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FRACP Long Case > History and examination > Flashcards

Flashcards in History and examination Deck (12):
1

Organization of the history?

Opening statement
HOPC
List of intercurrent medical conditions- active and inactive
Explanation of each medical condition
Family History
Medications
Adherence to medications
Allergies
Social, occupational and travel history

2

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?

3

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

4

Steps to examination?

Vital signs
Appearance
BMI
Cognition - MMSE
Devices and Attachments
Entire body - Head to toe
Functionality - strength, neurology and joint mobility
Gait

5

What to examine on the face?

Appearance
Eyes - opthal
Cranial nerves
Oral cavity

6

What to examine in the neck?

Lymph nodes
Trachea
JVP
Carotid arteries
Thyroid gland
Spine

7

What to examine in the chest?

Appearance
Cardio-respiratory

8

What to examine in the abdomen?

Appearance
Palpation - organomegaly, masses
Auscultation

9

What to examine in the upper limbs?

Appearance
Neurology
Axillary lymph nodes

10

What to examine for in the lower limbs?

Appearance
Neurology
Peripheral pulses
Gait

11

How to present issues from the case?

Acute/short term issues
Long-term issues

Should have 5 issues - mix of medical and social
Must have a basic management plan for each issue

12

Management of medical issues?

Name issue
Differential diagnosis
Investigations
Expected results
Treatment