Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015

following tips may help:

Choose a quiet, private, well-lit interview setting away from distractions.

Introduce yourself; then ask the patient to sit down. Make sure the patient is comfortably seated. Explain to the patient that the purpose of the health history and assessment is to identify his or her problem and to provide information for planning care.

Speak slowly and clearly. Avoid using medical terms and jargon.

Listen attentively and use reassuring gestures to encourage the patient to talk.

Watch for nonverbal cues that indicate the patient is uncomfortable or unsure about how to answer a question. Make sure that he or she understands each question.

Ask Specific Questions

Asking the right question is a critical part of any interview. To obtain a complete health history, gather information from each of the following categories, in sequence:

Biographical data: name, address, phone number, date of birth, birthplace, sex, marital status, ethnic origin, occupation

Source of history: patient, family member, friend

Chief complaint: a brief statement by the patient describing the reason for seeking care

History of present illness: a chronological description of the present illness from the time of symptom onset

Current medications: prescribed and over-the-counter medications, herbal remedies, and supplements

Past medical history: childhood illnesses, accidents, injuries, hospitalizations, surgeries, blood transfusions, serious or chronic illnesses, obstetric history in females, immunizations, and allergies (drug, food, environmental, and latex)

Family history: health status or cause of death of immediate relatives

Psychosocial history: how the patient feels about self, his or her place in society, and relationships with others; coping strategies; feelings of safety, which may refer to physical, psychological, emotional, or sexual abuse issues

Activities of daily living: diet and elimination patterns; exercise and sleeping patterns; work and leisure activities; alcohol, tobacco, or illicit drug use; religious observances; and use of safety measures, such as seat belts, bike helmets, and sunscreen

Health maintenance: date of last examination or office visit with family physician, dentist, and optometrist; also, screening procedures and immunizations.

Review of Systems

The last part of the health history is a systematic review of each body system to make sure that important symptoms weren’t missed. The systems are reviewed from head to toe.

General health

Skin and hair

Head

Eyes, ears, and nose

Mouth and throat

Neck

Respiratory system

Cardiovascular system

Breasts

Gastrointestinal system

Urinary system

Reproductive system

Musculoskeletal system

Neurologic system

Endocrine system

Hematologic system

Emotional status

SELECTED REFERENCES

American Heart Association. (2005) . Guidelines 2005 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 112(Suppl 24), 1825–1852.

Baronski, S., & Ayello, E. A. (2012). Wound care essentials: Practice principles (3rd ed.). Philadelphia, PA : Lippincott Williams & Wilkins.

Bickley, L. S. (2013). Bates’ guide to physical examination and history taking (11th ed.). Philadelphia, PA: Wolters Kluwer Health. Colyar, M. R. (2003). Well-child assessment for primary care providers. Philadelphia, PA: F.A. Davis.

Hockenberry, M. J., & Wilson, D. (2011). Wong’s nursing care of infants and children (9th ed.). St. Louis, MO: Mosby-Year Book, Inc.

Kanwal, R., Kullman, G., Piacitelli, C., Boylstein, R., Sahakian, N., Martin, S., …, Kreiss, K. (2006). Evaluation of flavorings-related lung disease risk at six microwave popcorn plants. Journal of Occupational and Environmental Medicine, 48(2), 149–157.

Karasz, A. (2007). Cultural differences in the experience of everyday symptoms: A comparative study of South Asian and European American women. Culture, Medicine, and Psychiatry, 31(4):473–497.

Kovach, P. ed. (2013). Professional guide to diseases. (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Longo, D., Fauci, A., Kasper, D., & Hauser, S. eds. (2011). Harrison’s principles of internal medicine . (18th ed.). New York, NY : McGraw-Hill Book Co.

Pillitteri, A. (2014). Maternal and child health nursing: Care of the childbearing and childrearing family (7th ed.) . Philadelphia, PA: Lippincott Williams & Wilkins.

Porth, C. M., & Matfin, G. (2009) . Pathophysiology: Concepts of altered health states (8th ed.) . Philadelphia, PA : Lippincott Williams & Wilkins.

Relman, D. A. (2006). Bioterrorism—preparing to fight the next war. The New England Journal of Medicine, 354(2), 113–115. Schulmeister, L., & Holmes, G. B. (2008). Symptom management issues in oncology nursing. Nursing Clinics of North America, 43(2),

205–220.

Selwyn, A. P. (2007). Weight reduction and cardiovascular and metabolic disease prevention: Clinical trial update. American Journal of Cardiology, 100(12A), 33–37.

Spector, N., Connolly, M. A. , & Carlson, K. K. (2007) . Dyspnea: applying research to bedside practice. AACN Advanced Critical Care, 18(1), 45–58.

Index

A

Abdomen, quadrants of Abdominal aortic aneurysm

abdominal mass and abdominal pain and abdominal rigidity and back pain and

bruits and

Abdominal aortic atherosclerosis, bruits and Abdominal cancer

abdominal distention and abdominal pain and

Abdominal distention causes and findings detecting ascites emergency interventions

history and physical examination medical causes

patient counseling patient position

Abdominal mass causes discovery

emergency interventions

history and physical examination locations and causes

medical causes patient counseling structure

Abdominal pain

causes and findingst diagnostic procedure drugs

emergency interventions

history and physical examination listeriosis, during pregnancy medical causes

monitor, patient patient counseling types and locations

Abdominal rigidity emergency interventions

history and physical examination involuntary rigidity

medical causes patient counseling voluntary rigidity

Abdominal surgery, absent bowel sounds and Abdominal trauma

abdominal distention and abdominal pain and

Abnormal gag reflex. See Gag reflex abnormalities Absence seizures

Absence status Accessory muscles

diagnostic tests and treatments emergency interventions

history and physical examination locations and functions

medical causes patient counseling using activities

Achalasia, dysphagia and Achilles tendon reflex Acne vulgaris

papular rash pustular rash Acoustic neuroma

with corneal reflex and hearing loss tinnitus

vertigo

Acquired immunodeficiency syndrome (AIDS) anorexia and

chills and diaphoresis and with fatigue

lymphadenopathy and

mouth lesions Acrocyanosis, mottled skin and Acromegaly

diaphoresis and excessive weight gain

Acroparesthesia, and insomnia Actinomycosis

cervicofacial, mouth lesions productive cough and

Acute adrenal insufficiency, hypotension and Acute angle-closure glaucoma

eye pain and halo vision and headache and mydriasis and

nonreactive pupils and vision loss

Acute lymphocytic, lymphadenopathy and Acute renal failure, causes of

Acute respiratory distress syndrome (ARDS) accessory muscles and

anxiety and crackles and dyspnea and nasal flaring and

shallow respirations tachycardia tachypnea

Acute subdural hemorrhage, level of consciousness in Acute tubular necrosis (ATN)

anuria and oliguria and polyuria

Adenofibroma, breast nodule and Adenoid hypertrophy, and hearing loss Adenomyosis, dysmenorrhea and Adie’s syndrome

mydriasis and sluggish pupils

Adrenal carcinoma, with gynecomastia Adrenal crisis

abdominal pain and level of consciousness in

Adrenal hyperplasia, oligomenorrhea and Adrenal insufficiency

excessive weight loss nausea and

orthostatic hypotension and vomiting

Adrenal tumor, amenorrhea and Adrenocortical hyperplasia, amenorrhea and Adrenocortical hypofunction

amenorrhea and anorexia and

Adrenocortical insufficiency with fatigue tachycardia

Affective aura

Affective disorder, insomnia and Agitation. See also Anxiety

definition drugs

history and physical examination medical causes

patient counseling radiographic contrast media

Agranulocytosis

gum bleeding and throat pain

Airway obstruction accessory muscles and apnea and

dysphagia and nasal flaring and

stertorous respirations

Airway occlusion, nonproductive cough and Airway trauma, stridor

Alcohol abuse with confusion

with depression intoxication, diplopia and LOC caused by

toxicity, hypotension and Alcohol withdrawal syndrome

agitation and diaphoresis and with insomnia tremors

Alcoholic cerebellar degeneration, dysarthria and Alcoholic ketoacidosis, fruity breath odor and Alcoholism

anorexia and

orthostatic hypotension and Alkalosis, tremors

Allergic reaction edema of face and erythema and

Alzheimer’s disease amnesia and aphasia and dystonia and myoclonus and

Amaurosis fugax, vision loss Amenorrhea

classification drugs

history and physical examination medical causes

pathologic results patient counseling

radiation therapy and surgery Amenorrhea-lactation disorders Aminoglutethimide

Amnesia anterograde

causes and findings drugs

electroconvulsive therapy history and physical examination medical causes

organic

patient counseling

patient teaching techniques

temporal lobe surgery Amyloidosis

with hepatomegaly orthostatic hypotension and

Amyotrophic lateral sclerosis (ALS) accessory muscles and Babinski’s reflex

dysarthria and dysphagia and dyspnea and fasciculations and with hyperactive DTR muscle atrophy and muscle flaccidity and muscle spasms and muscle spasticity and muscle weakness and paralysis

shallow respirations Anal fissure, hematochezia and Analgesia

classification drugs

emergency interventions

history and physical examination medical causes

patient counseling prevention testing fori

Anaphylactic shock anxiety and hypotension and tachycardia tachypnea

Anaphylaxis

nasal flaring and stridor

urticaria wheezing

Anemia

bruits and

dizziness and with fatigue hypertension and

muscle weakness and pallor and

pruritus tachycardia

Anesthesia, and gag reflex abnormalities Angina/angina pectoris

anxiety and arm pain and

with atrial gallop chest pain and and jaw pain Ludwig’s

drooling and and jaw pain

Angiodysplastic lesions, hematochezia and Angioedema. See also Angioneurotic edema

hereditary, urticaria and Angioneurotic edema

characteristics edema of arm and

generalized edema and Angular gyrus

Anhidrosis classification drugs dysfunction in

emergency interventions

history and physical examination medical causes

patient counseling wrapping

Anhidrotic asthenia, anhidrosis and Ankylosing spondylitis

back pain and neck pain and

Anomic aphasia Anorexia

diagnostic procedures

drugs

history and physical examination medical causes

patient counseling patient malnourish radiation therapy TPN

Anorexia nervosa amenorrhea and anorexia and excessive weight loss fruity breath odor and oligomenorrhea and

Anterior cord syndrome analgesia and

Anterior tibial muscle, testing strength Anthrax

cutaneous fever and

headache and lymphadenopathy and

gastrointestinal abdominal pain and with diarrhea

fever and hematemesis nausea and

inhalation

chest pain and chills and dyspnea and fever and hypotension and

nonproductive cough and papular rash

pruritus stridor vomiting

Antipsychotics, opisthotonos and Anuria

definition