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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