Escolar Documentos
Profissional Documentos
Cultura Documentos
The History
Welcome the patient - ensure comfort and privacy Know and use the patient's name introduce and identify yourself Set the Agenda for the questioning
The History
Use open-ended questions initially Negotiate a list of all issues - avoid excessive detail initially
Chief complaint(s) and other concerns Specific requests (i.e. medication refills)
Clarify the patient's expectations for this visit - ask the patient "Why now?"
The History
Elicit the Patient's Story Return to open-ended questions directed at the major problem(s) Encourage with silence, nonverbal cues, and verbal cues Focus by paraphrasing and summarizing
Chief Complaint
This is why the patient is here in the emergency room or the office Examples:
Shortness of breath for 2 days Chest pain of 3 hours
Quality
Is there pain, and if so what typehow would the patient describe it is words
Scale
On a scale of 1 to 10, how bad are the symptoms
Timing
When do the symptoms occur?
At night, all the time, in the mornings, etc
Pain
Location Length of time Severity Quality
Medications
Include all meds the patient is oneven over the counter meds and herbals Try to include the dosages if the patient knows them Include how often the patient takes them
Allergies
Make sure to ask about medication allergies and the reaction that the patient has to them Ask about latex, food and seasonal allergies
Social History
Things to include:
Occupation Marriage status Tobacco usehow much and for how long Alcohol use Illicit drug use Immunization status
Family History
Ask if the patients parents, grandparents, siblings or other family members had any major medical conditions
Examples:
Heart disease, heart attacks, hypertension, hyperlipidemia, diabetes, sickle cell disease
Review of Systems
The review of systems is just that, a series of questions grouped by organ system including: General/Constitutional Skin/Breast Eyes/Ears/Nose/Mouth/Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neurologic/Psychiatric Allergic/Immunologic/Lymphatic/Endocrine
Physical Exam
General Heart Lungs Abdomen Extremities Neck GU if pertinent to the chief complaint
Physical Exam
Make sure to include vital signs as part of this Develop a systematic approach for doing the physical exam
Methods of Examination
Inspection Palpation
Light Deep
Percussion
flatness dullness resonance hyperresonance tympany
Auscultation
pitch intensity duration quality
Stethoscope
General Survey
Age, sex, race Body build, height, weight Posture and gait Hygiene and grooming Signs of Illness Affect Cognitive Processes
Skin
Color Vascularity Lesions Temperature Turgor Texture Wounds
Clubbing of Fingernails
Chest: Lungs
Respirations
labored unlabored
Abdomen
Contour Size Bowel sounds Tenderness Palpate bladder
Extremities
ROM present Strength Capillary refill Peripheral pulses Edema Nails