Ch 4 – The Complete Health History

purpose of a complete health history
collect subjective data and combine it with objective data from physical examination and diagnostic tests
8 characteristics to describe present health
location – precise site of pain
character/quality – description ex: burning, stabbing, throbbing
quantity or severity – quantify symptoms, quantify pain (1-10)
timing – onset, duration, frequency
setting – triggers
aggravating and relieving factors
associated factors – symptoms that accompany the primary
patient’s perception – how pt feels about issue
PQRSTU
P – provocative or palliative
Q – quality or quantity
R – region or radiation
S – severity scale
T – timing/onset
U – understand patient’s perception
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goal of review of systems
1. evaluate past and present health state
2. double-check in case significant data was omitted
3. evaluate health promotion practices
HEEADSSS
Method of interviewing adolescents that focuses on:
Home environment
Education/employment
Eating
Activities, peer-related
Drugs
Sexuality
Suicide/depression
Safety from injury/violn
SPICES
Assessment for older adults with focus on “marker conditions” for increased death rates, hospitalization, costs:
Sleep problems
Problems with eating/feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
disease burden
the impact on ADL’s of older adults
two sections of child’s health history that become separate sections b/c of importance to current health status
developmental and nutritional history
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
Functional assessment measures a person’s self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value-belief system.

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