HISTORY

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HISTORY PHYSICALOBJECTIVES

• Purpose and guidelines for obtaining a medical
  history
• Procedures for obtaining information for a
  medical history
• Appropriate interviewing skills to obtain a
  comprehensive history
• Terminology used in a medical history
• Factors and equipment concerning accurate vital
  signs
• Recognize normal parameters of the history and
  survey
• Appropriate documentation of patient history

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DEFINITION MEDICAL HISTORY

• First step in the health care process
• An account of events in the patients life
  relevant to
• mental health
• emotional health
• physical health
• Provide as much data as necessary to accurately
  evaluate
• a patients condition

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HEALTH HISTORY GUIDELINES

• Develop Therapeutic Relationship
• Explain Purpose of the Interview
• (Basic History in Patients Own Words)
• Patient Comfort
• (Environment Interview)
• Confidentiality Concepts
• (Visual and Auditory Privacy)
• Same Gender Standby (Spouses do not qualify)

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INTERVIEWING TECHNIQUES

• Use open ended questions to elicit verbalization
  of feelings and additional information.
  
  What brings you here Sir/Maam
  ? What seems to be the
  problem ?

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INTERVIEWING TECHNIQUES

• Facilitation
• Reflection
• Empathy
• Confrontation
• Verbal
• Nonverbal messages
• Transitions
• Closing

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STANDARD SEQUENCE OF EVENTS

• Introduce yourself
• Identifying Information
• Verify patients name and SSN
• Patients own words
• One or two symptoms
• Assess reliability expectations

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STANDARD SEQUENCE OF EVENTS

• Chief Complaint
• Reason patient sought health care ,
  The Chief Complaint may not be the
  apparent reason for seeking medical attention.

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HEALTH HISTORY FORMAT

• PRESENT ILLNESS
• Current symptoms of the chief complaint.
• Time Intervals/Duration
• Character or Quality
• What helped
• What made it worse
• Seek Facts

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PAST HEALTH HISTORY General Patient Perceptions

• Allergies
• Hospitalization
• Trauma
• Transfusions
• Medications(RX AND OTC)
• Examinations
• Females LMP, GRAVIDA/PARA
• Psychosocial History
• Diseases/Immunizations

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FAMILY HISTORY Include family members Major
health or genetic disorders PERSONAL/SOCIAL
HISTORY Cultural background Educational
Economic status Environment
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• Cultural Sensitivity
• Culture has a profound effect on the way people
  communicate. Sensitivity to culture should
  influence how the interview ( and Therapeutic
  Relationship ) should be.
• Being aware of a persons cultural background is
  important in assessing values and beliefs, and in
  determining a plan of care.

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• Keep in mind that cultural background, religion,
  believes, language (verbal nonverbal) and
  customs may influence the communication process
  and the Patient -Health Care Provider
  relationship, therefore the quality of Health
  Care and its process might be affected.
• Avoiding cultural blindness, ethnocentrism,
  cultural imposition, and stereotyping is crucial
  in providing effective care.

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How Various Cultures Define Health and Illness

• Definitions of health varies from culture to
  culture. Some examples are as follows
• Chinese Health is a state of spiritual and
  physical harmony with nature the human body is a
  gift from ancestor and must be maintained.
• Illness represents an upset in the balance of yin
  and yang Yin positive energy, Yang negative
  energy. To heal, the disharmony must be brought
  into harmony.
• Treatment include acupuncture, herbal teas,
  vegetable, spicy foods and burning incense.

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• Hispanic Health is a reward for good behavior, a
  gift from God.
• Illness represents either physiological imbalance
  or punishment for wrong doing.
• Imbalances may be viewed as hot or cold.
• Hot illnesses are treated with cold substances,
  and cold illnesses with hot substances.

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• Native Americans Health is living in harmony
  with nature.
• Sources of illness are caused by evil spirits,
  disharmony between positive and negative forces,
  and displeasure of holy people.
• Illness affects the persons spiritual as well as
  physical nature, and both must be treated.

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• African Americans Health is harmony with nature.
• Illness is viewed as a disharmony of the mind,
  body and spirit with nature.
• Prayer, laying of hands and home remedies (folk
  medicine) may be used for treatment.

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• German Americans Health is the ability to carry
  out responsibilities, enjoy life, and think and
  behave as expected.
• Illness is viewed as the result of infection,
  stress, or other physiological imbalances.
• Illness may also be viewed as punishment from
  God.

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TYPES OF HEALTH ASSESSMENTS

• COMPLETE HEALTH ASSESSMENT
• Military Entrance Exams
• Periodic (Readiness, Separation, Special
  Programs,
• Occ. Health Medical Surveillance)
• Admission
• EPISODIC (Acute Care)
• FOLLOW-UP or CHRONIC HEALTH PROBLEMS
• EMERGENCY PROBLEMS

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USE APPROPRIATE FORM

• 1. COMPLETE ASSESSMENT
• SF2807 Report of Medical Examination
• SF2808 Report of Medical History
• ADMISSIONS
• SHORT FORM (under 24 H)
• HX Part IV
• PROFILE
• 24 H Nursing Assessment
• 2. EPISODIC
• SF600
• 3. EMERGENCY (ETRs)

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AGE SPECIFIC CONSIDERATIONS
PEDIATRICS Interview parents or
guardians Observe Interactions and Parenting
Prenatal or Birth History Growth and
Development APGARs or
gestational age PRENATAL Current Health Risk
Factors Health Habits LMP, Gravida/Para
status GERIATRICS Physical Changes Health
status, Meds, Abilities Needs
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GENERAL SURVEY

• OBSERVATIONS DURING INTERVIEW
• Appearance
• Body Structure
• Mental Status
• Motor Activity (gait)
• Odors

• INTEGRATE AND CONSOLIDATE FINDINGS
• Whole patient
• Does Chief Complaint associate with observations?
• Specific problems lead to focused attention

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REVIEW OF PHYSICAL STATUS (Head to Toe)

GENERAL SURVEY SKIN HEAD NECK
CHEST ARMS ABDOMAN PELVIS LOWER
EXTREMITIES
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REVIEW OF PHYSICAL STATUS BY SYSTEMS

GENERAL ( HT, Wt, TPR, B/P, Mental
Health) NEUROMUSCULOSKELETAL LYMPHATIC
RESPIRATORY CARDIOVASCULAR
GASTROINTESTINAL URINARY REPRODUCTIVE

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VITAL SIGNS

• The most crucial skill learned by Corpsmen.
• Temperature
• Pulse
• Respiration
• Blood Pressure

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TEMPERATURE

• TERMINOLOGY
• Fever
• Febrile
• Afebrile
• Hypothermia
• Hyperthermia

• EQUIPMENT
• Clinical
• Glass (Blue/Red)
• Plastic Disposable
• Electronic
• Tympanic
• Patch or Tape

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PULSE

• TERMINOLOGY
• Tachycardia
• Bradycardia
• Thready
• Bounding
• Arrhythmia

• LOCATIONS
• Temporal
• Carotid
• Brachial Radial
• Femoral
• Popiteal
• Posterior Tibialis
• Dorsalis Pedis

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RESPIRATIONS

• TERMINOLOGY
• Inhalation
• Exhalation
• Dyspnea
• Apnea
• Tachypnea

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BLOOD PRESSURE

• EQUIPMENT
• Sphygmomonometer
• Manual
• Electronic
• Stethescope
• B/P by Palpation

• TERMINOLOGY
• Systolic
• Diastolic
• Hypotension
• Hypertension
• Perfusion
• Orthostatic Hypotension

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FACTORS THAT INFLUENCE VITAL SIGNS

• Exercise, Eating and Anger
• Rest and Depressions
• Some Medications
• Children have increased pulse and resps with
  lower B/Ps

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VITAL SIGN VALUES

• Temperatures
• Oral 98.6F/37C
• Rectal 99.6F/37.5C
• Axillary 97.6F/36.5C
• Tympanic 98.6F/37C

• Pulse
• 60-100 beats/min
• 100/min (infant)
• Respirations
• 12-20 breaths/min (adult)
• 20-40 breaths/min (child/infant)

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BLOOD PRESSURE VALUES

• 90 to 140 mm Hg
• 60 to 90 mm Hg

• SYSTOLIC
• DIASTOLIC

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ABNORMAL READINGS

• Repeat Abnormal Readings to rule out faulty
  technique
• ALWAYS notify provider
• CIRCLE Abnormal Readings in RED

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EXAM TECHNIQUES
ORDER OF USE 1. Inspection (see, hear,
smell) 2. Auscultation (naked ear first,
stethescope) 3. Percussion (tapping-tympany,
dullness, resonance) 4. Palpation (touch,
light to deep)
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RECORD FINDINGS

• Describe briefly and objectively.
• Use measurements (centimeters or millimeters)
• Use scales (reflexes, pulses, pain levels,
  strength)
• Use diagrams