This is the foundation of the diagnosis of the patient's condition. A good history taking is very important in finding out what has happened and why it has happened.
This is the foundation of the diagnosis of the patient's condition. A good history taking is very important in finding out what has happened and why it has happened.
Medical college of wasit
Department of medicine
Case sheet history
Thing to remember :-
1) Stand on the right side of the patient with good confidence .
2) Introduce yourself as a medical student not as a doctor . ( you may face difficult question ).
3) Talk the patient gently with clear comprehensible words .
4) Remember don’t hurt the patient in your speak & touch .
History taking in medicine is one of the challenge all medical students face. This brief guide was prepared based on the teachings of Prof.A.S.B.Wijekoon, Prof.I.Amarasinghe & many senior registrars/registrars met during my career. This explans the basics of what must be included in your history, how to plan your investigations/ treatment in a methodical way.
Ulcerative Colitis: Case Presentation & Disease Overviewfarah al souheil
patient presenting with bloody stools and systemic signs with no previous medical complaints was diagnosed with amoebiasis on top ulcerative colitis (sigmoid-proctitis)
Medical college of wasit
Department of medicine
Case sheet history
Thing to remember :-
1) Stand on the right side of the patient with good confidence .
2) Introduce yourself as a medical student not as a doctor . ( you may face difficult question ).
3) Talk the patient gently with clear comprehensible words .
4) Remember don’t hurt the patient in your speak & touch .
History taking in medicine is one of the challenge all medical students face. This brief guide was prepared based on the teachings of Prof.A.S.B.Wijekoon, Prof.I.Amarasinghe & many senior registrars/registrars met during my career. This explans the basics of what must be included in your history, how to plan your investigations/ treatment in a methodical way.
Ulcerative Colitis: Case Presentation & Disease Overviewfarah al souheil
patient presenting with bloody stools and systemic signs with no previous medical complaints was diagnosed with amoebiasis on top ulcerative colitis (sigmoid-proctitis)
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Some of the slides, i hide it from my real presentations for my own reference. Download to see all of them.
CardiologyEndocrine Case Study Course Student Learning Outcom.docxannandleola
Cardiology/Endocrine Case Study
Course Student Learning Outcomes
Upon completion of the case study, students will be able to …
1. Apply the principles of pharmacology relative to pharmacotherapeutics across age levels including the effect of race, gender, ethnic group, and special populations.
2. Describe the uses, actions, effects and nursing implications of general classifications of drugs and selected specific drugs.
3. Investigate media resources and information technologies to enhance knowledge base of pharmacology.
4. Analyze the responsibilities of the nurse when administering drugs.
5. Apply pharmacological research to nursing practice.
Purpose The purpose of this case study is to apply concepts from pharmacology and
pathophysiology, national guidelines, and evidenced based clinical practices in the management of chronic disease. Remember this paper must follow APA guidelines for font, in text citations, reference list etc. No abstract is needed. Provide headings for the different questions in your paper.
Setting This case study takes place in a primary care setting in a small rural hospital clinic that provides health care services to predominately Latino field workers and their families. The rural clinic serves children and adults for all medical needs including well care, acute care, and chronic conditions. Some clients have seasonal insurance, state health insurance, or no insurance. Many live below poverty level according to the federal guidelines. Most do not own a vehicle. Most do not speak English; so, a translator is provided at each visit. The clinic is one hour from the nearest city where higher level of care can be offered to patients in need of specialty care. The clinic is staffed by one family medicine physician, an internist, two nurse practitioners, an RN, two LVNs, a lab tech, eight MAs and support staff. Once a week a cardiologist, podiatrist, pain specialist, orthopedist and ophthalmologist service the clinic. There is an on-site lab and a pharmacy two blocks away. There are two ambulances servicing the entire south end of the county with poor availability for emergencies.
Client
Jose is a 47 year old morbidly obese Latino male who presents to the clinic for follow up evaluation of headaches, dizziness, ringing in his ears and frequent urination. He reports having a headache that “comes and goes” with ringing in his ears and sometimes he sees spots. Jose has taken acetaminophen and states that seems to help. Due to his work schedule of six 12 hour days, Jose has not had preventive care. He reports fatigue and is depressed regarding his current income situation. Jose has just been laid off for the season and will lose his insurance in 30 days until the restart of the harvesting season in March. He is concerned about paying for any health care that may go beyond his benefit period. Jose lives with his pregnant wife, who does not work, and their seven children in a three bedroom one bath house that they share.
History Taking
1.Name, age, sex, marital status, occupation, address (Demographics)
2. Presenting complaints
3. History of present illness
4. Systemic inquiry
5. Past history
6. Menstrual history
7. Treatment history
8. Family history
9. Personal and social history
10. Occupational history
SOAP NOTE
Name:
Date:
Time:
Age:
Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI: Use OLDCART acronym
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med ) write medicine the same way you write a Rx
PMH (list approximate year of Dx of the disease or when surgical procedure performed)
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
Family History (list immediate family, age, disease, and whether is dead or alive)
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status
ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”.
Weight BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)
Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)
Diagnosis
Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out)
· 1-
· 2-
· 3-
Diagnosis with ICD 10 Code
CPT Code/Office visit code:
Plan/Therapeutics
· Plan:
· Further testing
· Medication
· Education
· Non-medication treatments
· Follow Up
· Referral
· When to seek emergency care
Evaluation of patient encounter
Document your level of interaction with the patient.
Weaknesses:
Strengths:
Reflection:
References:
Week 2: Respiratory Clinical Case
Patient Setting:
65 year old Caucasian female that was discharged from the hospital 10 weeks ago after a motor vehicle
accident presents to the clinic today. States she is having severe wheezing, shortness of b.
Approach to internship (mbbs in bangladesh perspective)Pritom Das
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
The Impact of Meeting: How It Can Change Your Life
History taking
1.
2. 1. Introduction and Describing Aim &Objectives 20 min
2. Chief complaint 10min
3. History of present illness 10min
4. Past medical history 10min
5. Systemic enquiry 10min
6. Family history 10min
7. Drug history 10min
8. Social history 10 min
PairGroupandRolePlay
3. Aim:
› At the end of the session students should
know fundamentals of history taking and take
a history of a simple disease
Objectives:
At the end of the session students should
record:
› Chief complaint
› Present illness
› Past medical history
› Systemic enquiry
› Family history
› Drug history
› Social history
4. Obtaining an accurate history is the
critical first step in determining the
etiology of a patient's illness
A large percentage of the time ) 70%),
you will actually be able make a
diagnosis based on the history alone.
5. The sense of what constitutes important
data will grow exponentially in future as you
learn about the pathophysiology of disease
You are already in possession of the tools
that will enable you to obtain a good
history.
An ability to listen and ask common-sense
questions that help define the nature of a
particular problem.
A vast and sophisticated fund of
knowledge not needed to successfully
interview a patient.
6. Introduce yourself.
•Note – never forget patient names
•Creat patient appropriately in a friendly relaxed way.
•Confidentiality and respect patient privacy.
General ApproachGeneral Approach
Try to see things from patient point of view. Understand
patient underneath mental status, anxiety, irritation or
depression.
Always exhibit neutral position.
Listening
Questioning: simple/clear/avoid medical terms/open, leading,
interrupting, direct questions and summarizing.
7. .
Always record personal details:
› name,
› age,
› address,
› sex,
› ethnicity,
› occupation,
› religion,
› marital status.
› Record date of examination
8. Chief complaint
History of present illness
Past medical history
Systemic enquiry
Family history
Drug history
Social history
9.
10. The main reason push the pt. to seek for
visiting a physician or for help
Usually a single symptoms, occasionally
more than one complaints eg: chest pain,
palpitation, shortness of breath, ankle
swelling etc
The patient describe the problem in their
own words.
It should be recorded in pt’s own words.
What brings your here? How can I help
you? What seems to be the problem?
11. Cheif Complaint (CC)Cheif Complaint (CC)
Short/specific in one clear sentence
communicating present/major problem/issue.
Timing – fever for last two weeks or since
Monday
Recurrent –recurring episode of abdominal
pain/cough
Any major disease important with PC e.g. DM,
asthma, HT, pregnancy, IHD:
Note: CC should be put in patient language.
12. Chief complaint
History of present illness
Past medical history
Systemic enquiry
Family history
Drug history
Social history
13.
14. Elaborate on the chief complaint in
detail
Ask relevant associated symptoms
Have differential diagnosis in mind
Lead the conversation and thoughts
Decide and weight the importance of
minor complaints
15. Sequential presentation
•Always relay story in days before admission e.g. 1 week before the
admission, the patient fell while gardening and cut his foot with a stone.
•Narrate in details – By that evening, the foot became swollen and patient
was unable to walk. Next day patient attended Khorshid hospital and
they gave him some oral antibiotics. He doesn’t know the name. There
is no effect on his condition and two days prior to admission, the foot
continued to swell and started to discharge pus. There is high fever and
rigors with nausea and vomiting.
History of Presenting Complaint(HPC)History of Presenting Complaint(HPC)
In details of symptomatic presentation
•If patient has more than one symptom, like chest pain, swollen legs and
vomiting, take each symptom individually and follow it through fully
mentioning significant negatives as well. E.g the pain was central
crushing pain radiating to left jaw while mowing the lawn. It lasted for
less than 5 minutes and was relieved by taking rest. No associated
symptoms with pain/never had this pain before/no relation with food/he
is Known smoker,diabetic & father died of heart attack at age of 45.
In details of present problem with- time of onset/ mode of evolution/ any
investigation;treatment &outcome/any associated +’ve or -’ve symptoms.
16. Avoid medical terminology and make
use of a descriptive language that is
familiar to them
Describe each symptom in
chronological order
17. Pain (OPQRST)Pain (OPQRST)
Position/site
Severity – how it affects daily work/physical activities. Wakes
him up at night, cannot sleep/do any work.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Quality, nature, character – burning sharp, stabbing, crushing;
also explain depth of pain – superficial or deep.
Timing – mode of onset (abrupt or gradual), progression
(continuous or intermittent – if intermittent ask frequency and
nature.)
Treatment received or/and outcome.
Onset of disease
Are there any associated symptoms? Check with SR.
18.
19. Start by asking the patient if they have
any medical problems
IHD/Heart Attack/DM/Asthma/HT/RHD,
TB/Jaundice/Fits :E.g. if diabetic- mention time
of diagnosis/current medication/clinic check up
Past surgical/operation history
E.g. time/place/ and what type of operation.
Note any blood transfusion and blood grouping.
History of trauma/accidents
E.g. time/place/ and what type of accident
20.
21. Drug History (DH)
Always use generic name or put trade
name in brackets with dosage, timing
and how long. Example: Ranitidine
150 mg BD PO
Note: do not forget to mention
OCP/Vitamins/Traditional
medicine/KAP
22. bd (Bis die) - Twice daily (usually morning and
night)
tds (ter die sumendus)/tid (ter in die) = Three
times a day mainly 8 hourly
qds (quarter die sumendus)/qid (quarter in die)
= four times daily mainly 6 hourly
Mane/(om – omni mane) = morning
Nocte/(on – omni nocte) = night
ac (ante cibum) = before food
pc (post cibum) = after food
po (per orum/os) = by mouth
stat – statim = immediately as initial dose
Rx (recipe) = treat with
23.
24. Any familial disease/running in families
e.g. breast cancer, IHD, DM,HTN
schizophrenia, Developmental delay,
asthma etc.
25.
26. Smoking history - amount, duration and
type. A strong risk factor for IHD
Drinking history - amount, duration and
type. Cause cardiomyopathy,
vasodilatation
Occupation, social and education
background, ADL, family social support
and financial situation
27. Gyane/Obstetric history if female
Immunization if small child
Note: Look for the child health card.
Travel and sexual history if suspected STI or
infectious disease
Note:
If small child, obtain the history from the care
giver. Make sure; talk to right care giver.
If some one does not talk to your language, get
an interpreter(neutral not family friend or
member also familiar with both language). Ask
simple & straight question but do not go for yes
or no answer.
28. System Review (SR)System Review (SR)
This is a guide not to miss anything
Any significant finding should be moved to HPC or PMH
depending upon where you think it belongs.
Do not forget to ask associated symptoms of PC with the
System involved
When giving verbal reports, say no significant finding on
systems review to show you did it. However when writing
up patient notes, you should record the systems review so
that the relieving doctors know what system you covered.
29. System ReviewSystem Review
Respiratory System
•Cough(productive/dry)
•Sputum (colour, amount, smell)
•Haemoptysis
•Chest pain
•SOB/Dyspnoea
•Tachypnoea
•Hoarseness
•Wheezing
Cardiovascular
•Chest pain
•Paroxysmal Nocturnal Dyspnoea
•Orthopnoea
•Short Of Breath(SOB)
•Cough/sputum (pinkish/frank blood)
•Swelling of ankle(SOA)
•Palpitations
•Cyanosis
Gastrointestinal/Alimentary
•Appetite (anorexia/weight change)
•Diet
•Nausea/vomiting
•Regurgitation/heart burn/flatulence
•Difficulty in swallowing
•Abdominal pain/distension
•Change of bowel habit
•Haematemesis, melaena, haematochagia
•Jaundice
General
•Weakness
•Fatigue
•Anorexia
•Change of weight
•Fever
•Lumps
•Night sweats
30. System ReviewSystem Review
Urinary System
•Frequency
•Dysuria
•Urgency
•Hesitancy
•Terminal dribbling
•Nocturia
•Back/loin pain
•Incontinence
•Character of urine:color/ amount
(polyuria) & timing
•Fever
Nervous System
•Visual/Smell/Taste/Hearing/Speech
problem
•Head ache
•Fits/Faints/Black outs/loss of
consciousness(LOC)
•Muscle weakness/numbness/paralysis
•Abnormal sensation
•Tremor
•Change of behaviour or psyche
Genital system
•Pain/ discomfort/ itching
•Discharge
•Unusual bleeding
•Sexual history
•Menstrual history – menarche/ LMP/
duration & amount of cycle/
Contraception
•Obstetric history – Para/ gravida/abortion
Musculoskeletal System
•Pain – muscle, bone, joint
•Swelling
•Weakness/movement
•Deformities
•Gait
31. SOAPSOAP
Subjective: how patient feels/thinks about him. How does
he look. Includes PC and general appearance/condition of
patient
Objective – relevant points of patient complaints/vital
sings, physical examination/daily weight,fluid
balance,diet/laboratory investigation and interpretation
Plan – about management, treatment, further investigation,
follow up and rehabilitation
Assessment – address each active problem after making a
problem list. Make differential diagnosis.