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Health Assessment South University
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1. Forwhich ofthe followingpatients would acomprehensivehealth historybe
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appropriate?
A) Anewpatientwiththechiefcomplaintof―Isprainedmyankle‖
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B) Anestablishedpatientwiththechiefcomplaintof―Ihaveanupperrespiratory
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infection‖
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C) Anewpatientwiththechiefcomplaintof―Iamheretoestablishcare‖
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D) Anewpatientwiththechiefcomplaintof―Icutmyhand‖
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Ans: C
Feedback:
Thispatientisheretoestablishcare,andbecausesheisnewtoyou,acomprehensive health
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history is appropriate.
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2. Thecomponents ofthehealth historyincludeall ofthefollowingexcept which one?
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A) Reviewof systems ‘; ‘;
B) Thoraxand lungs ‘; ‘;
C) Presentillness ‘;
D) Personalandsocialitems ‘; ‘; ‘;
Ans: B
Feedback:
Thethoraxandlungs arepartofthephysicalexamination,notpartofthehealth history. The
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others answers are all part of a complete health history.
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3. Isthefollowinginformation subjectiveor objective?
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Mr.M.hasshortnessofbreaththathaspersistedforthepast10days;itisworsewith activity and
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relieved by rest.
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A) Subjective
B) Objective
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,Ans: A
Feedback:
Thisisinformationgivenbythepatientaboutthecircumstancesofhischief complaint. It
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does not represent an objective observation by the examiner.
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4. Isthefollowinginformation subjectiveor objective?
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Mr.M. has arespiratoryrateof 32and apulserateof 120.
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A) Subjective
B) Objective
Ans: B
Feedback:
Thisisameasurement obtainedbytheexaminer,soit isconsideredobjective data.
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Thepatientisunlikelytobeableto givethisinformationto the examiner.
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5. The following information is recorded in the health history: ―The patient has had
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abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes.
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The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is
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located in the mid-epigastric area.‖
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Whichofthesecategoriesdoes it belongto? ‘; ‘; ‘; ‘; ‘; ‘; ‘;
A) Chiefcomplaint ‘;
B) Presentillness ‘;
C) Personalandsocialhistory ‘; ‘; ‘;
D) Reviewof systems ‘; ‘;
Ans: B
Feedback:
This information describes the problem of abdominal pain, which is the present illness.
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The interviewer has obtained the location, timing, severity, and associated
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manifestations of the pain. The interviewer will still need to obtain information
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concerning the quality of the pain, the setting in which it occurred, and the factors that
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aggravateandalleviatethepain. Youwillnoticethatitdoesincludeportionsof the
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pertinent reviewof systems, but because it relates directlyto thecomplaint, it is
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included in thehistoryofpresent illness. ‘; ‘; ‘; ‘; ‘; ‘;
6. Thefollowinginformationisrecordedinthehealthhistory:―Thepatientcompleted 8th
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grade.Hecurrentlyliveswithhiswifeandtwochildren.Heworksonoldcarson the weekend.
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He works in a glass factory during the week.‖
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Whichcategorydoes itbelong to? ‘; ‘; ‘; ‘; ‘;
A) Chiefcomplaint ‘;
B) Presentillness ‘;
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,C) Personalandsocialhistory ‘; ‘; ‘;
D) Reviewof systems ‘; ‘;
Ans: C
Feedback:
Personal and social history information includes educational level, family of origin, ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘;
current household status, personal interests, employment, religious beliefs, military
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history,andlifestyle(includingdietandexercisehabits;useofalcohol,tobacco,and/ or
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drugs; and sexual preferences and history).All of this information is documented
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inthis example.
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7. Thefollowinginformationisrecordedinthehealthhistory:―Ifeelreallytired.‖
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Whichcategorydoes itbelong to? ‘; ‘; ‘; ‘; ‘;
A) Chiefcomplaint ‘;
B) Presentillness ‘;
C) Personalandsocialhistory ‘; ‘; ‘;
D) Reviewof systems ‘; ‘;
Ans: A
Feedback:
The chief complaint is an attempt to quote the patient's own words, as long as they are
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suitabletoprint.Itisbrief,likeaheadline,andfurtherdetailsshouldbesoughtin the present
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illness section. The above information is a chief complaint.
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8. Thefollowinginformationisrecordedinthehealthhistory:―Patientdenieschest pain,
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palpitations, orthopnea, and paroxysmal nocturnal dyspnea.‖
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Whichcategorydoes itbelong to? ‘; ‘; ‘; ‘; ‘;
A) Chiefcomplaint ‘;
B) Presentillness ‘;
C) Personalandsocialhistory ‘; ‘; ‘;
D) Reviewof systems ‘; ‘;
Ans: D
Feedback:
Reviewofsystemsdocumentsthepresenceorabsenceofcommonsymptomsrelated to ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘;
each major body system. The absence of cardiac symptoms is listed in the above example.
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9. Thefollowinginformationis best placedin whichcategory?
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―Thepatienthashadthreecesareansections.‖ ‘; ‘; ‘; ‘; ‘; ‘;
A) Adult illnesses ‘;
B) Surgeries
C) Obstetrics/gynecology
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, D) Psychiatric
Ans: B
Feedback:
Acesareansectionisasurgicalprocedure.Approximatedatesortheageofthe patient at
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the time of the surgery should also be recorded.
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10. Thefollowinginformationis best placedin whichcategory?
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―Thepatienthadastentplacedintheleftanteriordescendingartery(LAD)in1999.‖
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A) Adult illnesses ‘;
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A
Feedback:
The adult illnesses category is reserved for chronic illnesses, significant hospitalizations,
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significantinjuries,andsignificantprocedures.Astentisamajor procedure but does not
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involve a surgeon.
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11. Thefollowinginformationis best placedin whichcategory?
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―Thepatientwastreatedforanasthmaexacerbationinthehospitallastyear;the
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patienthasnever been intubated.‖ ‘; ‘; ‘; ‘;
A) Adult illnesses ‘;
B) Surgeries
C) Obstetrics/gynecology
D) Psychiatric
Ans: A
Feedback:
This is information about a significant hospitalization and should be placed in the adult
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illnesses section. If the patient is being seen for an asthma exacerbation, you mayconsider
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placingthisinformationinthepresentillnesssection,becauseitrelates
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tothechiefcomplaint at thatvisit.
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1. Apatientpresentsforevaluationofasharp,aching chestpain whichincreases with
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breathing.Whichanatomicareawould you localizethesymptomto? ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘; ‘;
A) Musculoskeletal
B) Reproductive
C) Urinary
D) Endocrine
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