1st Lecture Health History

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HEALTH HISTORY

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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.

So its a screening tool for abnormal symptoms, health problems & records

ways of responses.

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*THE ADVANTAGES OF HH ARE

1- it provides a complete picture of thepersons past & present health

2-it describes the individual as a whole &how the person interacts with the

environment.3- it records health strengths & coping

skills

HH for the well person assess his life style

as exercise, diet, risk reduction, for the illperson a detailed & chronologic recordof the health problem, for all its ascreening tool for abnormal symptoms.

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BIOGRAPHICAL DATA

- Name- address- phone no- age- gender-

marital status- occupation- religion.

Source of Hx:

1. record who give the information

usually the person himself or a relative

or a friend

2. judge how reliable & how willing to

communicate

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REASON FOR SEEKING CARE

- a brief spontaneous statement in the persons own words that describesthe reason for the visit, as a title for the story to follow, a symptomis asubjective sensation that the person feels from the disorder, a signisan objective abnormality that you as the examiner could detect onphysical exam or in lab results.

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PRESENT HEALTH OR HISTORY

OF PRESENT ILLNESS

- For the well person, this is a shortstatement about the general state ofhealth. For the ill person this is sectionis a chronologic record of the reason forseeking care, if started along time agowhy he seeks care now. Dont jump tothe conclusions & bias the story byadding your opinion, your final summaryof any symptom he has should includethese ch.ch: {COLDSPA}

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PAST HISTORY

- may have residual effects on the current

health state, also the pervious illness maygive clues as to how the person responds to

illness

1. Childhood illnesses: measles, mumps,

rubella

2. Accidents or injuries

3. PMH: chronic illnesses: DM, HTN, Heart

disease, cancer, renal diseases

4. PSH: operations: type of surgery, date,

name of the hospital & surgeon

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5. Hospitalizations: cause, name of the

hospital, RX

6. Obstetric history: No of pregnancies,deliveries, living babies, abortions,

complications after deliveries ..etc.

2. Immunizations: MMR, DPT, HB, HIB

3. Allergies: food, drugs, contrast & the

reaction (rash, itching, dyspnea...)

4. Current medications: prescribed &

over-the counter medications.

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FAMILY HISTORY

(GENOGRAM)

- 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

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GENOGRAM

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REVIEW OF SYSTEMS: FROM HEAD TO TOE

the purposes : 1- toevaluate the past&present health state of

each system.2- to double check incase any significant datawere omitted in thepresent illness section.

3- to evaluate healthpromotion practices

only the most commonsymptoms are listed

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General overal l Health s tate:

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& hairHead: injuries- headache

Eyes:decreased acuity-diplopia-swelling-diseases, wearing glasses orlenses.

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Ears:infections, tinnitus, hearing loss, using hearing aids

Nose & sinuses:discharge, obstructions, allergiesMouth & throat:bleeding gum- dysphagia, dental care

Neck:limitation of movement swelling- tender nodes.

Breast:lumps- discharge-surgery-breast self exam

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Urinary sys tem: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

Neuro logical s ystem:hx of seizures,,

stroke. In motor function: tremor,

paralysis. In sensory function numbness,in cognitive function memory disorders, &

interpersonal relationship

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FUNCTIONAL ASSESSMENT (ADL):

1- self-esteem, self- concept: education - financial status- value belief.

2- activity/exercises: bathing , dressing, toileting 3- sleep/rest: naps- sleep aids

4- Nutrition/elimination:

5- interpersonal relations: social roles

6- spiritual resources:

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7- coping & stress management

8- alcohol& smoking

9- street drugs

10- environment hazards

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1st Lecture Health History

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