Health History

by; Ryan Rems Acain

The health history precedes the physical examination and involves interviewing the patient about his or her perception of his or her health status. The health history interview includes a broad range of questions so that possible problems associated with each of the systems of the abdomen may be identified. Information collected as part of the health history may uncover problems related to systems outside the abdomen like M.I.

A. Biographical Data
Gathering biographical information can provide valuable insights about the patient’s health status in several ways. Certain age groups are at greater risk for problems in the GI system. For example, infants and toddlers have a higher incidence of hernias than older children. Preschoolers are more likely to get parasitic infections, and teenagers may have abdominal symptoms as a result of pregnancy, sexually transmitted diseases (STDs),eating disorders like anorexia nervosa or bulimia. .Appendicitis occurs more frequently in children and teenagers than it does in adults. Older adults commonly develop problems with digestion, absorption, metabolism, and elimination because of changes caused by the aging process. Women aged 65 and over are commonly diagnosed with hiatal hernia, constipation, and diverticulosis. The potential for exposure to environmental and occupational hazards can also be discovered in the biographical data. Where a person lives or works may raise questions about environmental hazards such as lead exposure in children (from inhalation of lead-based paint dust in older houses) or occupational health hazards such as chemical exposure (arsenic, benzene).

B. Chief Complaint:
The most common abdominal complaints—pain, changes in weight, changes in bowel habits (constipation, diarrhea), indigestion, nausea, and vomiting—are analyzed using the PQRST format. The nature and intensity of the symptoms dictate the order and extent of questioning during the symptom analysis.

1. Abdominal Pain The most common complaint related to the abdomen, pain is often classified as visceral, parietal, or referred. Visceral pain results from distension of the intestines or stretching of the solid organs. It is often described as burning, cramping, diffuse,

Pancreatitis.and poorly localized. especially after a meal. Patients with a hiatal hernia may complain of substernal chest pain and difficulty breathing. ■ Pain in scapula: Cholelithiasis. Pain Location The location of the pain is often diagnostically significant. unhealthy lifestyles. A careful analysis of this symptom provides data that allow the nurse to distinguish between medical and behavioral problems causing the weight change. MI. Weight Change Weight change may indicate diseases in many body systems. ■ Pain in lower and middle back: Abdominal aortic aneurysm. and eating disorders. .4 kg) within 48 hours result from fluid changes. so chest pain can indicate either an abdominal problem or a cardiac event. neck. Note location of pain by quadrant orregion: ■ Pain in shoulder: Ruptured spleen. congestive heart failure with fluid retention. Vital signs provide information about the possibility of cardiac irregularities and reveal symptoms of shock and signs of an infectious process such as peritonitis. Patients with a gastric ulcer can have pain in the upper epigastric region left of midline. Patients with gastro-esophageal reflux disease (GERD) may have chest pain that radiates to the back. For instance. pancreatitis. Acute abdominal pain (“acute abdomen”) may indicate a life-threatening abdominal condition that requires immediate medical intervention. or jaw. localized. pain in the umbilical region may indicate an abdominal aortic aneurysm or early appendicitis. Weight changes of 2 to 3 lb (1 to 1. which is also the location for angina and MI. we need to prioritize the symptom assessment questions to elicit the most essential information. genitals. Referred pain is felt at a site away from the site of origin.which also mimics an MI. Parietal pain results from inflammation of the parietal peritoneum. metabolic or endocrine disorders. angina. we should assess the patient’s vital signs to determine whether she or he is in imminent danger. Unexplained weight loss in an adult should raise suspicions of underlying malignancy. reflect unhealthy behaviors. cancer. biliary colic. ■ Pain in thighs. Weight changes can be a sign of GI disease. Recognizing the relationship between the location of the pain and the possible health problem has important implications for immediate nursing assessment and care of the patient. major depressive disorder. The pain is usually severe. ectopic pregnancy. 2. or even reveal a normal state such as pregnancy. ureteral colic. and aggravated by movement. In addition. Some disorders have classic signs located in specific regions of the abdomen. Impulses from the internal organs and structures that share nerve pathways inside the central nervous system explain the nature ofreferred pain. lower back: Renal problems. In this situation. Abdominal problems may also cause referred pain to the chest.

3.medications. GERD has heartburn as its chief symptom. but the epigastric dis. and reactions to medications. first establish a baseline by asking general questions about bowel habits. inner ear problems. Indigestion Indigestion—also called dyspepsia or pyrosis—is a frequent abdominal complaint that is usually described as “heartburn. Diarrhea (frequent loose bowel movements) can have a variety of causes:diet. 5. such as straining. 4. Nausea Nausea is caused by stresses on the stomach wall or esophagus. bloody: Lower GI bleeding. such as malabsorption disorders. Distension. as well as nonGI disorders. Vomiting . constipation. ■ Clay colored: Increased bile in obstructive jaundice. Bowel patterns range from two movements per day to two or three per week. irritable bowel syndrome. causing the burning sensation. To determine whether a patient is having health problems that affects bowel functio . cancer. Acid from the stomach flows into the lower esophagus. 6. lasts longer. irritable bowel syndrome. Identify the color of the stool: ■ Black. bacterial. negative olfactory stimulation. food intolerance. and has more severe symptoms than indigestion.tress occurs more frequently. or medications can also cause nausea. or diarrhea?”Then ask more specific questions to help identify the origin of the problem. tarry: Upper GI bleeding.”This burning sensation is usually worse after eating a meal. Heartburn is also a common complaint in both gastric ulcer and duodenal ulcer disease and gallbladder disease. Indigestion associated with belching (eructation) and flatulence suggests cholecystitis. ■ Red. infections (viral. pain. and medical problems such as ulcerative colitis. Change in Bowel Patterns Alterations in bowel movements are associated with a variety of GI disorders. parasitic). and Crohn’s disease. Indigestion that increases when the person is lying flat may indicate a hiatal hernia or GERD. alterations in peristalsis.Many GI medical conditions have nausea as an assessment finding. viral or bacterial infections. such as: “How often do you have bowel movements? Do you have any problems with your bowels.

■ Surgical procedures increase risk for adhesions. and head injury. and if so. injuries. ■ Do you have sickle cell anemia? Hospitalizations ■ Have you ever been hospitalized for GI problems? ■ Have you ever had any GI diagnostic tests? Surgeries ■ Have you had any of the following. ■ Did you have malabsorption diseases? ■ Did you have an eating disorder? ■ May indicate celiac disease (impaired GI absorption related to wheat and rye ingestion). infections. such as an ■ Present symptoms may relate to previously diagnosed condition. ■ Abdominal pain is associated with sickle cell crisis. and appendicitis.A person with repeated vomiting is always at risk for fluid and electrolyte problems. or distension. C. trauma. peptic ulcer. stimulation of the vomiting center in the brain (medulla). immunizations. and faulty vitamin absorption. . viral or bacterial infection. when? ■ Abdominal surgery.During vomiting. ■ May indicate a pattern of GI problems or risk for developing megacolon. allergies. and medications that can affect the abdominal structures. Some GI conditions that cause vomiting are intestinal obstruction. ■ Eating disorders often begin during adolescence and continue into adulthood. RISK FACTORS/QUESTIONS TO ASK Childhood Illnesses ■ Did you have chickenpox (varicella)? RATIONALE/SIGNIFICANCE ■ Did you have digestive problems? ■ Varicella always precedes herpes zoster or “shingles” (vesicular rash on lower aspect of rib cage in hypochondriac regions of the abdomen). Past Health History This section of the health history involves asking questions about childhood and adult illnesses. peristalsis is reversed and the esophageal sphincter opens to allow the contents of the stomach to be ejected. Remember to document specific dates in the patient’s record.The involuntary emptying of stomach contents is caused by irritation of the stomach lining caused by chemicals. obstructions. hospitalizations.

abdominal pain or pressure. and ■ Do you have inflammatory bowel disease (Crohn’s disease)? ■ Hypertension? ■ Heart disease? ■ HIV or acquired immunodeficiency syndrome (AIDS)? ■ Diabetes? . ■ Blood transfusions? ■ Recent insertion of GI tubes? Serious Injuries ■ Have you had recent trauma. ■ HIV patients are at high risk for developing Kaposi’s sarcoma of the abdominal organs. ■ Cancer in one site in the body may spread to other locations. ■ High risk for developing colorectal cancer. often present with indigestion.appendectomy? ■ Rule out appendix as origin of current abdominal problem. Serious/Chronic Illnesses ■ Have you had cancer? ■ Hemorrhage is a danger. and nausea and vomiting. ovaries. or sports injury? ■ Can injure organs such as the spleen. colon. ■ Hepatitis and human immunodeficiency virus (HIV) are transmitted via blood. including angina and MI. abdominal pain. ■ Assess signs and symptoms of infection. ■ Right-sided heart failure increases systemic venous pressure. and weight loss. which causes spleen and liver enlargement and GI complaints. and uterus is often associated with abdominal complaints.workplace injury. ■ Cardiac problems. pancreas. such as auto accident. intestines. spleen. ■ Cancer of the stomach. The liver is a common site for cancer metastasis. including changes in bowel habits. infections. ■ Increases risk for infection. ■ Increases risk for abdominal aortic aneurysm. ■ Symptoms may develop hours or days after an accident.

weight loss. D.Then you can help the patient plan lifestyle changes that will help prevent those diseases and promote health. Symptoms of food allergies range from GI upset with diarrhea and vomiting to hives to life-threatening anaphylaxis. such as nutritional supplements. chocolate. and laxatives? ■ NSAIDs and aspirin increase the risk for GI bleeding. increase the risk of colon cancer. what are you taking. such as anorexia. Opioids. ■ Antiviral agents used to treat HIV have side effects that compound these problems. ■ Many medications have GI effects. antacids. ■ Note dates of all immunizations. RISK FACTORS/QUESTIONS TO ASK Genetically Linked Gastrointestinal Conditions ■ Do you have a family history of colorectal cancer? RATIONALE/SIGNIFICANCE ■ Some colorectal conditions. ■ Overuse of laxatives may contribute to bowel problems. ■ Discuss need for other primary prevention activities. wheat. Patients over age 35 with a family history of FAP should be screened with FOBT and endoscopic assessment of .Family History Questioning about diseases in the patient’s family enables you to identify those that the patient may be at risk for because of genetic predisposition. Milk (lactose intolerance). and shellfish are common food allergens. peanuts.Immunizations ■ Have you had hepatitis A or B series immunizations? Allergies ■ Do you have allergies to any medications or foods? Medications ■ Are you currently taking any medication? If so. psychiatric medications. and iron supplements cause constipation ■ Are you taking any OTC medications. antihistamines. ■ Diabetes can result in gastroparesis. and what are the dosages and frequencies? multiple GI problems. ■ Note all allergens and responses. such as familial adenomatous polyposis (FAP). and cachexia.

and reduced pancreatic functioning. oats).. wheat. ■ Alcoholism has severe GI consequences. ■ One of several factors contributing to aneurysm formation is a genetic link. ■ Cystic fibrosis is a life-threatening. ■ Stress high-fiber. pancreatic enzyme deficits. genetically transmitted disease that usually occurs in infancy and causes severe respiratory problems. low-fat diet to minimize risk of colorectal cancer. ■ Assess abdominal vasculature for signs of abdominal aneurysm. Tell patients about the availability of genetic testing. leading to digestive difficulty. ■ Do you have a family history of colorectal cancer? Absorption Disorders ■ Do you have a family history of celiac disease (also called nontropical sprue and gluten-sensitive enteropathy)? ■ Do you have a family history of cystic fibrosis? Familial/Genetically Linked Disorders With Gastrointestinal Symptoms ■ Do you have a family history of alcoholism? ■ Do you have a family history of aneurysm? ■ Do you have a family history of GI cancers? ■ Assess colorectal cancer in family and polyps that may precede some types of colon cancer. Results in malabsorption of nutrients in small intestine.g. rye. ■ Do you have a family history of sickle cell disease? ■ Sickle cell disease is an inherited autosomal recessive disorder caused by a genetic aberration in hemoglobin A. ■ Vaso-occlusive crisis (“sickle cell crisis”) may cause severe abdominal pain.colon. ■ Teach about diet free of cereal glutens Inflammatory Bowel Disorders . ■ Genetic susceptibility exists for this sensitivity to the protein from cereal grains (e. ■ Family history of GI cancer increases risk of cancer. ■ Teach preventive activities and recommended cancer screening procedures.

■ Type 1 (insulin-dependent diabetes mellitus [IDDM]) is an autoimmune disorder that occurs more frequently in children whose parents. ■ Both genetic and environmental factors may contribute to obesity .which is an important risk factor for many serious diseases. ■ Do you have a family history of obesity? ■ Type 2 (non–insulin-dependent diabetes mellitus [NIDDM]) occurseven more frequently in children whose parents have the disease.■ Do you have a family history of Crohn’s disease or ulcerative colitis? Metabolic Disorders ■ Do you have a family history of diabetes mellitus? and lactose. Psychosocial Profile The psychosocial profile describes our patient’s lifestyle and habits. Regular flossing reduces the risk of . and copes with the stresses of every day has an impact on the health of the GI system. and teach proper nutrition and lifestyle changes to family. abdominal pain. have IDDM. explore desire for weight reduction. rests. ■ Teach patients about increased risk for colorectal cancer with Crohn’s disease and ulcerative colitis and importance of havingregular cancer screening exams. How our patient eats. ■ Do you have a family history of porphyria? E. and neurological and psychological problems. vomiting. exercises. ■ Porphyria is a relatively rare type of anemia that causes nausea. CATEGORY/QUESTIONS TO ASK Health Practices and Beliefs/Self-Care Activities ■ When was your last dental exam? RATIONALE/SIGNIFICANCE Good dentition is required for proper mastication and digestion of food. especially the father. Assess family eating and exercise patterns.

and ascites in abdomen. Screens for eating disorders. fluid retention. stress level. ■ Immobility contributes to constipation.infection. and eating disorders such as anorexia nervosa. Have you ever had: ■ Your stool tested for occult blood? ■ An endoscopy? ■ Women: When was your last gynecologic examination? ■ Men: Have you ever had a prostate examination or prostate-specific antigen test? Typical Day ■ How do you usually spend your days? Recommended screenings include: ■ Men after age 40: Digital rectal and prostate examination annually. Assesses eating patterns and nutritional knowledge. ■ Men and women after age 50: Baseline endoscopy. Weight loss is associated with longstanding diarrhea. cancer. Assesses usual dietary intake. ■ Has your daily pattern changed? Nutritional Patterns ■ What have you eaten in the past 24 hours? ■ Are you on a special diet? ■ Are you concerned about your weight? ■ Have you lost your appetite? ■ Who prepares your meals and does the food shopping? ■ Have you lost weight? May indicate cancer. ascites. depression. then every 5 to 10 years depending on results and history. Improper food preparation and cooking puts patient at risk for salmonella and other infections. such as colitis and gastric ulcers. Reflects energy expenditure and stressors that exacerbate GI problems. ■ Exercise expends calories and strengthens abdominal muscles. ■ Have you gained weight? Activity and Exercise Patterns ■ Do you have any mobility problems? ■ Do you exercise regularly? What do you do and h often? ■ Pregnant patients should avoid . which facilitates elimination. ■ Women: Gynecologic/rectal examination annually. Pattern changes indicate how abdominal problem affects life and what adjustments patient has made.

Recreation/Pets/Hobbies ■ Do you have any pets? If so. how much? ■ Alcohol can damage the GI tract. Personal Habits ■ Do you drink alcohol? If yes. vomiting. and with chronic abuse. and hiatal hernias may interfere with falling asleep. ■ IV drug use and reused tattoo or bodypiercing needles put patient at risk for hepatitis and HIV. ■ Smoking increases risk for mouth.such as Escherichia coli and hepatitis. ■ Indigestion. ■ Assess whether pain or abdominal symptoms awaken patient from sleep. ■ Establishes baseline sleep schedule. ■ How old is your home? ■ Older homes may contain lead-based paint. GERD. and other GI symptoms. ■ Farmers may be exposed to insecticides or leaded gas (used in farm machines). which cause diarrhea. ■ Careless personal hygiene increases risk for infections. throat. what? ■ Are you responsible for animal care? ■ What are your hobbies? Sleep/Rest Patterns ■ What is your usual sleep pattern? ■ Do you ever awaken with indigestion? handling cat feces to prevent infection with toxoplasmosis. putting young children at risk for . and GI cancer. create vitamin deficiency states. cause cirrhosis and esophageal varices. ■ Public water may also contain chemicals that cause abdominal and neurological complaints. lung. Handwashing is most important preventive measure. which increase risk of GI problems.inhaling model airplane glue causes kidney problem. ■ Do you use tobacco? ■ Do you use street drugs or share IV needles? ■ Do you have body piercing or tattoos? ■ Do you wash your hands after using the bathroom preparing food? Environmental Health Patterns ■ Where do you live? ■ Do you have public water or well water? ■ Wells may be infected with microbes such as Giardia or Cryptosporidium. ■ Hobbies may involve toxic substances. For example. chewing tobacco increases risk of mouth cancer.

F. SYSTEM/NORMAL FINDINGS General Health Survey ■ Do you have changes in your energy level? Weakness? A general feeling of ill health? ■ Do have fever or chills? ■ Have you been sweating? ■ Do you have pain with movement or inability to perform daily activities? ABNORMAL FINDINGS/RATIONALE ■ Fatigue or weakness may reflect poor nutritional state. So be sure to keep an open mind about the nature of the patient’s health problem and not conclude that it lies in the GI system simply because he or she has abdominal complaints. jaundice. The problem in another body system depends on which organ of the abdomen is involved. we may uncover medical illnesses that have abdominal symptoms. and fluid in the abdomen. ■ Stress exacerbates ulcers and colitis. Another reason is that the ROS might reveal that the primary health problem does not originate in the abdomen. For example.■ Are you exposed to insects or parasites? lead poisoning. Instead. This is one reason why taking a careful review of systems (ROS) is so important. acute lead poisoning has symptoms of colicky abdominal pain and constipation or diarrhea. ■ Difficulty with changing positions may . ■ Sweating may indicate infection. bruising. nausea and vomiting. Review of Systems A disruption in the systems contained in the abdominal cavity can cause problems in many other areas of the body. Instead. ■ Fever or chills are seen with infections. or thyroid disturbances. Chronic lead poisoning is associated with appetite loss. ■ Malaise is commonly associated with GI diseases. anemia related to blood loss in the GI tract. liver problems may cause malaise. ■ Explore what patient perceives as stressful and identify adaptive and maladaptive coping strategies. or vitamin B12 deficiency. ■ Black widow spider bites cause abdominal pain. Stress and Coping ■ How do you deal with anger and stress? ■ Tapeworms and other parasitic intestinal worms cause abdominal symptoms. female hormonal changes. assess each system methodically until we have collected all the data.

■ Dizziness is a sign of Ménière’s disease. ■ Have you noticed any neck masses. swollen nodes. can cause spleen enlargement. ■ History of goiter (hypothyroidism) may be related to iodine deficiency in diet. and diarrhea. ■ Icteric sclera are seen with liver disease. ■ Jaundice is associated with liver disease. cramping.Integumentary Skin ■ Do you have any rashes? indicate musculoskeletal problems. ■ Other rashes may reflect reactions to an antibiotic. ■ Infections. pain. such as strep throat. ■ Associated with liver disease. or stomach. or an infection in the abdomen. ■ Complaints of pruritus or pain along a dermatomally distributed vesicular rash located on the lower aspectsof the rib cage indicates herpes zoster (shingles). which may also cause pain. ■ Do you have itching? ■ Have you noticed any skin color changes? ■ Do you have any swelling (edema)? HEENT Head/Neck ■ Have you had a recent head injury? ■ Can be related to projectile vomiting. often cause abdominal discomfort. such as mononucleosis. or may be caused by . ■ Weight loss or gain is associated with thyroid problems. which impinge on respiratory structures. ■ Inability to carry out daily activities indicates the severity of the abdominal problem. or thyroid problems? Eyes/Ears ■ Have you seen any changes in the whites of your eyes? ■ Do you have ear or balance problems? Nose/Throat ■ Do you have difficulty swallowing? ■ May be a sign of esophageal mass. which causes nausea. ■ Ascites is associated with liver disease and edema with renal disease. esophagus. ■ Infections. muscular or neurological problems. ■ Do you have a sore throat or fever? Respiratory ■ Dyspnea may be caused by edema in the abdomen or large tumors of the liver. or benign diagnoses. nausea.

orange. ■ Cardiac disease often mimics GI complaints. ■ Patients with chronic obstructive pulmonary disease(COPD) often have right-sided heart failure that may cause liver enlargement. ■ After menopause.■ Do you have any difficulty breathing? portal hypertension from liver congestion. glomerulonephritis. Congestive heart failure can cause liver enlargement and ascites. ■ Pain associated with a pulsating mass may indicate an abdominal aortic aneurysm. which in turn may affect the GI system. ■ Unprotected sex increases the risk for STDs for both men and women. ■ May indicate vaginal infection that could lead to PID. Blood in the urine is caused by renal calculi. . urgency. frequency. ■ Arthritis and osteoporosis are extraintestinal complications of ulcerative colitis. bleeding may signal a gynecological problem. ■ Amenorrhea may indicate an eating disorder such as anorexia nervosa. ■ Do you have any respiratory problems? Cardiovascular ■ Do you have cardiovascular disease such as congestive heart failure? ■ Do you have pain and pulsations in your navel or back? Genitourinary ■ What color is your urine? ■ Dark yellow. renal infarct. or brown urine can be caused by excessive breakdown of RBCs or liver problems. ■ Do you have burning. or pyelonephritis. or blood in your urine? Female Reproductive ■ When was your last menstrual period? ■ Do you have any vaginal discharge or itching? Male Reproductive ■ Do you have a discharge from your penis? ■ Do you practice safe sex? Musculoskeletal ■ Penile discharge is related to sexually transmitted diseases (STDs). ■ Difficulty starting urine stream or urinary hesitancy indicates possible prostate disease in men. ■ Urinary tract infections can cause flank pain and CVA tenderness. ■ Important to rule out pregnancy in women of childbearing age.

Immunologic/Hematologic ■ Do you have food allergies? ■ Do you have HIV/AIDS? ■ May cause GI tract pain and changes in bowel habits. ■ Patients with AIDS have problems maintaining their weight. CASE STUDIES APPROACH. Nursing Health Assessment: A CRITICAL THINKING.■ Do you have joint pain? Have you had any broken bones? ■ Do you have rheumatoid arthritis? Neurological ■ Do you drink alcohol? How much? ■ Splenomegaly is associated with rheumatoid arthritis. ■ A deficiency of vitamin B1 (thiamine) may present with numbness or paresthesias in the extremities and is commonly seen in alcoholics and people with long-standing diarrhea.M. appetite. herniated disk. P. A. numbness. polyuria. ■ Loss of bowel and bladder control can occur with disk problems. and polydipsia. ■ Do you have back problems. Source: Dillon. ■ Risk of an enlarged tender spleen.(2007). (2nd Edition). ■ Do you have mononucleosis? ■ Do you have sickle cell anemia? ■ Often causes abdominal pain. F. or loss of bowel and bladder control? Endocrine ■ Do you have diabetes or thyroid disease? ■ Diabetes can result in gastroparesis. and bowel patterns. Davis Company . ■ Thyroid disease can affect weight. such as cauda equina syndrome.

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