During a health history assessment, where is the symptoms description/narrative typically documented?
Review of Systems
Chief Complaint
History of Present Illness
Past Medical History
The Correct Answer is C
Choice A Reason:
The Review of Systems (ROS) is a systematic approach for collecting the patient's self-reported data on all body systems. It is not typically where the narrative of symptoms is documented. Instead, the ROS is used to uncover symptoms the patient may not have mentioned during the initial recounting of their history.
Choice B Reason:
The Chief Complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, or other factors that are the reason for the encounter, usually stated in the patient's words¹. While it does include the symptom prompting the visit, it is not the section where a detailed narrative or description of symptoms is provided.
Choice C Reason:
The History of Present Illness (HPI) is indeed where the detailed narrative of the patient's symptoms is documented. It includes the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date. The HPI tells the story of the patient's chief complaint and provides context for the clinical reasoning process.
Choice D Reason:
The Past Medical History (PMH) includes information about the patient's past experiences with illnesses, operations, injuries, and treatments. It does not contain the current symptoms' narrative but rather the patient's health status before the present illness or concern.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Acute pain is typically sudden in onset and is usually the result of a specific injury or illness. It is characterized by its sharp quality and tends to last for a short duration, generally not longer than six months. Since the patient's knee pain has persisted for eleven months, it does not fall under the category of acute pain.
Choice B reason:
Intermittent pain is pain that comes and goes at intervals. Although the patient's pain could be intermittent, the classification based on duration would not be described as intermittent. This term refers more to the pattern of the pain rather than its chronicity or cause.
Choice C reason:
Chronic pain is defined as pain that persists for longer than six months, often continuing even after the injury or illness that caused it has healed. The patient's bilateral knee pain has been present for eleven months, which exceeds the six-month threshold, thus categorizing it as chronic pain.
Choice D reason:
Idiopathic pain refers to pain that arises without a clear cause. It is not categorized based on the duration of the pain but rather on the absence of an identifiable underlying reason. Since the patient's pain has a specific duration, it is not appropriate to classify it as idiopathic without further information regarding its cause.
Correct Answer is B
Explanation
Choice A reason:
Discussing reactions to allergens typically focuses on environmental or food triggers that may cause allergic reactions. While it's important to understand a client's allergies, this topic is not closely related to alcohol use, which has different implications for health and lifestyle choices.
Choice B reason:
Asking about alcohol use naturally follows the discussion about cigarette smoking because both involve substance use and have potential health risks. It allows the nurse to transition smoothly from one lifestyle factor to another, which can impact the client's overall health. This approach also helps in creating a comprehensive picture of the client's habits that may contribute to or affect their current health status.
Choice C reason:
Reviewing current medications is an essential part of the health history, as it can reveal potential interactions with alcohol. However, it might be more appropriate to ask about alcohol use after discussing other lifestyle habits such as smoking, as they are more directly related. Once the client's substance use habits are established, the nurse can then discuss how these might interact with prescribed medications.
Choice D reason:
Asking about previous surgeries is important for understanding a client's medical history, but it is not directly related to the client's current lifestyle habits like alcohol use. Therefore, it would be more natural to ask about alcohol use in the context of other substance use discussions rather than after surgical history.
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