Flashcards in History and examination Deck (12):
Organization of the history?
List of intercurrent medical conditions- active and inactive
Explanation of each medical condition
Adherence to medications
Social, occupational and travel history
Which details are required for each intercurrent illness?
When, how and how made the diagnosis?
What treatment has been used?
What complications or side effects have occured from the treatment?
For each drug - dosage and frequency?
What is the current level of disease activity?
What is the impact of the disease on the patients life?
What details are required for social history?
JIGS IF CHIPPEDD
J = Job
I = Independence - ADLs
G = GP - does the patient have a GP and do they have a therapeutic alliance.
S = Sleep
I = Intercourse - sexual history
F = Finances
C = Circumstances - Where living? What is the hourse like? Has it been modified? Living with who? Pets? Social supports?
H = Happy - depression screening
I = Insight - knowledge of disease, living with it and prognosis
P = Preventative health activities - Vaccinations, cancer screening and osteoporosis
P = Problem - what is the patients perceived main problem?
E = EtOH and drugs
D = Diet - nutrition
D = Driving
Steps to examination?
Cognition - MMSE
Devices and Attachments
Entire body - Head to toe
Functionality - strength, neurology and joint mobility
What to examine on the face?
Eyes - opthal
What to examine in the neck?
What to examine in the chest?
What to examine in the abdomen?
Palpation - organomegaly, masses
What to examine in the upper limbs?
Axillary lymph nodes
What to examine for in the lower limbs?
How to present issues from the case?
Acute/short term issues
Should have 5 issues - mix of medical and social
Must have a basic management plan for each issue