Term
| what is the purpose of the health history? |
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Definition
| to collect subjective data |
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Term
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Definition
| what the person says about him/herself |
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Term
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Definition
| gathered from the physical exam and lab studies |
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Term
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Definition
- subjective data + objective data + lab studies
- used to make a judgment or diagnosis about the health status of the person
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Term
| what should the health history do? |
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Definition
- recognize and affirm what the person is doing right
- assess lifestyle
- include a detailed and chronological record of health problems
- screen for abnormal symptoms, health problems, and concerns
- record ways of responding to the health problems
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Term
| what does the complete health history include? |
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Definition
- Bigmama Reba Prefers Peanuts For Real Food
- biographical data
- reason for seeking care
- present health or history of present illness
- past history
- family history
- review of systems
- functional assessment or ADLs
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Term
| what are the 12 components of biographic data? |
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Definition
- name, address, phone number, age
- DOB and POB
- gender
- marital status
- race and ethnic origin
- occupation
- usual and present
- primary language & authorized representative
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Term
| what does source of history include? |
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Definition
- record of who furnishes the information
- how reliable the informant seems to be and how willing he/she is to communicate
- notes of any special circumstances (interpreter, etc)
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Term
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Definition
- a brief spontaneous statement in the person's own words that describes the reason for the visit
- recorded & enclosed in quotation marks to indicate the person's exact words
- not a diagnostic statement
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Term
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Definition
| a subjective sensation that the person feels from the disorder |
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Term
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Definition
| an objective abnormality that the examiner detects on physical examination or in lab reports |
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Term
| what is the present health or history of present illness? |
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Definition
- for the well person: a short statement about general state of health
- for the ill person: a chronological record of the reason for seeking care, from the time the symptoms first started until now
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Term
| the final summary of any symptom the person has should include what eight critical characteristics? |
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Definition
- OLDCAAARTS
- onset
- location
- duration
- character
- aggravating, alleviating, associated factors
- radiation to other areas
- timing
- severity
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Term
| when asking the patient about the quantity/severity of their pain, what should be avoided and asked? |
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Definition
- avoid adjectives
- ask how it affects daily activities
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Term
| what 10 components does past health include? |
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Definition
- childhood, serious, and chronic illnesses
- accidents or injuries
- hospitalizations & operations
- OB history
- immunizations
- last exam date
- allergies
- current meds
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Term
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Definition
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Term
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Definition
| number of deliveries in which the fetus reached full term |
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Term
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Definition
| number of incomplete pregnancies |
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Term
| what are the two types of abortions a female could have? |
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Definition
- spontaneous (record as "S")
- induced (record as "I")
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Term
| what are the components of the OB history part of past health? |
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Definition
- gravidity
- term
- preterm
- abortions (S or I)
- living
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Term
| what kinds of medications does the "current meds" section of past health include? |
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Definition
- prescription meds
- over the counter meds
- vitamins
- birth control
- aspirin
- antacids
- herbal remedies
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Term
| what information should be record for each of the current medications reported by the patient? |
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Definition
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Term
| what does the family history portion of the complete health history include? |
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Definition
- age & health/age & cause of death of blood relatives (parents, siblings, gparents)
- heart disease, high BP, stroke
- diabetes, arthritis, allergies, obesity
- blood disorders, sickle-cell
- cancer, kidney disorders, TB
- alcoholism & mental illness seizure disorders
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Term
| what are the purposes of the review of systems? |
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Definition
- to evaluate the past and present health of each body system
- to double-check in case any significant data were omitted in the present illness section
- to evaluate health promotion practices
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Term
| what should be included in the review of systems? |
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Definition
- head-to-toe review
- record "presence" or "absence" of symptoms
- hx should be limited to patient statements/subjective data
- general overall health state of systems
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Term
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Definition
| measures a person's self-care ability in the areas of general physical health or absence of illness |
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Term
| what 13 components does the functional assessment (ADLs) include? |
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Definition
- self-esteem/self-concept
- activity/exercise & sleep/rest
- nutrition/elimination
- interpersonal relationships/(spiritual) resources
- coping & stress management
- personal habits
- alcohol, illicit/street drugs
- environment/hazards & occupational health
- intimate partner violence
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Term
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Definition
- faith
- influence
- community
- address
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Term
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Definition
| does religious faith or spirituality play an important part in your life? |
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Term
| influence question (FICA) |
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Definition
| how does your religious faith or spirituality influence the way you think about your health or the way you care for yourself |
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Term
| community question (FICA) |
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Definition
| are you a part of any religious or spiritual community? |
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Term
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Definition
| would you like me to address any religious or spiritual issues with you? |
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Term
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Definition
- a screening questionnaire used to identify excessive or uncontrolled drinking
- Cut down, Annoyed, Guilty, and Eye-opener
- if the person answers "yes" to two or more CAGE questions, you should suspect alcohol abuse
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Term
| Cut down question of CAGE test |
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Definition
| have you ever thought you should cut down your drinking? |
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Term
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Definition
| have you ever been annoyed by criticism of your drinking? |
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Term
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Definition
| have you ever felt guilty about your drinking? |
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Term
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Definition
| do you drink in the morning? (eye-opener) |
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Term
| what additional information should be acquired by the examiner in past health when the patient is a child? |
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Definition
- prenatal status
- labor and delivery
- postnatal status
- immunizations
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Term
| how often should height and weight be recorded for children? |
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Definition
| at birth, 1, 2, 5, and 10 years |
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Term
| what should be included in the developmental history of a child? |
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Definition
- growth
- milestones
- current development
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Term
| when acquiring nutritional history of a child, what should the examiner remember? |
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Definition
| the younger the child is, the more detailed and specific the data should be |
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Term
| when the patient is a child, what should the functional assessment include? |
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Definition
- interpersonal relationships
- activity/rest
- economic status
- home environment
- coping/stress management
- habits
- health promotion
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Term
| with a child, what information should be recorded in the interpersonal relationships part of the functional assessment? |
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Definition
- the child's position in the family
- family cohesion
- information regarding the child's friends
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Term
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Definition
- method of interview for the adolescent
- focuses on assessment of the following:
- home environment
- education/employment, eating
- peer-related activities
- drugs
- sexuality, suicide/depression, safety from injury and violence
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Term
| what method of interview should be used with an adolescent when completing the health hx and why? |
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Definition
the HEEADSSS method because it minimizes the stress → moves from expected and less threatening questions to those that are more personal
- green = essential
- blue = explore if time permits
- red = delve in more deeply if the situation demands it
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Term
| what additional information should be acquired when completing the health hx of an older adult |
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Definition
- general health: health state in the last 5 years
- functional assessment (ADLs): disease burden
- date of last mammography, colonoscopy, and tonometry
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Term
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Definition
- the impact of a disease on daily activity and overall quality of life
- more important to older adults than the actual disease diagnosis or pathology
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Term
| what is included in the self-esteem/self-concept part of the functional assessment? |
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Definition
- education
- financial status
- value-belief system
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Term
| what should be included in the activity/exercise part of the functional assessment? |
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Definition
- usually daily activities
- ability to perform ADLs
- use of wheelchair, prosthesis, or mobility aids
- leisure activities
- exercise pattern
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Term
| what can help incorporate the person's spiritual values into the health history during functional assessment? |
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Definition
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Term
| what illicit/street drugs should the examiner specifically ask the patient about? |
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Definition
- weed
- cocaine
- crack cocaine
- amphetamines
- barbiturates
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Term
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Definition
| when older adults compare symptoms and share medications |
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Term
| what is an early sign of cardiac dysfunction in an older adult? |
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Definition
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