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問題一覧
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Subjective data
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Objective data
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7 components health history
Identifying Data and Source of the History, Chief Complaint, History of Present Illness, Past Medical History, Family History, Personal and Social History, Review of Systems
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demographics, ie. age, gender, occupation, etc.
Identifying Data
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usually the patient, but can be a family member or friend, letter of referral, or the medical record
Source of History
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Chief Complaint
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History of Present Illness
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History of Present Illness
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5 narratives history of present illness
onset of the problem, setting in which it has developed, Manifestations, Treatments attempted, Answers question: Did anything make it better or worse?
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5 Past Medical History
childhood illnesses, adult illnesses and surgeries with dates, health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety, Hospitalizations, Psychiatric illnesses and time frame, diagnoses, hospitalizations, and treatment
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8 screening tests
Tuberculin skin tests, Pap smears, Mammograms, Stool tests for occult blood, Cholesterol tests, Sickle cell tests, HIV tests, Hepatitis A, B, C
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Family History
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Personal and Social History
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Personal and Social History
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Personal and Social History
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Personal and Social History
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Review of Systems
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Review of Systems
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number 1 Sequence of Clinical Examination
General appraisal (including temperature, pulse rate, and blood pressure
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number 9 and last Sequence of Clinical Examination
Occlusion
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Temperature elevation
Hyperthermia
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Temperature depression
hypothermia
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systolic pressure
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Resting blood pressure
Diastolic
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anthropometric longitudinal growth of an individual
Height
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device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2.
Statiometer
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Height declines during the day because of compression of the
Intervertebral discs
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used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.
BMI
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Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity
Auscultation
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method used by a doctor to find out about the changes in the thorax or abdomen. tapping on a surface to determine the underlying structure.
Percussion
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method of examination in which the examiner feels the size or shape or firmness or location of something.
Palpation
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used by doctors particularly for thoracic and abdominal examinations, but also for examination of edema and palpation of pulses.
Palpation
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Listening to any sounds emanating from the patient ●Odors that may be present
Inspection
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6 gross deviation
abnormal contour, scars and striae, visible masses, discoloration, swelling, tremor
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thorough and unhurried visualization of the client. This requires the use of the naked eye.
Inspection
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4Methods of Clinical Examination
Inspection-Visual Inspection, Palpation, Percussion, Auscultation
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6 endocrine
Thyroid conditions, Heat or cold intolerance, Excessive sweating, Excessive thirst or hunger, Polyuria, Change in glove or shoe size
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4 Hematologic
Anemia, Easy bruising or bleeding, Past transfusions, Transfusion reactions
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6 Psychiatric
Nervousness, Tension, Mood, Including depression, Memory change, Suicide attempts
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7 Musculoskeletal
Muscle or joint pain, Stiffness, Arthritis, Gout, Backache, Neck or low back pain, Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness
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7 Peripheral Vascular
Intermittent claudication, Leg cramps, Varicose veins, Deep vein thrombosis, Swelling in calves, legs, or feet, Color change in fingertips or toes during cold weather, Swelling with redness or tenderness
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4 breast
Lumps, Pain, Nipple discharge, Self-Examination practices
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5 neck
Swollen glands, Goiter, Lumps, Pain, Stiffness
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8Throat (Mouth and Pharynx)
Condition of teeth and gums, Bleeding gums, Dentures, Sore tongue, Last dental examination, Dry mouth, Frequent sore throats, Hoarseness
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7Nose and Sinuses
Frequent colds, Nasal stuffiness, Discharge, Itching, Hay fever, Nosebleeds, Sinus Infections
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Ears 4
Tinnitus, Vertigo, Infection, Discharge
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Head 5
Dizziness, Syncope, Vertigo, Lumps, Sores
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eyes 4
Glaucoma, Itching, Specks, Spots
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Respiratory 7
Sputum, Hemoptysis, Dyspnea, Wheezing, Pleurisy, Chest X-Ray, Cough
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10 Cardiovascular
Rheumatic fever, Dyspnea, Orthopnea, Edema, Palpitations, Chest pain, Hypertension, Paroxysmal nocturnal dyspnea, Electrocardiograms, Echocardiograms
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6 urinary
Polyuria, Kidney stones, Suprapubic pain, Incontinence, Hesitancy, Dribbling
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genital 4 male
Hernias, sexually transmitted diseases, HIV infection or exposure, Sexual habit,
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9 neurologic
Syncope, Seizures, Weakness, Paralysis, Tingling or “pins and needles”, Tremors or involuntary seizures, Vertigo, Syncope, Numbness or loss of sensation
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Hemoptysis
Respiratory
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Sputum
Respiratory
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Pleurisy
Respiratory
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Dyspnea Orthopnea
Cardiovascular
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Edema • Electrocardiograms • Echocardiograms
Cardiovascular
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Palpitations
Cardiovascular
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Hypertension Rheumatic fever
Cardiovascular