NUR 816 Lecture Notes - Lecture 2: Rheumatic Fever, Pap Test, Pertussis
Document Summary
Source of history or referral: (e. g. client, family friend, officer, and consultant) Reliability: the client is consistent about the description of her/his symptoms but vague about when began. Chief complaints (when possible in client"s own words) Present illness: chronological account of the problems for which is seeking care. Measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever, polio. Medical - diabetes, hypertension, hepatitis, asthma, hiv disease. Hospitalization - surgical - include dates, indication and outcome. Obstetric/ gynaecological - menstrual history and obstetrical history, birth control, number and gender of partners, at risk practices. Accidents, injuries and transfusions - include dates, diagnoses, hospitalizations, treatments. Ask about coffee, tea and other caffeine containing beverages. Age, health, cause of death of each immediate family member. Note any: diabetes, heart disease, hypercholesterolemia, high bp, stroke, kidney disease, Tb, cancer, arthritis, anemia, allergies, asthma, headaches, epilepsy, mental illness, alcoholism, drug addiction, and symptoms like those of client.
