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What is a Health History?
â–ª You would want to ask about subjective data using communication
strategies, ask reason for seeing health care, and history of present
illness
â–ª Ask about Past Medical History
o Birth, family hx, past hospitalizations, accidents, surgeries
o Allergies, immunizations/medications, habits and behaviors,
family structure
o Developmental/nutritional because you need to know if they are
where they should be for their age (grade, learning disabilities,
challenges, nutritional hx)
â–ª Anything invasive you do last. Different in your approach, but same
physical assessment
Review of Physical Systems
â–ª SKIN: color, rashes, bruising, acne, sunscreen, sunburnt, blisters
o Odor might mean poor hygiene or infection
o Observe for moisture, skin should be dry, mucus membranes
should be moist
o Nailbeds should be pink, cap refill 1-2 sec
o Hair with white eggs are indicative of lice, brittle hair is a sign of
nutritional abnormalities
â–ª HEAD: lice, lesions, infestation
o Observe for shape and symmetry. Inspect fontanels- they should
not be bulging, pulsating, or sunken in
o Head lag may be a sign of poor muscle development in kids over
6 months
â–ª EYES: watery, yellow, green discharge, glasses, PERRLA
o Inspect for symmetry
o Swelling, redness, or discharge may be related to a blocked tear
duct. Dark shadow under eye might mean fatigue or allergy
â–ª EARS: infections
o Inspect for discharge and palpate for tenderness. Low set ears
may be a sign of genetic disorder
o Hearing tests on all newborns before discharge
â–ª NOSE: colds, often, trouble breathing
o Flaring nose may indicate respiratory distress
o Yellow/green discharge may indicate infection
o Pain with palpation may indicate sinus infection
â–ª THROAT: stre
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