27 Dec Nervousness/anxiety; depression; memory

MN552 Advanced Health Assessment

Unit 2 Documenting Subjective information

History and Interview

Please select a volunteer friend or family member to interview and gather data to complete this Assignment. The following guide will assist you in gathering subjective data in an organized, systematic manner to prevent omission of important components of the health history.

Date of History/Interview:

Source of history and Reliability:

Biographical Data

a. Name (use initials only)

b. Primary language

c. Age and Date of Birth

d. Place of Birth

e. Gender

f. Race

g. Marital Status

h. Ethnic/Cultural Origin

i. Education ( highest level completed)

j. Occupation/Professional

k. Health insurance (ie commercial, state, federal)

2. Chief Complaint (reason for seeking health care):

a. Brief spontaneous statement in client’s own words

b. Includes when the problem started ( “chest pain for 2 hours”)

3. History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the OLD CARTS pneumonic.

P – Provocative or palliative (What brings it on? What makes it better or worse?)

Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?)

R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?).

S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).

T – Timing (Inquire about time of onset, duration, frequency, etc.)

U – Understand Patient’s Perception of the problem (What do you think it means?)

** Put all of that information into the heading HPI in a story format.

4. Past Medical History (list down not across)

a. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilities

b. Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, strep throat

c. Surgical Hx; procedures, dates, inpatient or outpatient

d. Obstetric HX: Number of pregnancies, term deliveries, preterm births, abortions

(spontaneous or induced), number of children living

e. Immunizations

f. Psychiatric Hx: childhood and adult (treated or hx of)

g. Allergies: Medications, food, inhalants or other (what occurs with reaction)

h. Current Medications: Include all prescription, herbal/supplements and OTC, dosage, frequency

i. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, TB skin test; other health maintenance tests for infants/children may include sickle-cell, PKU, lead level, and hematocrit

5. Family History list FHx

a. Include parents, grandparents, spouse, and children.

b. Health conditions, familial and communicable diseases/illnesses

c. Note whether family member deceased or living

II. Life style patterns

a. Immigrant status

b. Spiritual resources/religion

c. Health perception

d. Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type

e. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence

f. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins

g. Occupational health: Known exposure to environmental toxins at work

h. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook)

i. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on family

j. Cognitive function: Memory; speech; judgment; senses

k. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleep

l. Exercise patterns: Type and frequency

m. Hobbies/recreation: Leisure activities; any travel outside of the US

n. Social habits: Tobacco; alcohol; street drug use

o. Intimate partner violence (review screening questions on page 58 in the Jarvis textbook)

p. Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helps

q. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function

III. Review of Symptoms

Symptoms to Inquire About

(please see page 54–56 in Jarvis textbook)

Document pertinent negatives and/or positives

The first system is addressed to provide a guide

General

Wgt Δ; weakness; fatigue; fevers

Pertinent negatives: No weight gain or losses; no weaknesses, fatigue, or fevers

Pertinent positives: Positive weight gain over past 2 months with fatigue and weakness; no fevers

Skin

Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails

Head

Headache; head injury; dizziness or vertigo

Eyes

Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma

Ears

Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use

Nose/

Sinuses

Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain

Throat/

Mouth

Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste

Neck

Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion

Breasts

Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area

Pulmonary

Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin test

Cardiac

Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD

G/I

Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance

GU

Frequency; nocturia; urgency; dysuria; hematuria; incontinence

Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding;

Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often

Peripheral Vascular

Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers

Musculo-skeletal

Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease

Neuro

Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations

Heme

Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation

Endo

Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distribution

Psych

Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses

Rating:
4.1/5