1) Components of adult health history (p. 6-23)
a. Identifying Data:
i. Identifying data- such as age, gender, occupation, marital status
ii. Source of the history- usually the patient, but can be a family member or
...
1) Components of adult health history (p. 6-23)
a. Identifying Data:
i. Identifying data- such as age, gender, occupation, marital status
ii. Source of the history- usually the patient, but can be a family member or
friend, letter of referral, or the medical record (may need to establish
source of referral to assess the type of information provided and any
possible bias)
iii. Reliability- varies according to the patient’s memory, trust, and mood
b. Chief Complaint (pg. 7-8): the one or more symptoms or concerns causing the
patient to seek care; make every attempt to quote their own words
c. History of Present Illness (pg. 7-8):
i. Amplifies the chief complaint; describes how each symptom developed
ii. Each principal symptom (1 per paragraph) should be well-characterized
with descriptions of the 7 Attributes of an Assessment (pg. 8, pg. 70)
1. Location: Where is it? Does it radiate?
2. Quality: What is it like?
3. Quantity or severity: How bad is it? (For pain, ask for a rate on a
scale of 1-10)
4. Timing including onset, duration, and frequency: When did (does)
it start? How long does it last? How often does it come?
5. The setting in which it occurs: include environmental factors,
personal activities, emotional reactions, or other circumstances that
may have contributed to the illness
6. Factors that have aggravated or relieved the symptom (remitting or
exacerbating factors): Is there anything that makes it better or
worse?
7. Associated manifestations: Have you noticed anything else that
accompanies it?
iii. Includes the patient’s thoughts and feelings about the illness and what
effect the illness has had on the patient’s life (the data flows spontaneously
from the patient, but the task of oral and written organization is yours)
iv. Pulls in relevant portions of the Review of Systems called “pertinent
positives and negatives”: major health events, presence or absence of
symptoms relevant to the differential diagnosis, which identifies the most
likely diagnoses explaining the patient’s condition
v. May include medications (name, dose, route, and frequency of use),
allergies (include specific reactions), and habits of smoking (pack-years, if
quit-how long) and alcohol, which are frequently pertinent to the present
illness
d. Past History
i. Lists childhood illnesses
ii. Lists adult illnesses with dates for at least four categories: medical,
surgical, obstetric/gynecologic, and psychiatric
iii. Includes health maintenance practices such as immunizations, screening
tests, lifestyle issues, and home safety
607 Exam 1 Study Guide
Weeks 1-4 (Chapters 1-4, 7, 9, 12, 16, 17)
e. Family History
i. Outlines or diagrams age and health, or age and cause of death, of siblings,
parents, grandparents
ii. Documents presence or absence of specific illnesses i......................................................
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