For illnesses status of illness and dates past

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Unformatted text preview: Tuesday, September 06, 2005 Profile What are the 8 dimensions for Illnesses - status of illness and dates past medical history? Hospitalizations - status of illness and dates Surgeries - status of illness and dates Accidents/Injuries - status of illness and dates Gynecologic and obstetrical history - gravida ( number of pregnancies), para (number of births), aborta (number of abortions) Allergies - what happens Medications Immunizations What are the 5 dimensions for Demographics and Occupational History social history? Lifestyle - nutrition/diet, activities/exercise, tobacco, alcohol, recreational drugs Spirituality and Beliefs - FICA (Faith, Influence, Community, Address) Relationships - support system, marital or other (domestic violence) Sexual History Coulehan: p. 61 - 73 ot her act ive problems family hist ory availabilit y Coulehan: p. 74 - 94 social hist ory FICA SAFE Chronic conditions that may affect their current distress. The systematic exploration of the presence or absence of any disease in the patient's family t hat may influence the patient's health or risk of particular diseases. Includes hereditary diseases, familial illnesses (i.e. heart disease, diabetes, cancer), family traits (i.e. shortness), illnesses (i.e. manic depressive disorder, alcoholism), current illnesses (may suggest infectious process). An unusual illness that happens to occur in a family member is highly visible and available to t he patient. Therefore, it has a greater impact on his or her fears than we, as medical practitioners, might feel is justified. Attempts to learn something about the patient as a person. Often one of the most useful parts of an entire history is a detailed description of what the patient usually does on an ordinary day and exactly how this is modified by the illness. Spiritual Assessment Faith - do you consider yourself a spiritual or religious person? Influence - does this belief influence how you take care of yourself? Influence your behavior during illness? Community - are you part of a spiritual or religious community? Address - would you like me to address these issues in your healthcare? Detecting domestic violence Stress/Safety Afraid/Abused Friends/Family Emergency plan Coulehan: p. 113 - 127 4 levels of selection and interpretation when recording a history 1. Patient's experience - raw data, what happened 2. Conceptualization of the experience - how the patient organized the facts to construct a s tory (value & beliefs) 3. Clinical tale - story you generate by means of the clinical interview 4. Write-up - portions of history selected for written record What goes into the written record? Not just the facts 1. Patient’s experience, raw data, facts as they actually happened 2. Patient’s conceptualization of the experience; values & beliefs 3. Clinical tale: the story generated by the interview; reconstruct patient’s story in medical t erms 4. Select some of story as the “write up.” Be careful in what you write i...
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