Physical exam history taking ppt

60問 • 1年前

問題一覧

Subjective data

Objective data

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

demographics, ie. age, gender, occupation, etc.

Identifying Data

usually the patient, but can be a family member or friend, letter of referral, or the medical record

Source of History

Chief Complaint

History of Present Illness

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?

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

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

Family History

Personal and Social History

Review of Systems

number 1 Sequence of Clinical Examination

General appraisal (including temperature, pulse rate, and blood pressure

number 9 and last Sequence of Clinical Examination

Occlusion

Temperature elevation

Hyperthermia

Temperature depression

hypothermia

systolic pressure

Resting blood pressure

Diastolic

anthropometric longitudinal growth of an individual

Height

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

Height declines during the day because of compression of the

Intervertebral discs

used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.

BMI

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

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

method of examination in which the examiner feels the size or shape or firmness or location of something.

Palpation

used by doctors particularly for thoracic and abdominal examinations, but also for examination of edema and palpation of pulses.

Palpation

Listening to any sounds emanating from the patient ●Odors that may be present

Inspection

6 gross deviation

abnormal contour, scars and striae, visible masses, discoloration, swelling, tremor

thorough and unhurried visualization of the client. This requires the use of the naked eye.

Inspection

4Methods of Clinical Examination

Inspection-Visual Inspection, Palpation, Percussion, Auscultation

6 endocrine

Thyroid conditions, Heat or cold intolerance, Excessive sweating, Excessive thirst or hunger, Polyuria, Change in glove or shoe size

4 Hematologic

Anemia, Easy bruising or bleeding, Past transfusions, Transfusion reactions

6 Psychiatric

Nervousness, Tension, Mood, Including depression, Memory change, Suicide attempts

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

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

4 breast

Lumps, Pain, Nipple discharge, Self-Examination practices

5 neck

Swollen glands, Goiter, Lumps, Pain, Stiffness

8Throat (Mouth and Pharynx)

Condition of teeth and gums, Bleeding gums, Dentures, Sore tongue, Last dental examination, Dry mouth, Frequent sore throats, Hoarseness

7Nose and Sinuses

Frequent colds, Nasal stuffiness, Discharge, Itching, Hay fever, Nosebleeds, Sinus Infections

Ears 4

Tinnitus, Vertigo, Infection, Discharge

Head 5

Dizziness, Syncope, Vertigo, Lumps, Sores

eyes 4

Glaucoma, Itching, Specks, Spots

Respiratory 7

Sputum, Hemoptysis, Dyspnea, Wheezing, Pleurisy, Chest X-Ray, Cough

10 Cardiovascular

Rheumatic fever, Dyspnea, Orthopnea, Edema, Palpitations, Chest pain, Hypertension, Paroxysmal nocturnal dyspnea, Electrocardiograms, Echocardiograms

6 urinary

Polyuria, Kidney stones, Suprapubic pain, Incontinence, Hesitancy, Dribbling

genital 4 male

Hernias, sexually transmitted diseases, HIV infection or exposure, Sexual habit,

9 neurologic

Syncope, Seizures, Weakness, Paralysis, Tingling or “pins and needles”, Tremors or involuntary seizures, Vertigo, Syncope, Numbness or loss of sensation

Hemoptysis

Respiratory

Sputum

Respiratory

Pleurisy

Respiratory

Dyspnea Orthopnea

Cardiovascular

Edema • Electrocardiograms • Echocardiograms

Cardiovascular

Palpitations

Cardiovascular

Hypertension Rheumatic fever

Cardiovascular

Sporeformers

Tameyra Stefani Al-Suhairy · 44問 · 1年前

Sporeformers