HSCI 201 Lecture Notes - Lecture 1: Brachioradialis, Vital Signs, Respiratory Rate
26 Mar 2017
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Comprehensive history for adults (record date/time)- make sure to list things as subjective or objective: identifying data: age, gender, occupation, marital status, source of history: patient (usually), family, friend, medical record. Establish source of referral if needed: reliability: depends on patient"s memory, mood, and trust, chief complaint: symptoms/signs causing them to seek care, present illness: how symptoms developed, thoughts/issue about illness, setting in which issue developed, any treatment. Medications (name, dose, route, frequency of use) Tobacco, alcohol, and drug use: past history: Medical (diabetes, hiv, cancer, asthma: dates of onset, hospitalizations and dates, number of sex partners (including gender and risky sex behaviors) Obstetric and gynecological (menstrual history and birth control, and sexual function) Psychiatric (illness, timing, diagnoses, hospitalizations, treatments, and medications) Home safety: family history (immediate relatives: grandparents, siblings, parents, children and grandchildren) as present or absent in diseases listed. Age, health, cause of death: personal and social history.
