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    The History

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    basssssem
    The document provides a template for documenting a patient's history and physical examination. It includes sections for collecting a history of present illness, past medical history, social history, family history, review of systems, and physical examination. The history of present illness section guides the clinician to obtain detailed information about symptoms, including their quality, radiation, severity, timing, exacerbating and alleviating factors, and related symptoms. Relevant systems should be questioned in more detail. The physical examination section lists vital signs and a general exam including checks for jaundice, anemia, cyanosis, clubbing, edema and lymphadenopathy.

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    The History

    Uploaded by

    basssssem
    63 views1 page
    The document provides a template for documenting a patient's history and physical examination. It includes sections for collecting a history of present illness, past medical history, social history, family history, review of systems, and physical examination. The history of present illness section guides the clinician to obtain detailed information about symptoms, including their quality, radiation, severity, timing, exacerbating and alleviating factors, and related symptoms. Relevant systems should be questioned in more detail. The physical examination section lists vital signs and a general exam including checks for jaundice, anemia, cyanosis, clubbing, edema and lymphadenopathy.

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    The document provides a template for documenting a patient's history and physical examination. It includes sections for collecting a history of present illness, past medical history, social history, family history, review of systems, and physical examination. The history of present illness section guides the clinician to obtain detailed information about symptoms, including their quality, radiation, severity, timing, exacerbating and alleviating factors, and related symptoms. Relevant systems should be questioned in more detail. The physical examination section lists vital signs and a general exam including checks for jaundice, anemia, cyanosis, clubbing, edema and lymphadenopathy.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    63 views1 page

    The History

    Uploaded by

    basssssem
    The document provides a template for documenting a patient's history and physical examination. It includes sections for collecting a history of present illness, past medical history, social history, family history, review of systems, and physical examination. The history of present illness section guides the clinician to obtain detailed information about symptoms, including their quality, radiation, severity, timing, exacerbating and alleviating factors, and related symptoms. Relevant systems should be questioned in more detail. The physical examination section lists vital signs and a general exam including checks for jaundice, anemia, cyanosis, clubbing, edema and lymphadenopathy.

    Copyright:

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    of 1

    The History (Hx) The relevant system(s) - positives AND negatives.

    The first sentence (rehearse 20 times): The other systems - positive findings ONLY.
    Name,
    Age, Summary
    (Occupation),
    (Ethnicity), Investigation (Ix)
    Sex, Bedside (dipstick urine; peak air flow meter)
    Presenting complaint. Bleed - Haem (FBP, coag), Biochem (U+E, LFT, TFT, Glucose, Cholesterol), Special (PSA,
    cultures, cardiac enzymes(3 days) )
    Section 1: Imagery (eg. ECG, CXR, AXR, ECHO, CT)
    HPC - include history of the whole relevant system, including risk factors. Invasive (fine needle biopsies, ERCP)
    Symptoms = PQRST EAR:
    Position Management (Dependent on Hx)
    Quality Diagnosis = Hx + Ex + Ix
    Radiation Sieve: TIN MAIDENS = Trauma, Infection, Neoplasm, Metabolic, Alcohol/Autoimune,
    Severity Iatrogenic/Idiopathic, Degenerate, Endocrine, Neurological, Smoking
    Timing (Onset, Duration, Does it come and go?) Management = Diagnosis + Rx
    Exacerbating factors
    Alleviating factors Treatment (Rx):
    Related Symptoms Conservitive
    PMHx Medical
    Surgery
    Section 2:
    DHx - *ALLERGIES* From Dr Smith:
    SHx = SWARM (Smoking+Alcohol, Work, Accomodation, Relatives, Money) (or "A Mars a Set scene: Age/Occupation
    Day Helps you Work (job, income), Rest (home, family) and Play (smoking, alcohol & HPC: Red flags
    hobbies)" ) Start
    Progression
    Section 3: Relevant Systemic Questions: Resp, CVS
    FHx PMHx: relevant at top
    ROS - Other systems: Drugs *Allergies*
    BMJ TRADES CD = BP(hypertension), MI, Jaundice, TB, Rheumatic fever, Asthma, SHx: *ADLs*, social support, smoking, alcohol, occupation
    Diabetes, Epilepsy, Stroke, Clots, Duodenal ulcer. FHx
    Always: Weight loss, appetide. SQ
    Resp: SOB (+ distance can walk), wheeze, cough, sputum (+colour, how much), haemoptysis.
    CVS: Pain, palpitations (+tap rhythm), hypo/hypertension, orthnopea (how many pillows),
    PND, ankle swelling.
    Abd: Pain, dsyphagia, indigestion, vomiting, haematemesis, change in bowel habit,
    diarrrohea/constipation, blood in stool.
    Geno-uriary: Frequency, nocturia, incontinence, haematuria, bad smell, poor stream,
    hesitancy, post micturation dribbling.
    In female: pregancies, heavy periods, intermenstrual bleeding, recurrent abortions, premature
    menopause.
    Nervous: Fits, faints, visual disturbances, severe headaches, parathesia, memory loss,
    weakness, coordination.
    General: Skin problems, arthritis.

    The Examination (Ex)


    General appearance - including oxygen mask, nebs, etc.
    BP, Pulse, Temp, RR.
    JACCOL (Jaundice, Anaemia, Cyanosis, Clubbing, Oedema, Lympadenopathy).

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