Folleto
Folleto
Folleto
V- Management.
VI- Conclusion.
To inquire about:
Chief complaint
Site of pain
Radiation
Character of pain
Severity of pain
Time of onset
Type of onset
Duration
Accompanying symptoms
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Asking for much specific information.
History Taking
If the patient does not provide all the information the doctor needs.
More specific questions should be asked.
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Sometimes much more specific questions may be needed:
(Other possibilities should be included depending on the disease the patient may be
suffering from at the moment).
III- Examining the patient. (Does it hurt when I press here? And down here?
Have you had any pain in this area? Have you had any discharge of the nipple?
Giving instructions. (breathe in, breathe out, say 99, open your mouth).
IV- Reassuring the patient, giving opinions, giving advice.(calm down, take it
easy, everything’s going to be fine/ I think you should give up smoking/ You
shouldn’t drink alcohol or coffee).
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Doctor- Doctor Discussion.
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CLINICAL HEALTH HISTORY/ CASE HISTORY FORM.
Occupation:
Present Complaint:
O/E:
General condition:
ENT:
RS:
CVS:
GIS:
GUS:
CNS:
Musculoskeletal System:
Endocrine System:
Ciculatory System :
Points of notes:
Investigations:
Management:
_______________________________________________________________________
____________
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Symbols and Abbreviations.
Time 1/7 days (one day of the week) There are seven days in a week.
1/52 weeks (one week of the year) there are 52 weeks in a year.
1/12 months (one month of the year) there are 12 months in a year.
↑ Raised
Elevated
Enlarged
Increased
↓ Decreased
Down
Worse
Low
C/O- Complaining of
C- With, (in association with/ associated with)
+ - and, plus.
+++- severely, greatly
O/E- On examination
PMH- Past medical history
SH- Social history
FH- Family history
Ix- Investigations.
∆/ Dx- Diagnosis.
Rx- Treatment
CXR- chest x-ray
ECG/ EKG- electrocardiogram
HBP- high blood pressure
Hb/ Hgb- hemoglobin
HS- heart sounds
Abd- abdomen
?- possibly
<- less than
>- more/ greater than
=- equal
- minus
x- multiplied by
GP- General practitioner
Doctor home office
General Comprehensive Medicine
F- female/ M- male
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÷ divided by
Steps used for reporting cases
1. Introduction.
2. History of present illness.
3. Past medical history
4. Habits.
5. Family History.
6. Findings on the physical examination.
7. Investigations.
8. Differential Diagnosis.
9. Diagnosis.
10. Management.
11. Complications.
12. Prognosis.
When reporting cases we have to center the attention to important grammatical and
linguistic elements such as: present, past and perfect tenses, the use of the passive
voice, regular and irregular verbs, linking words used to give coherence and
cohesion, elements of puntuation mark (language discourse markers), etc.
III- Past medical history ( patient’s previous history/ disease/ medical problem).
- Present tense.
Eg: There is a past medical history of pneumonia
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-Past tense.
Eg : He had pneumonia two months ago.
-Past perfect tense.
Eg :- The patient had had pneumonia.
- He had suffered from pneumonia.
V- Family history.
- Simple present.
Eg: -There is a positive family history of heart diseases.
-Simple past.
Eg : His mother died of a heart attack..
VII-Investigations.
-Past simple / Passive voice.
There was nothing remarkable on examination except ,obesity.The chest x- ray and the
EKG were normal.
VII-Differential diagnosis.
-Passive voice.
Eg: The differential diagnosis was made with disecting aneurysm, myocardial infarction,
pulmonary embolus and acute pericarditis.
IX- Diagnosis.
- Present / Past tenses/ Pasive voice.
Eg: -The most likely diagnosis is angina pectoris.
-The most likely diagnosis was angina pectoris.
- A diagnosis of angina was confirmed.
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X- Management / Treatment.
- Passive voice / Present / Past tenses.
Eg: The patient should be treated with nitroglycerine and morphine to relieve the pain,
oxygen by face mask and was ordered rest in bed / The treatment includes nitroglycerine
and morphine to relieve the pain, oxygen by face mask and bed rest.
XII- Prognosis.
- Present tense.
Eg: The prognosis is favourable if the patient follows the treatment plan.
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