What is a Health History?

▪ You would want to ask about subjective data using communication

strategies, ask reason for seeing health care, and history of present

illness

▪ 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)

▪ Anything invasive you do last. Different in your approach, but same

physical assessment

Review of Physical Systems

▪ 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

▪ 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

▪ 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

▪ 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

▪ 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

▪ THROAT: stre