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    Personal Information Chief Complain History of Presenting Illness

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    Murad
    The document outlines the components of a comprehensive medical history and physical examination for a patient presenting with an injury. It includes sections for collecting information on the chief complaint, history of present illness, review of systems, past medical history, social history, family history, immunizations, allergies, physical examination, trauma assessment, secondary survey, summary and assessment, admission orders, and notes for an intraoperative procedure. The goal is to gather all relevant health details about the patient in order to make an accurate diagnosis and develop a treatment plan.

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    Personal Information Chief Complain History of Presenting Illness

    Uploaded by

    Murad
    74 views5 pages
    The document outlines the components of a comprehensive medical history and physical examination for a patient presenting with an injury. It includes sections for collecting information on the chief complaint, history of present illness, review of systems, past medical history, social history, family history, immunizations, allergies, physical examination, trauma assessment, secondary survey, summary and assessment, admission orders, and notes for an intraoperative procedure. The goal is to gather all relevant health details about the patient in order to make an accurate diagnosis and develop a treatment plan.

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    The document outlines the components of a comprehensive medical history and physical examination for a patient presenting with an injury. It includes sections for collecting information on the chief complaint, history of present illness, review of systems, past medical history, social history, family history, immunizations, allergies, physical examination, trauma assessment, secondary survey, summary and assessment, admission orders, and notes for an intraoperative procedure. The goal is to gather all relevant health details about the patient in order to make an accurate diagnosis and develop a treatment plan.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    74 views5 pages

    Personal Information Chief Complain History of Presenting Illness

    Uploaded by

    Murad
    The document outlines the components of a comprehensive medical history and physical examination for a patient presenting with an injury. It includes sections for collecting information on the chief complaint, history of present illness, review of systems, past medical history, social history, family history, immunizations, allergies, physical examination, trauma assessment, secondary survey, summary and assessment, admission orders, and notes for an intraoperative procedure. The goal is to gather all relevant health details about the patient in order to make an accurate diagnosis and develop a treatment plan.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    Introduction ( my name , ask for permission )

    Personal information : name , age , nationality


    Chief complain : site , duration , mechanism of injury
    History of presenting illness :
    Pain :
    1- site
    2- onset
    3- cheracter
    4- radiation
    5- timing
    6- exacerbation + relieving factor
    7- progression
    8- severity
    9- functionality
    10- Associated symptom

    Swelling :

    1- Site
    2- Another swelling
    3- Mechanism
    4- Severity
    5- Prosgression + regression + same
    6- Timing
    7- Off +on
    8- Exacerbation + relieving factor
    9- Associated symptom

    Redflag :

    1- Weight
    2- Fever
    3- Neurological symptom
    4- Dominant hand

    Past medical :
    1- Have you experienced this before
    2- Chronic medical illness ( diabetic , hypertension )
    3- Malignancy
    4- Medication

    Past surgical :
    1- Site
    2- When
    3- Where

    Social history :
    1- Smoking
    2- Alcoholic
    3- Occupation
    4- Iv drug used
    5- Travel
    6- Type of diet

    Family history :
    1- Mother , father , brother , sister
    2- Any disease
    3- Travel history

    Immunization history :
    Full or not

    Allegry history :
    1- Drugs
    2- Food

    Review of system :
    1- CVS ( palpitation , fatigue after work )
    2- CNS ( headache , syncope , seizure
    3- Respiratory ( shortness of breath , URTI )
    4- GIT ( abdominal pain , diarrhoea , constipation )
    5- Genitourinary/renal ( urine retention , haematuria )
    6- Psychiatry
    7- Endocrine ( cold intolerance , polyurea polydipsia

    Pediatric deformity :
    1- Onset
    2- Isolated + multiple
    3- Any precipitating event
    4- On +off
    5- Progression + regression + same
    6- Milestone
    7- exacerbation + relieving factor
    8- associated symptom ( fever , weight , )
    9- functionality ( affecting his life )
    10- prenatal + postnatal complication
    11- normal vaginal delivery or CS

    physical examination :
    general appearance : well built ,well nourishes

    vital sign : temperature , pulse , RR , BP , O2 sat , weight , Hight

    general examination :
    by systems

    local examination
    look , feel , move , neurovascular , measurement , special test

    ATLS :
    Announce trauma code

    While I am conducting ATLS code , I will ask the responsible staff to :

    M : monitor the patient

    O : administer O2

    V : vital

    I : insert to enlarge IV

    T : trauma Labs test

    1ry survey :
    A: airway and C collar

    B : breathing and ventilation ( inspection , palpation , percussion , auscultation )

    C : circulation ( abdominal examination : inspection , palpation ,percussion) pelvis


    instability , thigh deformity , external bleeding

    D : disability : GCS , pupil , lateralization sign

    E : exposure and environmental control :


    Adjunct 1ry survey :
    Chest xray , pelvis x ray . Labs ( ABG + cross match )

    Folly catheter

    NG tube

    FAST

    CT scan

    B-hcg

    AMPLE history :
    A : allergy

    M : medication

    P : past medical , past surgical , pregnancy

    L : last meal

    E : event

    2ry survey :
    Complete history , complete physical from head to toe

    Summury of history :
    Review old Labs and x-ray
    New Labs investigation and X-ray
    Admission order
    1. Diet:
    2. Activity:
    3. Vitals:
    4. Investigations: ECG, CXR
    5. Drugs:
    A. Pain
    B. Pus (antibiotics)
    C. Prophylaxis (enoxa, vomiting, strss ulcer, constipation)
    6. N nursing instructions: ice , elevation and weight of traction.
    7. C consultation
    8. OR preparation:
    A. Surgical consent
    B. Marking
    C. NPO IVF
    D. PRE-OP ANTIBIOTICS
    E. OR REQUEST
    F. INSTRUMENT AND C-ARM. TYPE OF TABLE
    9. B BLOOD

    Intra op:
    1. Position
    2. Shaving
    3. Tourniquet
    4. Scrubbing and draping.
    5. Time out

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