Escolar Documentos
Profissional Documentos
Cultura Documentos
Diagnostic Case
- Do nildocaafiat, then do relevant SR (also questions to rule
in/out your differential diagnoses) + red flags, and briefly
other SRs
History Taking
Nature (sharp, dull, burning, cramping, stabbing, throbbing)
Intensity
Location (radiate anywhere)
Duration
Onset (when did it start? What was the first thing you noticed? Has
anything changed since then)
Contributing (is there anything that might have caused this?)
Aggravating (does anything make it worse)
Alleviating (does anything make it better or help it improve)
Frequency for repeated episodes (Is it present continuously or
intermittently? how often does it occur?)
Impact- how is this affecting your life?
Attribute- what do you think is causing the problem?
Treatment- have you taken any medication for it?
Systems Review- ask general, CVS, RESP, GI, neuro, MSK,
haem, urinary, psych, genital
General- have you had any fevers lately? What about any nights
sweats? Change in weight? Rashes or any skin changes anywhere?
Cardiovascular History- Have you ever had any pain in your neck,
chest or arm? Do you get short of breath easily? Can you lie flat
without feeling breathless? Do you wake up at night being short of
breath? Do you ever feel like your hearts racing or skipping beats?
Do you have cold or blue hands or feet? Have you ever had
rheumatic fever? What about a heart attack or really high blood
pressure?
Respiratory- Have you had a cough lately? Do you cough up
anything? Have you ever coughed up blood? Do you snore loudly?
Have you had any wheezing? Have you ever had pneumonia? What
about TB? Have you recently had a chest x-ray?
GI- Have you had any stomach problems lately? Like nausea,
vomiting, diarrhea, pain or constipation? Have there been any
recent changes in bowel habits?
Neurological- Have you had fits before? Have you fainted? Do you
often get headaches? Have you noticed any changes in your vision?
Have you experienced weakness or numbness anywhere?
MSK- Do you get any muscle weakness or stiffness? What about
pain or stiffness in you joints?
Haematological- Do you bleed or bruise easily? Have you noticed
lumps anywhere over you body?
Psych- Are you sleeping well at night? Any mood changes recently?
Urinary- Do you have trouble with passing urine? Is it painful?
Liver mets
Social History
Occupation- are they able to get leave for rest, will they go back to
work, flexibility? Occupational exposure to dusts, gases, carcinogens
Overseas travel- gastroenteritis, PE
Home life- ADLs, help at home, family, main carer, spouse and their
health
Smoking
Nutrition
Alcohol
Physical exercise
Problem biggest
Drugs recreation (esp. marijuana use in COPD)
Hobbies
Allergies
Social supports
DOg (pets) driving
GP- frequent visits
Monetary financial situation, do they have private health insurance
AHD and will
Insight into condition
Sleep apnoea- for OBESITY (snoring, refreshed in mornings, early
morning diuresis, daytime somnolence) , sleep pattern
Mood
Screening tests already completed
Always ask what investigations have been done so far, what doctors
say they have, what examiners commented on, did physical
examination for
Hello Mr/Mrs My name is.This is a very important exam for me. I will
need to ask you a lot of questions very quickly. From time to time I may
need to cut you off.
Please dont feel that Im being rude, its just that I need to get a lot of
information very quickly.
How old are you? Are you allergic to anything? What are your health
problems, I need to make a quick list (also quickly look at the drug chart).