A): Determine what worsens the symptoms and identify any secondary symptoms.
- Relieving (R): Explore what alleviates the symptoms.
- Treatment (T): Discuss any treatments attempted and their efficacy.

Importance of Past Medical History

The past health history can significantly influence the patient's current health status and their responses to illness.

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Description

Test your knowledge on the crucial aspects of health history collection with these flashcards. Each card highlights key concepts essential for understanding the purpose and organization of health histories. Perfect for nursing and medical students preparing for clinical practice.