Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Matthew Catterall
SUBJECTIVE
OBJECTIVE
ASSESSMENT / ANALYSIS
PLAN
Health History
A thorough, accurate & systematic review Explores past & present problems Can lead to a diagnosis which can then be confirmed or rejected by an examination of the patient The history gives you subjective data from which to work
Medical History
PC Presenting Complaint HPC History of Presenting Complaint PMH/PSH Previous medical/surgical history DH Drug History SH Social History FH Family History ROS review of systems O/E On Examination (focussed systems exam) Assessment/Analysis Plan
Presenting Complaint
Presenting complaint A short description of the reason for seeking care Based on what the patient tells you
History of the presenting complaint The nature of the problem How and when it started How it has progressed over time Impact on the patient
HPC Example
2/7 ago playing football at 1100 Fell inverting left ankle whilst running for ball Able to play on for 1/24 Becoming progessively more painful despite analgesia Today pain ++ with inability to weight bear Unable to drive to work Driven to hospital by wife
Drug History
Drug, dose, route, frequency Prescribed medication Over the counter medication Herbal remedies Illicit, street or recreational drugs Allergies/ senstivities/ intolerance
Social History
Men 21 Women 14
Smoking (cigarettes/day) Actvities of Daily Living (ADLs) Any formal/informal care Relatives, family, friends etc Accomodation Mobility aids Hobbies Recent travel
Family History
Current family make up Grandparents, parents, siblings Causes of death where relavant Diagnosed diseases
Functional enquiry Tailored to the presenting complaint Record pertinent negatives as well as positives Includes all major systems
Documentation
the patient has been depressed since he started seeing me in 1983 the patient was to have a bowel resection. However he took a job as stockbroker instead
she slipped on the ice and her legs wen separate ways in early December
Documentation
Concise Relevant Legible Legal document & part of patients medical record NOT DOCUMENTED = NOT DONE!! Remember your notes may need to be defended in court
Use ink, write legibly, use abbreviations carefully, dont write humorous comments - record factual information only
Include contextual information Date & Time (24 Hour Clock), Location, Your Details, Patient Information (Name, Age, Gender, Occupation)
On Examination (O/E)
Pt sitting in chair, not distressed, responding appropriately. Mother present during examination
Examine appropriate system/s Consider limitations without chaperone During your assessment analyse the following factors Likely explanation for the presentation Is the patient
Comfortable or distressed Well or ill Well nourished/hydrated Exhibiting classical signs (syndromes)
Final diagnosis Synthesis of history and examination Not always clear Impression often suffices in urgent/emergency care Working diagnosis may be required
Differenetial Diagnosis (DDx) Dictates treatment Range of potential diagnoses Ruled in or out by investigations Demonstrates consideration of red flag presentations
Tailored to patient Specific instructions for interventions Advice to patient Discharge instructions Referral Follow up care Safety Net advice
Example Algorithm
Any questions?
References
Bickley, L. (2003). Bates' guide to physical examination and history taking. Philadelphia: Lippincott, Williams and Wilkins. Douglas, G., Nicol, F. & Robertson, C. (2009). Macleods clinical examination. (12th ed.). Edinburgh: Churchill Livingstone Elsevier. Wardrope, J., Driscoll, P., Laird, C. & Woollard, W. (2008). Community emergency medicine. Edinburgh: Churchill Livingstone Elsevier.
This presentation has been sourced from the above texts however there are many texts which refer to the same information.