1 Health History Prepared by: L- Manal tharwat Abouzaied

2 The purpose of the HH : is to collect subjective data- what the person says about himself, combined with the objective data from P/E & lab results to make a judgment or a diagnosis about health status. is to collect subjective data- what the person says about himself, combined with the objective data from P/E & lab results to make a judgment or a diagnosis about health status. So it ’ s a screening tool for abnormal symptoms, health problems & records ways of responses.

3 * The advantages of HH are: - it provides a complete picture of the person ’ s past & present health - it provides a complete picture of the person ’ s past & present health it describes the individual as a whole & how the person interacts with the environment. it describes the individual as a whole & how the person interacts with the environment. it records health strengths & coping skills it records health strengths & coping skills HH for the well person assess his life style as exercise, diet, risk reduction, for the ill person a detailed & chronologic record of the health problem, for all it ’ s a screening tool for abnormal symptoms. HH for the well person assess his life style as exercise, diet, risk reduction, for the ill person a detailed & chronologic record of the health problem, for all it ’ s a screening tool for abnormal symptoms.

4 * History contains information in this sequence of categories: 1. Biographical data 1. Biographical data 2. reason for seeking care 2. reason for seeking care 3. hx of present illness 3. hx of present illness 4. past history 4. past history 5. family history 5. family history 6. review of systems 6. review of systems 7. functional assessment or activities of daily living(ADLs) 7. functional assessment or activities of daily living(ADLs)

5 · Biographical Data: - Name- address- phone no- age- gender- marital status- occupation- religion. - Name- address- phone no- age- gender- marital status- occupation- religion. · Source of Hx: · Source of Hx: 1. record who give the information usually the person himself or a relative or a friend 1. record who give the information usually the person himself or a relative or a friend 2. judge how reliable & how willing to communicate 2. judge how reliable & how willing to communicate

6 · Reason for seeking care: - a brief spontaneous statement in the person ’ s own words that describes the reason for the visit, as a title for the story to follow, a symptom is a subjective sensation that the person feels from the disorder, a sign is an objective abnormality that you as the examiner could detect on physical exam or in lab results. - a brief spontaneous statement in the person ’ s own words that describes the reason for the visit, as a title for the story to follow, a symptom is a subjective sensation that the person feels from the disorder, a sign is an objective abnormality that you as the examiner could detect on physical exam or in lab results.

7 · Present health or history of present illness: - For the well person, this is a short statement about the general state of health. For the ill person this is section is a chronologic record of the reason for seeking care, if started along time ago why he seeks care now. Don ’ t jump to the conclusions & bias the story by adding your opinion, your final summary of any symptom he has should include these ch.ch: {COLDSPA} - For the well person, this is a short statement about the general state of health. For the ill person this is section is a chronologic record of the reason for seeking care, if started along time ago why he seeks care now. Don ’ t jump to the conclusions & bias the story by adding your opinion, your final summary of any symptom he has should include these ch.ch: {COLDSPA}

8 1. character or quality: descriptive terms 2. onset :when did it begin? 3. location: where is it ? 4. Duration : how long dose it last ? 5. severity : how bad is it ? 6. pattern : what makes it better ? 7. Associated factors: what other symptoms occur with it ?

9 · Past history: - may have residual effects on the current health state, also the pervious illness may give clues as to how the person responds to illness - may have residual effects on the current health state, also the pervious illness may give clues as to how the person responds to illness 1. Childhood illnesses: measles, mumps, rubella 1. Childhood illnesses: measles, mumps, rubella 2. Accidents or injuries 2. Accidents or injuries 3. PMH: chronic illnesses: DM, HTN, Heart disease, cancer, renal diseases 3. PMH: chronic illnesses: DM, HTN, Heart disease, cancer, renal diseases 4. PSH: operations: type of surgery, date, name of the hospital & surgeon 4. PSH: operations: type of surgery, date, name of the hospital & surgeon

10 5. Hospitalizations: cause, name of the hospital, RX 5. Hospitalizations: cause, name of the hospital, RX 6. Obstetric history: No of pregnancies, deliveries, living babies, abortions, complications after deliveries …..etc. 6. Obstetric history: No of pregnancies, deliveries, living babies, abortions, complications after deliveries …..etc. 2. Immunizations: MMR, DPT, HB, HIB 2. Immunizations: MMR, DPT, HB, HIB 3. Allergies: food, drugs, contrast … & the reaction (rash, itching, dyspnea...) 3. Allergies: food, drugs, contrast … & the reaction (rash, itching, dyspnea...) 4. Current medications: prescribed & over- the counter medications. 4. Current medications: prescribed & over- the counter medications.

11 Family history: (Genogram) Family history: (Genogram) - ask about the age& cause of the death of relatives as parents & grand parents & siblings (genetic significance) - ask about the age& cause of the death of relatives as parents & grand parents & siblings (genetic significance) - ask about family hx of heart disease, HTN, stroke, DM, blood disorders, cancer, and mental illness - ask about family hx of heart disease, HTN, stroke, DM, blood disorders, cancer, and mental illness

12 Genogram

13 · Review of Systems: from head to toe the purposes : 1- to evaluate the past& present health state of each system. the purposes : 1- to evaluate the past& present health state of each system. 2- to double – check in case any significant data were omitted in the present illness section. 2- to double – check in case any significant data were omitted in the present illness section. 3- to evaluate health promotion practices 3- to evaluate health promotion practices only the most common symptoms are listed only the most common symptoms are listed

14  General overall Health state: weight(gain or loss, weakness)  Skin: hx of skin disease (eczema), color change, dryness, or moisture. rashes  Hair: loss- texture-nails- self care of skin& hair  Head: injuries- headache  Eyes: decreased acuity-diplopia-swelling- diseases, wearing glasses or lenses.

15  Ears: infections, tinnitus, hearing loss, using hearing aids  Nose & sinuses: discharge, obstructions, allergies  Mouth & throat: bleeding gum- dysphagia, dental care  Neck: limitation of movement – swelling- tender nodes.  Breast: lumps- discharge-surgery- breast self exam

16  Respiratory system: lung diseases- chest pain with breathing, SOB- last CXR.  Cardiovascular system: retrosternal pain- cyanosis-orthopnea- CAD-HTN-last ECG  Peripheral vascular: coldness- numbness-swelling- discoloration varicose veins- work standing or sitting for long time  Gastrointestinal: appetite- dysphagia- heartburn- jaundice- bowel movements- use of laxatives or antacids.

17  Urinary system: frequency, urgency, nocturia, dysuria, hematuria, renal diseases, flank pain.  Musculoskeletal system: hx of arthritis. In joints: swelling or LOM, in muscle: pain, weakness, gait problem. In back: pain, LOM, disk disease. daily activities  Neurological system: hx of seizures,, stroke. In motor function: tremor, paralysis. In sensory function numbness, in cognitive function memory disorders, & interpersonal relationship

18   Hematological system: bleeding tendency, blood transfusion.   Endocrine system: DM, thyroid diseases …..etc.

19 Functional Assessment (ADL): 1- self-esteem, self- concept: education - financial status- value belief. 1- self-esteem, self- concept: education - financial status- value belief. 2- activity/exercises: bathing, dressing, toileting … 2- activity/exercises: bathing, dressing, toileting … 3- sleep/rest: naps- sleep aids 3- sleep/rest: naps- sleep aids 4- Nutrition/elimination: 4- Nutrition/elimination: 5- interpersonal relations: social roles 5- interpersonal relations: social roles 6- spiritual resources: 6- spiritual resources:

20 7- coping & stress management 7- coping & stress management 8- alcohol& smoking 8- alcohol& smoking 9- street drugs 9- street drugs 10- environment hazards 10- environment hazards

21 Thank you