HISTORY COLLECTION.docx
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This document contains sections for collecting a patient's medical history including identification data, chief complaints, present medical history, past medical history, family history, menstrual/obstetric history, lifestyle, social history, investigations, treatment, and a head-to-toe physical examination. The physical examination section includes assessments of multiple body systems such as cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and neurological through inspection, palpation, percussion, and auscultation techniques. The document aims to comprehensively document all relevant medical information for a patient.
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In this topic the student will be easily learn about how to collect history from the patient and also helpful nursing students to write their care plan and care study.
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The document discusses a seminar presentation about history collection and physical assessment. It covers key terminology, the importance and components of collecting a patient history, and the definition, principles, preparation, techniques, and components involved in performing a physical assessment. The presentation provides an overview of best practices for nurses to obtain comprehensive information about a patient's health status through thorough history collection and physical examination.
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In this topic the student will be easily learn about how to collect history from the patient and also helpful nursing students to write their care plan and care study.
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3. A thorough history should explore the patient's presenting complaints, history of present illness, investigation and treatment details, past medical history, personal history, and family history in order to understand how their illness started and progressed and arrive at the most likely diagnostic possibilities based on
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The patient presented with prolonged fever of unknown origin. His fever pattern was fluctuating and did not reach baseline, suggestive of a remittent fever. His history revealed no exposure risks, localized infections, or symptoms to suggest infectious, inflammatory, or malignant causes of fever. On examination, he had no abnormal findings except for mild splenomegaly. Differential diagnoses included viral infections, infective endocarditis, and lymphoma. Further investigations were needed to determine the cause of his prolonged, remittent fever.
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NameDateSexAgeDOBPlace of BirthSUBJECTIVEH.docx
Name:
Date:
Sex:
Age/DOB/Place of Birth:
SUBJECTIVE
Historian:
Present Concerns/CC:
Reason given by the patient for seeking medical care “in quotes”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)
HPI: (must include all components)
Medications: (List with reason for med )
PMH:
Allergies:
Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations:
Family History (Please identify all immediate family)
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS
General
Cardiovascular
Skin
Respiratory
Pediatric SOAP Note
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight
Temp
BP
Height
Pulse
Resp
General Appearance and parent‐child interaction
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
In-house Lab Tests – document tests (results or pending)
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment)
Diagnosis
· Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)
· Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives
· Primary diagnosis
· Is #1 on list of differentials
· Evidence for primary diagnosis should be supported in the Subjective and Objective exams.
PLAN including education
· Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.
· Include EB rationale for all aspects of your treatment plan:
· Vaccines administered this visit
· Vaccine administration forms given
· Medication-amounts and mg/kg for medications
· Laboratory tests ordered
· Diagnostic tests ordered
· Patient education including preventive care and anticipatory guidance
· Non-medication treatments
· Follow-up appointment with detailed plan of f/u
*ALL references must be Evidence Based (EB)
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The document provides guidance on how to conduct a thorough patient history, including how to structure the history taking session and how to approach each component of the history. It discusses taking the chief complaint, history of present illness, past medical history, drug history, family history, and social history. For each component, it provides tips on what information to obtain and how to record it in the patient's own words. It also describes doing a review of all body systems to check for any associated symptoms.
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HISTORY COLLECTION.docx
- 1. HISTORY COLLECTION IDENTIFICATION DATA Name age sex marital status occupation Religion Address Health care financing Family income/monthly income Educational qualification Language I.P.NO Bed no. Date of admission CHIEF COMPLAINTS
- 2. PRESENT MEDICAL HISTORY Onset Signs and symptoms Duration Treatment taken Other complaints PAST MEDICAL HISTORY Child hood illness: Allergies Medical diseases-HTN, DM, anemia etc. Accidents & injuries Surgery –any history of surgery Hospitalization-any hospitalization in the past PAST SURGICAL HISTORY FAMILY HISTORY Family tree MENSTRUAL HISTORY Age of menarche Duration of cycle
- 3. Amount Type of flow Association of pain MARITAL HISTORY Duration of married life Consanguinity Marital relationship Use of contraceptives OBSTETRIC HISTORY LIFE STYLE Personal habits Diet Sleep and rest pattern Activities of daily living Reaction or hobbies SOCIAL HISTORY patterns to quality of family relationship/friendships, Educational background Occupational history
- 4. Economic status Type of house Neighborhood conditions INVESTIGATIONS TREATMENT
- 5. PHYSICAL EXAMINATION General Weight Hight Vital signs B.P Temperature Pulse Respiration HEAD TO FOOT EXAMINATION HEAD Scalp Dandruff Hair distribution Face Eyes Eyebrows Eye lid
- 6. Conjunctiva Eye bolls Sclera Vision activity Ears External ear Ear canal Ear drum Hearing activity Nose Nose bleeding Nose obstruction Nasal septal deviation Nose bleeding Mouth Dental difficulties Gingival bleeding Dentures
- 7. Neck Neck stiffness Pain Tenderness, Masses in thyroid gland Chest CARDIO VASCULAR SYSTEM Substernal distress Palpations Syncope Dyspnea Orthopnea SOB Edema, cyanosis Hypertension Heart murmurs Varicosities Phlebitis
- 8. Inspection Palpation Percussion auscultation RESPIRATION SYSTEM Shortness of breath, wheezing, Stridor, Cough Hemoptysis Respiratory infection Tuberculosis Fever or night sweats Inspection Palpation Percussion auscultation GASTROINTESTINAL SYSTEM
- 9. • Appetite • Dysphagia • Indigestion • Abdominal heart burn • Nausea • Vomiting • Hematemesis • Jaundice • Diarrhea • Abdominal stools • Hemorrhoids • Recent changes in bowel habits • Inspection • Palpation • Percussion • auscultation GENITO URINARY SYSTEM Urgency
- 10. Frequency Dysuria Hematuria Polyuria Color of urine Stones Infections Incontinence Libido Venereal disease Inspection Palpation Percussion auscultation MUSCULO SKELITAL SYSTEM Pain Swelling Redness or heat of muscles
- 11. Crams Neurological system Convulsions Paralysis Tremor Incoordination Parathesias Sensory Nervousness Emotional problems Anxiety Depression Hallucinations Inspection Palpation Percussion auscultation IMMUNOLOGICAL SYSTEM
- 12. Reaction to the drugs Food Insects Skin rashes Trouble breathing Previous transfusions and reactions Inspection Palpation Percussion auscultation Extremities Upper extremities Lower extremities Genitalia Rectum Vagina Labia majora Labia minora