Clinical Practicum
, MEDICAL HISTORY TAILING
ESSENTIAL TERMS :
·
SYMPTOMS : COMPLAINTS REPORTED BY THE PATIENT
·
CLINICAL SIGNS : A PHYSICAL RESPONSE MEDICAL FACT OR CHARACTERISTIC OBSERVED BY A
,
MEDICAL SPECIALIST DURING THE EXAMINATION OF A PATIENT
·
DIFFERENTIAL DIAGNOSIS : THE DIFFERENT MEDICAL CONDITIONS THAT OFTEN CAUS THE SAM
SYMPTOMS
MEDICAL HISTORY TAKING STEPS
1. I INTRODUCE MYSELF .
2 IDENTIFICATION
-
NAME -
NAME -
HEIGHT
-
JOB TITLE/PROFESSION -
Sex -
AGE
-
"I AM HERE TO ASK YOU
-
WEIGHT -
EttiNicity
"
SOME QUESTIONS
CONSENT FOR NOTE-TAITING
-
ASSURE THE PATIENT THAT
-
THEY CAN BRING UD ANYTHING
WITHOUT ANY SHAME
. HISTORY
4
Of PRESENTING COMPLAINT
·
O ONSET-ACTIVE
: SUDDEN GRADUAL?
, ,
PART OF A CHRON.C PROBLEM ?
3
. PRESENTING COMPLAINT
·
P: PROVOCATION/PALLIATION -
WHAT HAPPENS
PATIENT'S MAJOR CONCERN WITH MOVEMENT PRESSURE ? ANYTHING That
MAIN PROBLEM OF THE PATIENT MAKES THE PROBLEM BETTER/WORSE ?
(CHIEF COMPLAIN) ·
Q : QUALITY OF PAIN -
HOW DO YOU DESCRIBE
THE PAIN ? SHARP BURNING , CRUSHING DULL
, , ,
TEARING ?
·
R: REGION/RADIATION : WHERE IS THE PAIN ?
DOES IT MOVES OR RADIATES ?
·
S : SeufRITY : SCORE THE SEVERITY OF PAIN
·
T: TIME : HOW LONG HAS THIS BEEN GOING On ?
HOW HAS IT CHANGED SINCE ONSET ?
, SOCRATES RULE (FOR Pain)
·
S : SITZ
·
O : ONSET
C :
CHARACTER/QUALITY
·
·
R : RADIATION
·
A :
ASSOCIATIONS/OTHER SYMPTOMS
·
T : Time /DURATION
·
E :
Exacerbating/provocation/RELIEvinG FACTORS
·
S : SEVERITY
$0 -They
. Forate
3
. PAST MEDICAL HISTORY
-
Th DONT TAYorI
-
GENERAL STATE OF HEALTH THAT SOMETHING IS
IS THE PATIENT DIFFERENT FROM PREVIOUS TIMES ? IMPORTANT
~
-
HOSPITALIZATIONS : WHEN ? ·
ANY CHRONIC (i .
e . HYDERTENSION
? DISEASES ? CHOLESTEROL)
·
WHY
·
DURATION? WE FIND out
FROM THE
.
6 Past Surgical History MEDICATION
-
WHEN ?
-
WHO /DOCTOR ?
-
WHERE ?
-
COMPLICATIONS ?
8
. MEDICATION
7 . ALLERGIES
-
WHAT
,
EVEN HERBs ? -
FOOD
DOSES MEDICATION
-
-
-
FREQUENCY WHAT HAPPENED
ASSURE THAT THE LAST TIME
-
THEY TARE
THE MEDICATION AS PRESCRIBED THEY TOOK IT ?
-
WHY DO THEY TAILE THESE PILLS ! LANAPHYLAXIS)
WE HArf TO KNOW THE SUBSTANCES
NILLS
IN THE
, MEDICAL HISTORY TAILING
ESSENTIAL TERMS :
·
SYMPTOMS : COMPLAINTS REPORTED BY THE PATIENT
·
CLINICAL SIGNS : A PHYSICAL RESPONSE MEDICAL FACT OR CHARACTERISTIC OBSERVED BY A
,
MEDICAL SPECIALIST DURING THE EXAMINATION OF A PATIENT
·
DIFFERENTIAL DIAGNOSIS : THE DIFFERENT MEDICAL CONDITIONS THAT OFTEN CAUS THE SAM
SYMPTOMS
MEDICAL HISTORY TAKING STEPS
1. I INTRODUCE MYSELF .
2 IDENTIFICATION
-
NAME -
NAME -
HEIGHT
-
JOB TITLE/PROFESSION -
Sex -
AGE
-
"I AM HERE TO ASK YOU
-
WEIGHT -
EttiNicity
"
SOME QUESTIONS
CONSENT FOR NOTE-TAITING
-
ASSURE THE PATIENT THAT
-
THEY CAN BRING UD ANYTHING
WITHOUT ANY SHAME
. HISTORY
4
Of PRESENTING COMPLAINT
·
O ONSET-ACTIVE
: SUDDEN GRADUAL?
, ,
PART OF A CHRON.C PROBLEM ?
3
. PRESENTING COMPLAINT
·
P: PROVOCATION/PALLIATION -
WHAT HAPPENS
PATIENT'S MAJOR CONCERN WITH MOVEMENT PRESSURE ? ANYTHING That
MAIN PROBLEM OF THE PATIENT MAKES THE PROBLEM BETTER/WORSE ?
(CHIEF COMPLAIN) ·
Q : QUALITY OF PAIN -
HOW DO YOU DESCRIBE
THE PAIN ? SHARP BURNING , CRUSHING DULL
, , ,
TEARING ?
·
R: REGION/RADIATION : WHERE IS THE PAIN ?
DOES IT MOVES OR RADIATES ?
·
S : SeufRITY : SCORE THE SEVERITY OF PAIN
·
T: TIME : HOW LONG HAS THIS BEEN GOING On ?
HOW HAS IT CHANGED SINCE ONSET ?
, SOCRATES RULE (FOR Pain)
·
S : SITZ
·
O : ONSET
C :
CHARACTER/QUALITY
·
·
R : RADIATION
·
A :
ASSOCIATIONS/OTHER SYMPTOMS
·
T : Time /DURATION
·
E :
Exacerbating/provocation/RELIEvinG FACTORS
·
S : SEVERITY
$0 -They
. Forate
3
. PAST MEDICAL HISTORY
-
Th DONT TAYorI
-
GENERAL STATE OF HEALTH THAT SOMETHING IS
IS THE PATIENT DIFFERENT FROM PREVIOUS TIMES ? IMPORTANT
~
-
HOSPITALIZATIONS : WHEN ? ·
ANY CHRONIC (i .
e . HYDERTENSION
? DISEASES ? CHOLESTEROL)
·
WHY
·
DURATION? WE FIND out
FROM THE
.
6 Past Surgical History MEDICATION
-
WHEN ?
-
WHO /DOCTOR ?
-
WHERE ?
-
COMPLICATIONS ?
8
. MEDICATION
7 . ALLERGIES
-
WHAT
,
EVEN HERBs ? -
FOOD
DOSES MEDICATION
-
-
-
FREQUENCY WHAT HAPPENED
ASSURE THAT THE LAST TIME
-
THEY TARE
THE MEDICATION AS PRESCRIBED THEY TOOK IT ?
-
WHY DO THEY TAILE THESE PILLS ! LANAPHYLAXIS)
WE HArf TO KNOW THE SUBSTANCES
NILLS
IN THE
