History and Clinical Examination PDF

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.. . y · 11 i:,.uw.....-- ,,: u1 I n an1 e •ar.it J status ke sur . th.at , · can r czo rd_ su.b e 0 m in er f wr - nee · . on , - n p. ogr· ss e e e .. g ms the ,' ~-:--~ st them in the - ___,,___~· al~ ~ r~- ·~ ' l f i i l a , - co plain , r of the ma1n com . n . o co_ .~~ ~~ gi e a fu.11 fi _cord of omp aJ n , ~ rem. ·ng questions t at ,o the patient complains of a ..·ar· · sw ~ of the Jtre·senting co nplaint, facial e,nts, etc.. ., ;..a t f . , a es , as . a ou r · e.g. .. t y ave o bt • • d you •re a ,. , fi d .11 relate.d qu tio ab, conp am d bo t ot er you .h e sk d.irect q ry - ' e . nge , • e h b. i · iovascul'ar .y~ p i t 0 1 Ge e of o rnal p ~ n) 0· t c. . t t t . as m . 1 P1" •. ious illn • rculo 1s, 6 .. .Soei I . op ratio, s, · . ert·.nsio11, acci ntY h'l'"1 • •• i.~ n .c " o y. h ck ~ ly th de ail r, garding housmg·, trav lli.ng .·b,road.., '. . ci"'.a.~.\ smoking, drink~ alcoh,o)s), eatmg habits.,. se . ual hab.tts, e c ... 1 '• · Lu1 (..'e. .,. 7. E>·n ig_history. ·€h the patie •s pr; sen~_medication. Make particular enquiri s about ste oi . , anticoagy •nts and anti~etic d~gs. Ask about allergies,. especiaUy; to antib"otL . - n:....·! - . Cil.J.II. .u ..,. Pain anywhere should have the same feature·s elic1ted. These can·ae·summarized - • the acronym s(i)"ca~ ·ES .. • Site. Where is the pam, is it localized., in a region, or generalized? • Onset. Gradual, rapid, or sudden? Intermittent o,r constant? (Fig,. .. ) • ~haracter. Sharp, staobing,. dull a_chmg,_tight, sore? • l{adiation and referral. Does it spre,a d to oth~r are·as~ 1 Difference betwee radiation and irefer al • Rad·ation.: A pain which extends to ·a nother . it-e whilst the irutial pain pe- 1 · Fer example, patients with anaplastic carcinqma of the thyroid can cl: el p n pain whldt so,metimes radiates to the ear (via va~ nerve). A pain may occur none site, disappear, and • en reappear in anether • no radiation, it is a new pain in another place. . RefettaL A pai which 1s felt at a distance fro it o ce. Eo de:ve opment of left arm or left 1aw pain as a res t of myocar .• 1 1 angina. 0I • I ~ u .e et I h ... 11g xa na o to . ,e pa ·ent you c.an s er or 't1 0 .~~-!ill a • ity ir treatm·· n . ·o a a· . -p ·. Sc I · (GCS). t eir en a a i . nt . J • t part of tl e 1 - po,ntan - :un 4 . . ........_ ... c_: . l,i gt cord I - ·· - l t a -d a s ne , J 4 2 3 nible s unds 1 fl. Wtthdr • l 1 ·on b ormal fl ~ion ,o l . _n~~on one . Sc r ~3- b e e a numb r o ys ch · tor , s ch a posture, . o ility~ e gh • color • • Y. u can or pallor), ac1al charact rs (e.g , Do etcu ) ( . 1. ) an ge eral o b ild dro e c n (e g , h ro --·JI!.@ and .tat_ af the lips. Ask to see the patien 's tongue; obse • and surface. , .· an gums. Use a spatula to inspect the soft pa a e . 1 1 f -oropharynx~ am· e ·n the neck are the j . gu ymp,h gla- ds~ al l · pair ofne e th _-ite neck region .. - ge _. Fet:tl o · ebraina In order: to tdentjfy he natur ~f eac on , remem.b ·r Marry Money. But r f Bro er ay ad Boy en ory; M • .P ure motor~ an --~--- e mnerrion·,e ~so . e -·. o ei . ~ . where S tsp to c ee is both. !'"' ' g.1 3 _gn be ~ . . ,. ----___ ., . Tes ~~~ bottle c .• 3g ara el ,. --.....,._---.:;_;;_~~ a . a.--~~ • Visual acuity: . Color · ·sion: U • g peciffo col 1 . Visual fie a: ,____p_ co nt • OR etho. • e (Ich·g~ . ,- . 1 • • - • - • b • yo • lnjuey to ~poglo sa - I p -0 ·1ater~ p_ 1rottu p a i c o a , I _ - - t . e an -rvi (as 1 • sub • andibular gland ting of _- t e deviat -s to affi a g u e s o f e u t h e s c l s 2 e c t e d i d _ n -