Professional Documents
Culture Documents
History Taking: - Identification
History Taking: - Identification
History Taking: - Identification
• IDENTIFICATION
-Name, Age, Sex, Address, Parental age, Parental
Ethnicity/religion, occupation
-Source of history - Mother/Father/care taker
• PREVIOUS ADMISSION
-Time
-Reason
-Duration
-Treatment
-Outcome
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CHIEF COMPLAINT/S:
-Cough
-Diarrhea
-Vomitting
-Fever
-Skin rashes/lesions
-Earache/discharge
-Loss of conciousness
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• PERSONAL,
-School attendance & performance
FAMILY & SOCIAL HISTORY
-Family size
-Number of siblings (age, sex, health status)
-Housing condition
-Type of house
-Number of rooms
-Number of doors/windows
-Isolated kitchen or no
-Isolated room for cattle or no
-Water source
-Waste disposal system
-Family income
-Any familial disease -DM, HTN, Asthma, Genetic disease
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PHYSICAL EXAMINATION
• GENERAL APPEARANCE
-Sick looking or not?(Acute/Chronic)
-Level of conciousnessin(Change in mentation)
-Behaviour
-Orientation of the patient
-Cardiorespiratory distress
-Nutritional state
-Any dysmorphic feature
-Any obvious swelling or pallor
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VITAL SIGNS
• Blood pressure
• Pulse rate (heart rate should be timed for 30 s)
• Respiratory rate
• Temperature
• Height
• Weight
• BMI
• Waist circumference
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VITAL SIGNS
-BP:
- Between= - SBP 90-120
- DBP 60-85
-Temperature:
- normal - 36.5-37.4 degree Celsius
-LGF - 37.5-38.4 degree Celsius
-HGF - >/= 38.5 degree celsius
-Hypothermia - <36.5 degree celcius
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BLOOD PRESSURE MEASURING APPARATUS
• Mercury sphygmomanometers
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• The cuff should be placed 1 to 2 cm above the
antecubital fossa to allow for placement of the
stethoscope over the brachial artery
• Neither the patient nor the observer should talk
during the measurement
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• Take at least two readings on each visit, separated
by as much time as possible; if readings vary by
more than 5 mmHg, take additional reading until
two consecutive readings are close
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GUIDELINES FOR THE MEASUREMENT OF BLOOD PRESSURE
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• The patient should be seated comfortably with the
back supported and the upper arm bared without
constrictive clothing
• The legs should not be crossed
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GUIDELINES FOR THE MEASUREMENT OF BLOOD PRESSURE
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Cont…
HEENT
-Pink/pale conjuctivae
-Color of isclerae
-Sunken eyes
-Periorbital swelling
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Cont…
-Any scalp lesion
-Nasal discharge, congestion,swelling, bleeding
-Dental carries
-Dental alignment
-Any lost tooth
-Ear discharge/ ulceration/bleeding
-Tonsils / uvula
-Oral thrash / ulceration
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LGS
-Any palpable LN -Size
-Concistency
-Ulceration
-attachment
-Breast - Shape
-Contour
-Discharge
-Ulcer
-Swelling/lump
-Testicles -Size
-Position
-Any swelling
-tenderness
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• RESPIRATORY
Inspection:
-RR
-Grunting
-Stridor
-Wheezing
-IC/SC{intercostal IC} {supcostal SC} retration
-Flarring of ala nasae
-Cyanosis
-Type of cough (barking, paroxysmal)
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Cont…
Palpation(4Ts)
-Tracheal position
-Tenderness to chest wall /mass
-Total Chest expansion
-Tactile fremitus
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Cont…
Percussion
-Diaphragmatic excursion =
-Resonant/dull/hyperresonant?
Auscultation
-Air entry
-Adventitious sounds (BBS, wheezing, bronchophony, egophony, etc.)
-Transmitted sounds
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EXAMINATION OF THE ARTERIAL
SYSTEM
EXAMINATION OF THE CARDIOVASCULAR SYSTEM
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• CARDIOVASCULAR SYSTEM
General examination
-Cyanosis
-Digital clubbing
-Cardiorespiratory distress
Arterial examination
-Pulse ( rate, character, volume, radiofemoral delay)
-BP
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EXAMINATION OF THE ARTERIAL SYSTEM
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RHYTHM
• Regular
• Regularly Irregular
• Irregularly Irregular
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Venous system examination
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MEASURING CVP
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PATHOLOGIC CAUSES OF RAISED JVP
• Heart failure
• Pericardial effusion
• Constrictive pericarditis
• Superior vena cava obstruction
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Precordial examination
-Inspection:
- Precordial bulge
-Active / silent precordium
-Apical impulse
-Palpation:
-PMI
-Heave
-Thrill
-Auscultation:
-Normal heart sounds
-Murmur (type, quality, grade, radiation)
-Accentuation / muffling of heart sounds
-Gallope rhythm
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WHAT TO AUSCULTATE?
1. Heart sounds
2. Murmurs
3. Pericardial friction rub
08/02/2020 . 28
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• ABDOMEN
Inspection
-Full / scaphoid /distended
-Any isolated swelling
-Moves with respiration or no
-Visible peristalisis
-Any scar
-Distended veins
-Hernial sites
-Umblicus ( everted, inverted)
Auscultation
-Bowel sounds
-Bruit
-Splenic rub
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Cont…
Palpation
-Superficial palpation: for tenderness or mass
-If any distended vein, direction of drainage
-Deep palpation: for organomegally, any mass, tenderness
Percussion
-Shifting dullness
-Fluid thrill
-Total liver span
08/02/2020 . 30
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• GENITOURINARY SYSTEM
-Bladder distension
-CVAT
-Suprapubic tenderness
-Urethral opening (epispadias, hypospadias)
-Testicles in the scrotum or no
-Scrotal swelling
-Urethral discharge
-Vaginal discharge / bleeding
-Vulvar erythema / ulceration
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INTEGUMENTARY SYSTEM
-Palmar pallor ( some / sever )
-Rash ( characteristic , distribution, color)
-Any skin lesion ( characterstic, distribution)
-Edema ( grade, pitting / nonpitting)
• NERVOUS SYSTEM
General
-Behaviour
-Abnormal facies
-Level of conciousness
-Seizure
-Abnormal odor- Fruity odor
-Pattern of breathing
-Kussmauls breathing
Cranial nerves
Sensory examination
-Pain
-Position
-Vibration
-Temperature
-Sensory level
-Superficial abdominal reflexes
Motor
-Power
-Tone
-Deep Tendon Reflex
-Muscle Bulk
-Motility & locomotion