Professional Documents
Culture Documents
PRO - History Taking
PRO - History Taking
Severity:
- Subjective scale of 1-10
- Objectivity how it affects your daily lifestyle/work?
HISTORY:
Vaccination history
- Are you up-to-date / vaccination card
- Did you have any recent vaccination
Allergies history
- Animals
- Food
- Environment/season
Travel history:
- Have you travelled recently
- Where, when (check for endemic areas)
- Have you had any contact with sick people (hajj)
Menstrual history:
- Age of menarche
- Last menstrual period and duration of it
- Regularity
- Flow (no. of tampons/pads)
- Associated symptoms
Cough:
- Site, radiation are removed
- Character dry, wet/productive:
- If wet: CABO: Color, Amount, Blood, and Odour.
- Associated symptoms: runny nose, burning, breathing problem
Fever:
- Site, radiation, severity are removed.
- Character did u measure, if yes how, highest value,
sweating, shivering
- Associated symptoms: headache, dizziness, loss of appetite, weight loss.
Constitutional symptom:
- Fever
- Fatigue
- Weight gain/loss
- Loss of apetite
Vital signs, general exam, blood pressure, Lymph nodes Approach patient from right side or from
the front
Heart rate report findings Beats per minute, regular/irregular rhythm, normal volume
- Ideally, longer the better (60 seconds)
- Average time 60-100 bpm
Respiratory rate Breaths per minute, regular rhythm, normal depth, accessory muscles
- Average 12-20 breaths per minute
- Observe chest movements
BP:
- Cubital fossa at heart level.
- Brachial artery is medial to biceps tendon
- Palpatory method taking the radial pulse
- 2-3 cm above cubital fossa
- Baseline pulse is the pulse at which radial pulse disappears
- Next time add 20-30 mmHg when you are measuring with stethoscope
- First heart beat that you hear systolic pressure
- The last heart beat you hear diastolic pressure
- Record then thank
General exam:
- Conjuctiva pallor
- Sclera jaundice
- Lips dehydration, central cyanosis
- Tongue dehydration, central cyanosis, oral thrush, blood flow under tongue
- Firm pressure above medial malleolus by 3cm, press on tibia.
Upper LN:
- Clavicular LN are the only one that u examine from the front
- 2-3 fingers
- Right hand right side for support and vice versa
- Epitrochlear lymph nodes above the medial epicondyle
- Size, location, consistency (firm, soft, hard), contour (rough, smooth edges), mobility,
tenderness (non-tender, tender/pain), pulsatile
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