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607 Exam 1 Study Guide

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1) Components of adult health history (p. 6-23) a. Identifying Data: i. Identifying data- such as age, gender, occupation, marital status ii. Source of the history- usually the patient, but can be ... a family member or friend, letter of referral, or the medical record (may need to establish source of referral to assess the type of information provided and any possible bias) iii. Reliability- varies according to the patient’s memory, trust, and mood b. Chief Complaint (pg. 7-8): the one or more symptoms or concerns causing the patient to seek care; make every attempt to quote their own words c. History of Present Illness (pg. 7-8): i. Amplifies the chief complaint; describes how each symptom developed ii. Each principal symptom (1 per paragraph) should be well-characterized with descriptions of the 7 Attributes of an Assessment (pg. 8, pg. 70) 1. Location: Where is it? Does it radiate? 2. Quality: What is it like? 3. Quantity or severity: How bad is it? (For pain, ask for a rate on a scale of 1-10) 4. Timing including onset, duration, and frequency: When did (does) it start? How long does it last? How often does it come? 5. The setting in which it occurs: include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness 6. Factors that have aggravated or relieved the symptom (remitting or exacerbating factors): Is there anything that makes it better or worse? 7. Associated manifestations: Have you noticed anything else that accompanies it? iii. Includes the patient’s thoughts and feelings about the illness and what effect the illness has had on the patient’s life (the data flows spontaneously from the patient, but the task of oral and written organization is yours) iv. Pulls in relevant portions of the Review of Systems called “pertinent positives and negatives”: major health events, presence or absence of symptoms relevant to the differential diagnosis, which identifies the most likely diagnoses explaining the patient’s condition v. May include medications (name, dose, route, and frequency of use), allergies (include specific reactions), and habits of smoking (pack-years, if quit-how long) and alcohol, which are frequently pertinent to the present illness d. Past History i. Lists childhood illnesses ii. Lists adult illnesses with dates for at least four categories: medical, surgical, obstetric/gynecologic, and psychiatric iii. Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety 607 Exam 1 Study Guide Weeks 1-4 (Chapters 1-4, 7, 9, 12, 16, 17) e. Family History i. Outlines or diagrams age and health, or age and cause of death, of siblings, parents, grandparents ii. Documents presence or absence of specific illnesses i...................................................... [Show More]

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