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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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