The History



CHAPTER 1 The History



BUILDING THE HISTORY


The following outline of a patient history is a guideline and should not be considered a rigid structure. You are beginning your relationship with the patient at this point. Take care with this relationship. The information you gain in the history loses meaning if your bond with the patient is less than strong. Choose a comfortable setting and help the patient get settled. Maintain eye contact and use a conversational tone. Begin by introducing yourself and explaining your role. Help the patient understand why you are building the history and how it will be used. Explore positive responses with additional questions: Where, when, what, how, and why. Be sensitive to the patient’s emotions at all times. Avoid confrontation and asking leading questions.



CHIEF COMPLAINT



Problem or symptom: Reason for visit

Duration of problem

Patient information: Age, sex, marital status, previous hospital admissions; occupation

Other complaints: Secondary issues, fears, concerns, what made patient seek care

Always consider why this particular problem may be affecting this particular patient at this time. Why did this patient succumb to a risk or an exposure when others similarly exposed did not?


PRESENT PROBLEM



Chronologic ordering: Sequence of events patient has experienced

State of health just before onset of present problem

Complete description of first symptom: Time and date of onset, location, movement

Possible exposure to infection or toxic agents

If symptoms are intermittent, describe typical attack: Onset, duration, symptoms, variations, inciting factors, exacerbating factors, relieving factors

Effect of illness: On lifestyle, on ability to function; limitations imposed by illness

“Stability” of problem: Intensity, variations, improvement, worsening, staying same

Immediate reason for seeking attention, particularly for long-standing problem

Review of appropriate system when there is a conspicuous disturbance of a particular organ or system

Medications: Current and recent, dosage of prescriptions, home remedies, nonprescription medications

Review of chronology of events for each problem: Patient’s confirmations and corrections


MEDICAL HISTORY



GENERAL HEALTH AND STRENGTH



Childhood illnesses: Measles, mumps, whooping cough, chickenpox, smallpox, scarlet fever, acute rheumatic fever, diphtheria, poliomyelitis

Major adult illnesses: Tuberculosis (TB), hepatitis, diabetes, hypertension, myocardial infarction, tropical or parasitic diseases, other infections, any nonsurgical hospital admissions

Immunizations: Poliomyelitis, diphtheria, pertussis, tetanus toxoid, influenza, Haemophilus influenzae B, pneumococcal, cholera, typhus, typhoid, bacille Calmette-Guérin (BCG), hepatitis B virus (HBV), last purified protein derivative (PPD) or other skin tests; unusual reactions to immunizations; tetanus or other antitoxin made with horse serum

Surgery: Dates, hospital, diagnosis, complications

Serious injuries: Resulting disability (document fully for injuries with possible legal implications)

Limitation of ability to function as desired as a result of past events

Medications: Past, current, recent medications; dosage of prescription; home remedies and nonprescription medications, particularly complementary and alternative therapies

Allergies: Especially to medications but also to environmental allergens and foods

Transfusions: Reactions, date, number of units transfused

Emotional status: Mood disorders, psychiatric treatment

Children: Birth, developmental milestones, childhood diseases, immunizations


FAMILY HISTORY



The genetic basis for a patient’s response to risk or exposure may determine whether the patient becomes ill when others do not.

Relatives with similar illness

Immediate family: Ethnicity, health, cause of and age at death

History of disease: Heart disease, high blood pressure, hypercholesterolemia, cancer, TB, stroke, epilepsy, diabetes, gout, kidney disease, thyroid disease, asthma and other allergic states, forms of arthritis, blood diseases, sexually transmitted diseases, other familial diseases

Spouse and children: Age, health

Hereditary disease: History of grandparents, aunts, uncles, siblings, cousins; consanguinity


PERSONAL AND SOCIAL HISTORY



Personal status: Birthplace, where raised, home environment; parental divorce or separation, socioeconomic class, cultural background, education, position in family, marital status, general life satisfaction, hobbies and interests, sources of stress and strain

Habits: Nutrition and diet; regularity and patterns of eating and sleeping; exercise: quantity and type; quantity of coffee, tea, tobacco, alcohol; illicit and/or recreational drug use: frequency, type, amount; breast or testicular self-examination

Sexual history: Concerns with sexual feelings and performance, frequency of intercourse, ability to achieve orgasm, number and gender of partners

Home conditions: Housing, economic condition, type of health insurance if any, pets and their health

Occupation: Description of usual work and present work if different; list of job changes; work conditions and hours; physical and mental strain; duration of employment; present and past exposure to heat and cold, industrial toxins (especially lead, arsenic, chromium, asbestos, beryllium, poisonous gases, benzene, and polyvinyl chloride or other carcinogens and teratogens); any protective devices required, for example, goggles or masks

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Mar 25, 2017 | Posted by in PHYSIOLOGY | Comments Off on The History

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