IMPORTANT !!! White coat (clean) Stethoscope Shoes to change Identification card Missed classes?? - NO! SPEAK CZECH !!!!! PATIENT'S HISTORY & GENERAL EXAMINATION Doc. M U Dr. Ľubomír Kŕivan, Ph.D. Interní kardiologická klinika FN Brno Efakultní nemocnice brno Examination Subjective information □ Objective information □ Symptoms □ specific (swollen leg in DVT, exophtalmus in Basedow's disease, extreme thirst and urination in DM..) nonspecific (lost of weight, fatigue, elevated temperature, syncope...) Important!!! Always introduce yourself to the patient!!! □ Shake his /her hand. □ The more the atmposphere is friendly, the more information you get □ Save the patient's privacy Assure the patient that he may ask you anything he needs to know Always inform the patient what you want to do with him The information is strictly confidential History □ Current disease □ Chronic previous diseases □ Pharmacological history □ Alergies Use the patient's words in the report: □ Abuse „...it hurts like a dog's bite..." □ Family history □ Social history □ Occupation □ Physiological functions □ Gynecological history History - current disease Always start with present problems □ what are your complaints? □ is it for the first time in your life? □ don't put forceful Q : „does it hurt here?" □ guide the patient's history □ concentrate on the main problem try to get as detailed information as possible History - of chronic or previous diseases □ which other diseases you suffer from? □ injuries, operations, infectious diseases? □ monitored diseases: DM, CAD, Stroke, TBC, Hypertension, Hepatitis? □ blood transfusion □ is your disease followed by a specialist? where, who? how long are you aware of the disease? History - pharmacological □ which drugs do you take regulary? name, amount per day History - abuse □ do you smoke? □ did you smoke? how many cigarettes per day? how iong? □ do you drink alcohol? what kind? average daily, weekly consumption? □ any drugs? History - of occupation was the patient working manually, mentally? History - social History-allergies are you allergic or hypersensitive to some drugs, food, animals, pollen or plants ??? □ Never forget to ask !!! It may save the patient's life !!! ©Original Artist Reproduction rights obtainable from www. CartoonStock.com rrs <$en\h6 k^ps? evesr pay to make a liV;\'S at ThlS. History - family do your parents live? □ if not, what was the cause of death? in what age? □ do you have siblings, are they healthy? !!! don't pay attention to the husband or wife!!! History - physiological functions □ do you see well? □ do you hear well ? do you have healthy appetite? □ do you have your own teeth? is your urinating and stool regular without problems? did you loose some weight? History - gynecological □ do you have children? how many? □ how many times you were pregnant? □ abortion? spontaneous? or medical? □ do you have a period? □ how long have you been climacteric? when did you see your gynecologist last time? Physical examination □ sight □ palpation □ percussion □ auscultation □ olfactory sense (per rectum) Smells of the City 0 Alcohol ^ Mold & Wet *C| Body Odor Perfumes §t) Chemicals ^ Sewage Feces Urine Food Vomit General inspection of the patient www.bigstock.com • 1619399 General inspection of the patient Skin red - inflamation, fever, sun □ pale - anemia, prolonged sepsis □ yellow - icterus □ blue - cyanosis □ pigmentation scars naevi tension (turgor) Figure (habitus) □ normosthenic □ hypersthenic □ asthenic □ cachectic Position active - patient is able to make any position of the body □ passive - immobile □ involuntary : □ orthopnoic - during left ventr. heart failure □ on the belly, knees - retroperitoneal tumours head turned back, extremities in flexion - meningeal irritation Consciousness disorders - quantitative □ Somnolent patient, lethargy - patient is asleep, with delay in all activities □ Stupor - sleeping deeply, able to wake up by painful stimulation, but immediately slips into the sleep. Coma - impossible to wake up, no reaction to pain Consciousness disorders - qualitative □ Absence - patient is not aware of what is he doing, but motion and space orientation is OK (hypoglycaemie, epileptic seizure) Delirium - confused, disoriented, automatic movements, aggressive (alcoholics, cerebral ischaemia) 5 Wemu - [host - amish (SSH)] ] Soubor Editace Nastavení Okna Nápověda H h R M h É Z H ZŔKLňDhí fiHAľlHÉZfi RA: matka - léčila se s DM 2.typu, otec byl zdrauý, děti: Zdcery, zdraué Oŕ): Hypertenzní nemoc, snížená děloha - proto moč. inkontinence, st.p.fraktuře humeri l.dx, st.p.fraktuře předloktí bilat. Gfi: 2 porody, menopauza od 48 let asi SA: důchodkyně, žije s dcerou u Srně (trualé bydliště ještě není změněno) FA: finopyrin 100mg 0-1-0, Enap 1-0-0, figapurin 1-0-1 (dcera dodá gramáže) FF: Spánek bez potíží. Chuť k jídlu nemá, uáhouý úbytek u posledním půlroce asi 30kg (smrt manžela + u posledním měsíci hlauně nechutenství, nausea), moč.inkontinence (snížená děloha), stolice nepravidelná, bez patolog.příměsí, spíše zácpy. Sluch i zrak přim. uěku. Abuzus: neguje "IN3T HYHĚJSÍ OHEMOCHĚHÍ: Pacientka přivezena HZP pro synkopu, T K lOQ/BQmmHg, TF 91/miti. , bledá, dehydratovaná. Pac.udává už asi měsíc trvající nechutenství. Jí a pije Jen minimálně (po Jídle vždy nausea). Během posledního půl roku úbytek na váze cca 30kg, melénu či enterorhagii neguje. Dle laboratoře: Ery 3,25, Hb 73,7, Hct 0,23, Leu 14,B, CHP 73,7, Urea 10,3, kreat. 121, hraniční Ha 135. -Datum,čas: 20.OS.2012 14:47 -Podpis: pavlumar — > > Alergie pacienta.<< _ _ U IP □ m □ c laWLuna UWU lož JHjNyn . onem . /Zák 1 . anam . íJHBPřeruš 2 reasons for an excellent medical report 1. any following doctor may understand what happened, what was done including yourslef 2. makes your defence at the court easier Don't judge previous treatment or doctors ,The doctors of all the world bury their patients together Mika Waltari - Sinuhet the Egyptian