Beruflich Dokumente
Kultur Dokumente
Knowledge Skills
Skills
History taking Examination Investigation Management Common procedures and other interventions communicaton
History
Name gender DOB Address Presenting complaint with duration Other complaints History of presenting complaint in chronological order Systemic inquiry
Previously diagnosed illness(es) and surgeries Drug history Medications taken for current illness Regular medications Drug allergies Family history Social history Menstrual history Psychic assessment
Chest pain
Breathlessness Palpitation
Syncope
Ankle swelling
Respiratory System
Cough Sputum Haemoptysis Breathlessness Chest pain Wheeze
epigastric pain
loss of Appetite
faintishness
weakness
numbness
tinkling sensation
hearing problem
visual problems
Locomotor System
pain in joints and muscle swelling of joints
Endocrine System
heat/ cold intolerance
weakness/tiredness increased thirst
oliguria/polyuria
colour of Urine urinary Stream vaginal discharge
General inquiry
appetite
weight change
malaise sleep
mood
Examination
General examination. Relevant system examination
Cardio vascular system. Respiratory system. Abdomen. Central nervous system. Locomotor system. Psychiatric assessment.
1. 2. 3. 4. 5.
60 y, female with uncontrolled BP for several years, WHICH WOULD SUGGEST END ORGAN DAMAGE Displaced heaving apex Exudate and hemorrhage in fundi LDL C-180mg/dl (130-160) Radio-femoral delay K+ 3mmol/l(3.6-5.1)
Patient management
history taking. clinical examination bed side investigations- Urine dip stick, Hb,CBS,O2 satn.Wt
Investigations
E.C.G Chest X ray Exercise E.C.G Electrophysiological investigations. Echo : Trans Thorasic Trans esophageal Nuclear imaging Cardiac CT Cardiac MRI Cardiac catheterization
Pericardiocentesis
Heart diseases
Can affect
Myocardium. Heart valves. Pericardium.
Cardiovascular System
Syncope
Ankle swelling
The new York heart association grading of cardiac status (NYHA classifications)
Grade1- No breathlessness Grade 2- Breathlessness on severe exertion Grade 3- Breathlessness on mild exertion Grade 4 Breathlessness at rest