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Unformatted text preview: Tuesday, September 06, 2005
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
What are the 5 dimensions for
Demographics and Occupational 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)
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
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.
Faith - do you consider yourself a spiritual or religious person?
Influence - does this belief influence how you take care of yourself? Influence your behavior
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
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
4. Select some of story as the “write up.”
Be careful in what you write i...
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This note was uploaded on 09/19/2013 for the course MEDICINE All taught by Professor Johnsmith during the Fall '12 term at Eastern Virginia Medical School.
- Fall '12