Clean look in the Patient Medical History

Aug 6th, 2022
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How to clean look in the Patient Medical History

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the way that we teach clinical history taking a warrant medical school is to use the four frames and the four frames are a logical way to take the comprehensive history and not miss anything out at all so the first frame is a presenting complaint than the history of presenting complaint and the systems review and the red flags so we encourage our students to ask an open question so they can start eliciting the symptoms from the patient then we would click into one system what I mean by that is if somebody has chest pain for example then you would clearly need to ask about all the cardiac symptoms once youve had got a lot of detail about the patients pain using a mnemonic such as squid ass which is sight quality intensity timing aggravating factors relieving factors and associated symptoms I think then its very important to ask about other systems so we would do a systems review and then finish off by recapping the red flags that is for example blood anywhere lumps and bumps anywher

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A record of information about a persons health. A personal medical history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams and tests. It may also include information about medicines taken and health habits, such as diet and exercise.
In general, a medical history includes an inquiry into the patients medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking.
The overall impression of the patients physical state, including body habitus, posture, grooming, and signs of distress. How do you document general appearance? Record observations systematically, noting body build, grooming, posture, and any notable signs of distress or abnormalities.
Appearance Age: Does the patient appear to be his stated age, or does he look older or younger? Physical condition: Does he look healthy? Dress: Is he dressed appropriately for the season? Personal hygiene: Is he clean and well groomed, or unshaven and unkempt, with dirty skin, hair or nails?
General appearance: include information on the patients overall condition. It is appropriate to comment on level of comfort or distress, as well as general grooming and hygiene.
Appearance is an objective description of the patient as observed by the interviewer. Facial and/or bodily features suggestive of a medical or genetic disorder (i.e. Downs Syndrome, Fetal Alcohol Syndrome). Well-groomed, malodorous. Guarded, seductive, angry, attentive, cooperative.
YOUR GENERAL OBSERVATIONS of a patients appearance, mobility, communication ability, and cognitive function are an important part of your initial assessment. For example, when documenting a patients mobility, note whether he can walk and move independently or needs help, and whether he has weakness or paralysis.
PHYSICAL EXAMINATION - Normal. Vital signs: BP 120/80; P 68/min reg; RR 14/min; T 36.9 C; Wt. General: Well-developed, well-nourished, appearing stated age. Head: Normocephalic without scalp lesions. Neck: Neck supple with full range of motion (ROM). Chest back: No abnormal curvature of spine. Lungs: Cardiovascular:

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