Advanced Assessment

Essential to valid diagnosis is performing a __________.

List the components of History

What is the suggested format for History of present illness?

To determine the reason patient seeks care.
Important to consider using the patients terminolgy. Provides "title" or the encounter.

To provide a thorough description of the chief complaint and current problem. Suggested format: P-Q-R-S-T.

To identify factors that make symptom worse and/or better; any previous self-treatment or prescribed treatment , and response.

To identify patient's rating of symptoms (e.g., pain on 1-10 scale) and descriptors (e.g, numbness, burning, stabbing).

To identify the exact location of the symptom and any area of radiation.

To identify when the symptom's severity(e.g., how bad at its worst)and any associated symptoms(e.g., presence or absence of nausea and vomiting associated with chest pain).

To identify when complaint was first noticed; how it has changed/progressed since onset (e.g.,remained the same or worsened/improved)
whether onset was acute or chronic; whether it has been consant, intermittant or recurrent.

To identify past diagnoses, surgeries, hospitalizations, injuries, allergies, immunizations, current medications.

To describe any use of tobacco, alcohol, drugs and to identify patterns of sleep, exercise, etc.

To identify occupational and recreational activities and experiences, living environment, financial status

To identify potential sources of hereditary disease; a genogram is helpful; the minimum includes first degree relatives (parents, sibilings, children)although second and third orders are helpful.

To review a list of possible symptoms that the patient may have noted in each of the body systems