HEALTH HISTORY

The purpose of the health history is to collect

Subjective data what the person says about himself or herself.
Objective data physical examination, laboratory studies to form the data base.
The data base is used to make a judgement or a diagnosis about the health status of the individual.
Health history provides a complete picture of the person past & present health. t describes the individual as a
whole& how the person interacts with the environment.
Although history forms vary, most cotai iformatio i this se!uece of categories"
!. "iographical data
#. $eason for seeking care
%. &resent health or history of present illness
'. &ast history
(. )amily history
*. $eview of systems
+. )unctional assessment of activities of daily living ,-./s0
#iogra$hic data
1ame, address & phone number, age & birth date, birth place, gender, marital status, race, ethnic origin,
occupation, usual & present.
The person2s primary language & authori3ed representative, should be recorded here. This is in response to
research showing differences in language & culture may have an impact on the 4uality & safety of care.
Source of history
!. $ecord who furnishes the information usually the person by themselves. -lthough the source may be a
relative or friend
#. 5udge how reliable the informant seems & how willing he or she is to communicate.
%. 1ote any special circumstances, such as the use of an interpreter. 6ample statements include7
&atient himself, who seems reliable
&atient2s son, who seems reliable
8rs. 9, interpreter for $ who does not speak :nglish
Reaso for see%ig care
this is a brief spontaneous statement in the person2s own words that describes the reason for the visit. t states
one ,possibly two0 symptoms or signs & their duration.
- symptom is a subjective sensation that the person feels from the disorder.
- sign is an objective abnormality that the examiner could detect on physical examination or in laboratory
reports.
&reset health or history of $reset illess
t is the chronological record of the reason for seeking care, from the time the symptom first started until now.
-s the client talks, do not jump to conclusions & bias the story by adding opinions.
Te final summary of any symptom the person has should include the ; critical characteristics
'( Locatio
"e specific< ask the client to point the location. f the problem is pain, note the precise site. =head pain>
is vague, whereas, descriptions such as =pain behind the eyes>, =jaw pain & occipital painare more
precise & are diagnostically significant. s the pain locali3ed to this site or radiating? s the pain
superficial or deep?
)( *haracter or !uality
t includes terms like buring, sharp, dull, aching, gnawing, throbbing, shooting, viselike. @se similesA
does blood in the stool look like sticky tar? .oes bloof in vomitus look like coffee grounds?
+( ,uatity or severity
-ttempt to 4uantify the sign or symptom such as =profuse menstrual flow soaking five pads per hour>,
the symptom of pain is difficult to 4uantify because of individual perception.
Bith pain, avoid adjectives & how it affects daily activities.
-( Timig
,onset, duration, fre4uency0. Bhen did the symptom first appear? Cive the specific date & time, or state
specifically how long ago the symptom started prior to arrival ,&T-0.
.( Settig
Bhere was the person or what was the person doing when the symptom started? Bhat brings it on?
)or example7 did you notice the chest pain after shoveling snow, or did the pain start by itself?
/( Aggravatig or relievig factors
Bhat makes the pain worse? s it aggravated by weather, activity, food, medication, standing bent over,
fatigue, time of day, season, & so on? Bhat relieves ,:.g. rest, medication, or ice pack0? Bhat is the
effect of any treatment? -sk, =what have you tried? Dr =what seems t help?>.
0( Associated factors
s this primary symptom associated with any others ,e.g., urinary fre4uency & burning associated with
fever & chills0? $eview the body system related to this symptom now rather than wait for the review of
systems.
1( &atiet2s $erce$tio
)ind out the meaning of the symptom by asking how it affects daily activities. -lso ask directly. >what
do you think it means?> this is crucial because it alerts you to potential anxiety if the person thinks the
symptom may be omnius.
The !uestio se!uece could be arraged i &,RST
&" &rovocative or &alliative
Bhat brings it on? Bhat were you first noticed it? Bhat makes it better? Borse?
," ,uality or ,uatity
How does it look, feel, sound? How intenseEsevere is it?
R" Regio or Radiatio
Bhere is it? .oes it spread anywhere.
S" Severity Scale
How bad is it ,on scale of ! to !F0? s it getting better, worse, staying the same?
T" Timig
Dnset exactly when did it first occur?
.urationAhow long did it last?
)re4uencyAhow often does it occur?
3" 3derstad &atiet2s &erce$tio
@nderstand patients perception of the problem. Bhat do you think it means?
&ast health
&ast health events may have residual effects on the current health state.
*hildhood illess
8easles, mumps, rubella, chicken pox, pertusis, & strep throat. -void recording =usual childhood illness,>
because an illness common in the person2s childhood ,e.g., measles0 may be unusual today. -sk about serious
illnesses that may have se4uelae for the person in later years ,e.g., rheumatic fever, scarlet fever, &
poliomyelitis0.
Accidets or ijuries
-uto accidents, fractures, penetrating wounds, head injuries ,especially if associated with unconsciousness0 &
burns.
Serious or chroic illesses
.iabetes, hypertension, heart disease, sickleAcell anemia, cancer, & sei3ure disorder.
Hos$itali4atio
Gause, name of the surgeon, name of hospital, & how the person recovered.
O$eratios
Type of surgery, date , name of the surgeon, name of hospital, & how the person recovered.
Obstetric history
1o.of pregnancies ,gravidity0, no.of deliveries in which the fetus reached full term, no.of preterm pregnancies
,preterm0, no.of incomplete pregnancies ,abortions0, & no.of children living.
)or any incomplete pregnancies, record the duration & whether the pregnancy resulted in spontaneous ,60 or
induced ,0 abortion.
mmuni3ation
8easlesAmumpsArubella, polio, diphtheriaApertussisAtetanus, hepatitis ", human papiloma virus, haemophilus
influen3a type b, pneumococcal vaccine.
Last e5amiatio date
&hysical, dental, vision, hearing, electrocardiogram, chest xAray examinations
-llergies
1ote both the allergen ,medication, food, or contact agent, such as fabric or environmental agent0 & the raction
,rash, itching, runny nose, watery eyes, difficulty breathing0. Bith a drug, this symptom should not be a side
effect but a true allergic reaction.
Gurrent medications
1ote all prescription & overAtheAcounter medications. -sk specifically about vitamins, birth control pills,
aspirin, & antacids, because many people do not consider these to be medications.
6amilyhistory
-sk about the age & health or the age & cause of death of blood relatives, such as parents, grand parents, &
siblings.
6pecifically ask for any family history of heart disease, high blood pressure, stroke, diabetes, blood disorders,
cancer, sickleAcell anemia, arthritis, allergies, obesity, alcoholism, mental illness, sei3ure disorder, kidney
disease, & tuberculosis. Gonstruct an accurate family tree or genogram.
7OR8AL RA79E O6 6I7:I79S A#7OR8AL 6I7:I79S
A&&EARA7*E
&osture7 &osture is erect & position is relaxed 6itting on edge of chair or curled in bed, tense
muscles, frowning, darting watchful eyes, rstless
pacing occur with anxiety & with hyperthyroidism.
6iting slumped in chair, slow walk, dragging that
occur with depression & some organic brain diseases.
#ody movemets" "ody movements are voluntary,
deliberate, coordinated, & smooth & even.
$estless, fidgety movements, or hyperkinetic
appearance occur with anxiety.
-pathy & psychomotor slowing occur with depression
& organic brain disease.
-bnormal posturing & bi3arre gestures occur with
schi3ophrenia.
)acial grimaces
:ress( .ress is appropriate for setting, season, age,
gender, & social group. Glothing fits & is put on
appropriately
nappropriate dress can occur with organic brain
syndrome
:ccentric dress combination & bi3arre makeAup with
schi3ophrenia or manic syndrome
9roomig ; hygiee(
The person is clean groomed< hair is neat & clean<
women have moderate or no makeAup< men are shaved
or beard or mustache are well groomed. 1ails are
clean.
@nilateral neglect occurs following some
cerebrovascular accidents.
nappropriate dress, poor hygiene, & lack of concern
with appearance occur with depression & severe
-l3heimer2s disease.
#EHA<IOR
Level of cosciousess(
The person is awake, alert, aware of stimuli from the
environment & within the self, & responds
appropriately to stimuli.
/ethargic, obtunded, stupor or semi coma, coma.
-cute confusional state
6acial e5$ressio(
The look is appropriate to the situation & changes
appropriately with the topic.
)lat, mashlike expression occurs with parkinsonism &
depression
S$eech
5udge the 4uality of speech by noting that the person
makes laryngeal sounds effortlessly & shares
conversation appropriately.
.ysphonia is abnormal volume, pitch
8ood ; effect
5udge this by body language & facial expression
*O97ITI<E 637*TIO7S
Orietatio(
Time7 day of week, date, year, season
&lace7 where person lives, present location, type of
building, name of city
&erson7 own name, age, who examiner is, type of
worker
.isorientation occurs with organic brain disorders,
such as delirium & dementia
Attetio S$a
Gheck the person2s ability to concentrate by noting
whether he or she completes a thought without
wandering
Recet memory
-ssess recent memory in the context of the interview
by the #'Ahour diet recall or by asking the time the
person arrived at the agency
Remote memory
n the context of the interview, ask the person
verifiable past events
7e= learig>The four urelated =ords test
Thus tests the person2s ability to lay down new
memories. t is a highly sensitive & valid memory test.
t also avoids the danger of unverifiable material
&ick four words with semantic & phonetic diversity
"rown fun
Honesty carrot
Tulip ankle
:yedropper loyality
-fter ( minutes, ask for the recall of the four words, to
test the duration of memory, ask for a recall at !F
minutes & %F minutes.
The physical examination re4uires that the examiner develop technical skills & a knowledge base. The skills
re4uisite for the physical examination are inspection, palpation, percussion, auscultation.
Is$ectio
nspection is concentrated watching. t is close, careful scrutiny, first of the individuala as a whole & then of
each body system.
nspection always comes first. - focused inspection takes time & yields a surprising amount of data.
nspection re4uires good lighting, ade4uate exposure, occasional use of certain instruments ,otoscope,
ophthalmoscope, penlight, nasal & vaginal specula0.
&al$atio
&alpation follows & often confirms points noted during inspection. &alpation applies sense of touch to assess
these factors7 texture, temperature, moisture, organ location & si3e, as well as any swelling, vibration or
pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, & presence of tenderness or pain.
.ifferent parts of the hands arebest suited for assessing different factors7
)ingertipsAbest for fine tactile discrimination, as of skin texture, swelling, pulsation, & determining
presence of lumps.
- grasping action of the fingers & thumbAto detect the position, shape, & consistency of an organ or
mass
The dorsa ,backs0 of hands & fingersAbest for determining temperature because the skin here is thinner
than on the palms.
"ase of fingers ,metacarpophalangeal joints0 or ulnar surface of the handAbest for vibration.
&alpation techni4ue should be slow & systematic. 6tarting with light palpation & then deep palpation.
&ercussio
&ercussion is tapping the person2s skin with short, sharp strokes to assess underlying structures. The strokes
yield a palpable vibration & a characteristic sound that depicts the location, si3e & density of the underlying
organ.
&ercussion has the following uses
8apping out the location & si3e of an organ by exploring where the percussion note changes between
the borders of an organ & itsneighbours
6ignaling the density ,air, fluid, or solid0 of a structure by a characteristic note
.etecting an abnormal mass if it is fairly superficial< the percussion vibrations penetrate about ( cm
deepAa deeper mass would give no change in percussion
:liciting pain if the underlying structure is inflamed, as with sinus areas or over the kidney
:liciting a deep tendon reflex using the percussion hammer.
Two methods of percussion can be usedAdirect ,immediate0 & indirect,mediate0
n direct percussion the striking hand directly contacts the wall
n indirect percussion is used more often & involves both hands
ndirect percussion is used more often & involves both hands. The striking hand contacts the stationary hand
fixed on the person2s skin.
&roduction of sound
!. -mplitude or intensity
- loud or soft sound, the louder the sound, the greater the amplitude. /oudness depends on the force of
the blow & the structure2s ability to vibrate
#. &itch or fre4uency
The no.of vibrations per second, written as Hcps2 or cycle per second. 8ore rapid vibrations produce a
high pitched tone< slower vibrations yield a lowApitched tone
%. Iuality or timbre
- subjective difference due to sound2s distinctive overtones. - pure tone is a sound of one fre4uency.
'. .uration
The length of time the note lingers.
-mplitude &itch Iuality .uration 6ample location
$esonant 8ediumA
loud
/ow Glear, hollow 8oderate Dver normal lung tissue
Hyper
resonant
/ouder /ower "ooming /onger 1ormal over child2s lung
-bnormal in the adult, over lungs with
increased amount of air, as in
emphysema
Tympany /oud High 8usical &
drumlike
6ustained
longest
Dver airAfilled viscus
:g., the stomach, the intestine
.ull 6oft High 8uffled thud 6hort $elatively dense organ, as liver or
spleen
)lat Jery soft High - dead stop of
sound, absolute
dullness
Jery short Bhen no air is present, over thigh
muscles, bone, or over tumor
Auscultatio
-uscultation is listening to sounds produced by the body, such as the heart & blood vessels & the lungs &
abdomen. Gertain body sounds with ear alone for example, the harsh gurgling of very congested breathing.
However, most body sounds are very soft & must be channeled through a stethoscope to evaluate.
Settig
The examination room should be warm & comfortable, 4uite, private, & well lit.
E!ui$met
&latform scale with height attachment
6kinfold calipers
6phygmomanometer
6tethoscope with bell & diaphragm endpieces
Thermometer
&ulse oximeter
)lashlight or penlight
DtosopeEophthalmoscope
Tuning fork
1asal speculum
Tongue depressor
&ocket vision screener
6kinAmarking pen
)lexible tape measure & ruler marked in centimeters
$eflex hammer
6harp object
Gotton balls
"ivalve vaginal speculum
Glean gloves
8aterials for cytologic study
/ubricant
)ecal occult blood test materials