This document provides a revision on taking adult and pediatric health histories. It discusses the objectives, components, and techniques of comprehensive health history taking. For adults, it outlines the standard format including identification, chief complaints, history of present illness, past medical history, review of systems, and family history. For pediatrics, it notes similarities but also differences such as obtaining history indirectly and including immunization, nutritional, and developmental histories. The document aims to clarify clinical evaluation and revising basic history taking skills.
This document provides guidance on taking a patient's medical history. It discusses the importance of history taking in diagnosis and outlines the key components of a comprehensive health history, including identification, chief complaints, history of present illness, past medical history, review of systems, and social history. The document emphasizes building rapport with the patient, using open-ended questions, active listening, and taking thorough but concise notes.
This document provides guidance on performing a thorough patient history. It outlines the key components of a patient history, including chief complaint, history of present illness, past medical history, drug history, family history, and social history. The importance of obtaining an accurate history is emphasized as it allows the healthcare provider to determine the etiology of the patient's problem. Guidelines are provided on how to conduct each part of the history respectfully and obtain relevant information through active listening and open-ended questioning.
This document provides information on taking a case history for dental patients. It discusses the importance of the case history, outlines the key components that should be covered, and explains the purpose and importance of each component. These include gathering information on the chief complaint, medical history, dental history, social history, and performing an extraoral and intraoral examination. Taking a thorough case history is important for diagnosis, treatment planning, and managing the patient properly.
The document provides guidance on how to conduct a thorough patient history, including how to structure the history taking session and how to approach each component of the history. It discusses taking the chief complaint, history of present illness, past medical history, drug history, family history, and social history. For each component, it provides tips on what information to obtain and how to record it in the patient's own words. It also describes doing a review of all body systems to check for any associated symptoms.
This document provides an overview of health assessment and physical examination. It defines health assessment, describes the purposes of assessment, and outlines the different types of assessments including comprehensive, focused, and ongoing assessments. It also describes techniques used in physical examination such as inspection, palpation, percussion, and auscultation. Additionally, it provides details on preparing the patient and environment, positioning the patient, and assessing various body systems.
This document provides an overview of how to take a thorough medical history and conduct respiratory and cardiovascular examinations. It outlines the traditional framework for taking a medical history, including the presenting complaint, past medical history, allergies, medications, and review of systems. It emphasizes important details to obtain for patients with respiratory symptoms, including a frailty assessment. The document also provides guidance on examining the chest, heart, and lungs, with notes on auscultation findings and common respiratory and cardiac conditions.
This document outlines the process and components of taking a patient's medical history. It discusses introducing oneself to the patient, obtaining their chief complaint, history of present illness, past medical history, family history, drug history, and social history. It emphasizes listening to the patient, asking open-ended questions, avoiding medical terminology, and recording all information in the patient's own words. The goal is to accurately determine the etiology of the patient's illness based on their history.
3 history taking & physical examinationawadfadlalla1
This document provides information on nursing history taking and physical examination. It discusses the importance of obtaining an accurate patient history, which is critical for diagnosis. The key components of history taking are identified as demographic data, chief complaint, history of present illness, past medical history, family history, drug history, review of systems, and physical examination. The principles and techniques of physical examination are outlined, including inspection, palpation, percussion, and auscultation. A head-to-toe assessment approach is recommended to perform a thorough physical exam.
This document provides guidance on taking a patient's medical history. It discusses the importance of history taking in diagnosis and outlines the key components of a comprehensive health history, including identification, chief complaints, history of present illness, past medical history, review of systems, and social history. The document emphasizes building rapport with the patient, using open-ended questions, active listening, and taking thorough but concise notes.
This document provides guidance on performing a thorough patient history. It outlines the key components of a patient history, including chief complaint, history of present illness, past medical history, drug history, family history, and social history. The importance of obtaining an accurate history is emphasized as it allows the healthcare provider to determine the etiology of the patient's problem. Guidelines are provided on how to conduct each part of the history respectfully and obtain relevant information through active listening and open-ended questioning.
This document provides information on taking a case history for dental patients. It discusses the importance of the case history, outlines the key components that should be covered, and explains the purpose and importance of each component. These include gathering information on the chief complaint, medical history, dental history, social history, and performing an extraoral and intraoral examination. Taking a thorough case history is important for diagnosis, treatment planning, and managing the patient properly.
The document provides guidance on how to conduct a thorough patient history, including how to structure the history taking session and how to approach each component of the history. It discusses taking the chief complaint, history of present illness, past medical history, drug history, family history, and social history. For each component, it provides tips on what information to obtain and how to record it in the patient's own words. It also describes doing a review of all body systems to check for any associated symptoms.
This document provides an overview of health assessment and physical examination. It defines health assessment, describes the purposes of assessment, and outlines the different types of assessments including comprehensive, focused, and ongoing assessments. It also describes techniques used in physical examination such as inspection, palpation, percussion, and auscultation. Additionally, it provides details on preparing the patient and environment, positioning the patient, and assessing various body systems.
This document provides an overview of how to take a thorough medical history and conduct respiratory and cardiovascular examinations. It outlines the traditional framework for taking a medical history, including the presenting complaint, past medical history, allergies, medications, and review of systems. It emphasizes important details to obtain for patients with respiratory symptoms, including a frailty assessment. The document also provides guidance on examining the chest, heart, and lungs, with notes on auscultation findings and common respiratory and cardiac conditions.
This document outlines the process and components of taking a patient's medical history. It discusses introducing oneself to the patient, obtaining their chief complaint, history of present illness, past medical history, family history, drug history, and social history. It emphasizes listening to the patient, asking open-ended questions, avoiding medical terminology, and recording all information in the patient's own words. The goal is to accurately determine the etiology of the patient's illness based on their history.
3 history taking & physical examinationawadfadlalla1
This document provides information on nursing history taking and physical examination. It discusses the importance of obtaining an accurate patient history, which is critical for diagnosis. The key components of history taking are identified as demographic data, chief complaint, history of present illness, past medical history, family history, drug history, review of systems, and physical examination. The principles and techniques of physical examination are outlined, including inspection, palpation, percussion, and auscultation. A head-to-toe assessment approach is recommended to perform a thorough physical exam.
This document provides information on taking a case history. It discusses the importance of gathering a patient's chief complaint, medical history, dental history, and personal history. It outlines the key components of a case history, including statistics, examination findings, diagnosis, and treatment plan. It also describes different methods for obtaining a patient's history, such as interviews, questionnaires, and a combination approach. The goal of a case history is to understand the nature of a patient's illness and provide relevant information to aid in diagnosis and treatment decisions.
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.
The document provides guidance on taking a patient's medical history. It discusses the importance of obtaining an accurate history and outlines the general approach and structure for conducting a history, including introducing oneself, ensuring confidentiality, listening to the patient, and asking open-ended questions. It then covers how to record specific components of the history, such as the chief complaint, history of present illness, past medical history, drug history, family history, and social history.
Diagnosis and treatment planing of conservativeAjeet Kumar
This document provides an overview of patient evaluation, examination, diagnosis, and treatment planning for conservative and endodontic treatment. It discusses taking a thorough case history, medical history, and clinical examination including inspection, palpation, percussion, and exploration of the soft tissues, hard tissues, periodontal tissues, existing restorations, and use of radiographs and diagnostic tests to arrive at a diagnosis and treatment plan. The goal is to identify any dental or systemic issues, thoroughly examine the patient, and determine the appropriate treatment.
This document provides an overview of the components of a case history for dental patients. It discusses the importance of collecting demographic data, chief complaint, history of presenting illness, medical history, dental history, family history, and personal history from the patient. It also describes examining the patient's general health by checking vital signs, nutrition status, and for any signs such as cyanosis, pallor, or edema. Taking a thorough case history is important for diagnosis, treatment planning, and managing patients with underlying medical conditions.
Advanced Health Assessment NURS 6830 Spring 2021.docxwrite22
This document provides an overview and instructions for the Advanced Health Assessment NURS 6830 Spring 2021 course. It includes sections on conducting a patient health history, documenting a SOAP note, performing a self-reflection, and guidelines for physical exams of various body systems. Students will interview a virtual patient to complete a health history, document subjective and objective findings in a SOAP note, and reflect on their performance to improve clinical skills.
A 45-year-old female presented with a 1 month history of a swelling in her lower lip. Her past medical history included several episodes of angina over the past 4 years, treated with nitroglycerin as needed. Examination revealed a 2mm x 2mm hard, non-movable lesion consistent with a minor salivary gland injury. The patient was advised the lesion may resolve on its own or could be surgically removed under local anesthesia. Any dental treatment would need to consider her history of cardiovascular issues.
The document provides guidelines for writing patient write-ups, including their purpose, structure, and common mistakes to avoid. It recommends the write-up be 3-5 pages long and include sections for source of information, chief complaint, history of present illness, past medical history, family history, social history, review of systems, physical exam, labs, and assessment and plan. For the history of present illness section, it provides detailed instructions on how to construct the topic sentence, chronology, pertinent negatives, and concluding remarks. Common mistakes include omitting pertinent negatives, discussing related complaints separately, using long narrative descriptions, and incomplete assessment and plans.
This document outlines the key components of taking a patient's history and performing a physical examination. It discusses obtaining demographic information, chief complaints, history of present illness, review of systems, past medical history, medications, family history and social history. It also covers performing a general exam including vital signs and a systems-based physical exam using inspection, palpation, percussion and auscultation. The document stresses developing a provisional diagnosis followed by appropriate investigations, treatment and management of the patient's condition.
This document outlines the key components of conducting a physical examination, including:
- The purposes of a physical exam are to identify health issues and monitor a patient's condition over time. Exams can be comprehensive, focused on a specific issue, or ongoing.
- Proper preparation includes explaining the exam to the patient, ensuring privacy and comfort, and using appropriate exam techniques like inspection, palpation, percussion, and auscultation.
- A full exam involves a health history, assessment of each body system, and documentation of findings. Key steps are outlined for assessing things like the eyes, ears, nose, and neurological system.
Health assessment By - Jitendra Bokha.pptxJitendra Bokha
Health assessment is defined as systematic and dynamic process by which nurse through interaction with client, significant others and health care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
This document provides information on case history taking in dentistry. It discusses the objectives, steps, and components of obtaining a patient's medical history. The key methods of history taking are interviews, health questionnaires, and a combination approach. Important parts of the case history include the patient's statistics, chief complaint, medical/dental history, examination findings, diagnosis, and treatment plan. Thoroughly understanding a patient's history is essential for establishing a diagnosis and appropriate treatment.
History taking involves gaining information from patients through directed questioning to aid medical diagnosis and care. It is critical for determining the cause of a patient's illness, as diagnosis is often based on clinical history alone. An accurate history is obtained by addressing key components in order: chief complaint, history of present illness, past medical history, family history, and personal history. Open-ended questions allow patients to provide their own perspective, while closed questions clarify specific details chronologically. History taking is an essential medical skill developed through focused practice and attention to patient communication.
The document provides guidance on conducting an effective patient history. It emphasizes the importance of the history in making an accurate diagnosis in many cases. The summary should include the key components of a patient history: chief complaint, history of present illness, past medical/dental history, social history, and review of systems. The document also describes different methods for obtaining the history and important factors to address for different chief complaints like pain, swelling and ulcers.
Pediatrics History Taking and Physical Examination.pptxAJAY MANDAL
This document outlines the components and steps for taking a pediatric history and conducting a physical examination for newborns, infants, children, and adolescents. It discusses obtaining a thorough history, including chief complaint, history of present illness, review of systems, past medical history, family history, and social history. The document also provides guidance on performing a complete physical exam for newborns, assessing vital signs, appearance, and examining each body system.
Here are the key differences between the 1995 and 1997 E/M examination guidelines:
1995 Guidelines:
- Based on extent of exam (problem focused, expanded problem focused, detailed, comprehensive)
- Defines extent by number of body areas/organ systems examined
1997 Guidelines:
- Based on organ systems/body areas examined and elements documented
- Defines extent by minimum number of elements documented across organ systems/body areas
- More flexibility in choice of organ systems/areas examined
So in summary, 1995 based on scope of exam, 1997 based on documentation of exam elements.
This document provides information on history taking and physical assessment in nursing. It discusses the components of history taking, including patient profile, chief complaint, history of present illness, past medical history, family history, and system review. It also describes the four techniques of physical assessment: inspection, palpation, percussion, and auscultation. The nurse's role in maintaining privacy, lighting, patient comfort, and preparing equipment for physical examination is also outlined.
This document provides care plans for various medical conditions and procedures. It includes care plans for a neonate with hyperbilirubinemia, risk of overdose from drug toxicity, appendicitis post-operation, and sickle cell crisis. The care plans identify problems, goals, and interventions related to fluid balance, pain management, infection risk, and other common issues for each condition.
MN552 Advanced Health Assessment Unit 4 Comprehensive SOAP Note .docxannandleola
This guide provides instructions for completing a comprehensive SOAP note by documenting all elements of the patient's history and physical exam in an organized manner. The guide outlines the subjective, objective, assessment, and plan sections of the SOAP note and provides examples of what to include under each system of the physical exam. It emphasizes performing a full exam of all body systems rather than just those relevant to the chief complaint. Students are to use this guide to document a sample patient encounter and SOAP note.
This document provides information on taking a case history. It discusses the importance of gathering a patient's chief complaint, medical history, dental history, and personal history. It outlines the key components of a case history, including statistics, examination findings, diagnosis, and treatment plan. It also describes different methods for obtaining a patient's history, such as interviews, questionnaires, and a combination approach. The goal of a case history is to understand the nature of a patient's illness and provide relevant information to aid in diagnosis and treatment decisions.
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.
The document provides guidance on taking a patient's medical history. It discusses the importance of obtaining an accurate history and outlines the general approach and structure for conducting a history, including introducing oneself, ensuring confidentiality, listening to the patient, and asking open-ended questions. It then covers how to record specific components of the history, such as the chief complaint, history of present illness, past medical history, drug history, family history, and social history.
Diagnosis and treatment planing of conservativeAjeet Kumar
This document provides an overview of patient evaluation, examination, diagnosis, and treatment planning for conservative and endodontic treatment. It discusses taking a thorough case history, medical history, and clinical examination including inspection, palpation, percussion, and exploration of the soft tissues, hard tissues, periodontal tissues, existing restorations, and use of radiographs and diagnostic tests to arrive at a diagnosis and treatment plan. The goal is to identify any dental or systemic issues, thoroughly examine the patient, and determine the appropriate treatment.
This document provides an overview of the components of a case history for dental patients. It discusses the importance of collecting demographic data, chief complaint, history of presenting illness, medical history, dental history, family history, and personal history from the patient. It also describes examining the patient's general health by checking vital signs, nutrition status, and for any signs such as cyanosis, pallor, or edema. Taking a thorough case history is important for diagnosis, treatment planning, and managing patients with underlying medical conditions.
Advanced Health Assessment NURS 6830 Spring 2021.docxwrite22
This document provides an overview and instructions for the Advanced Health Assessment NURS 6830 Spring 2021 course. It includes sections on conducting a patient health history, documenting a SOAP note, performing a self-reflection, and guidelines for physical exams of various body systems. Students will interview a virtual patient to complete a health history, document subjective and objective findings in a SOAP note, and reflect on their performance to improve clinical skills.
A 45-year-old female presented with a 1 month history of a swelling in her lower lip. Her past medical history included several episodes of angina over the past 4 years, treated with nitroglycerin as needed. Examination revealed a 2mm x 2mm hard, non-movable lesion consistent with a minor salivary gland injury. The patient was advised the lesion may resolve on its own or could be surgically removed under local anesthesia. Any dental treatment would need to consider her history of cardiovascular issues.
The document provides guidelines for writing patient write-ups, including their purpose, structure, and common mistakes to avoid. It recommends the write-up be 3-5 pages long and include sections for source of information, chief complaint, history of present illness, past medical history, family history, social history, review of systems, physical exam, labs, and assessment and plan. For the history of present illness section, it provides detailed instructions on how to construct the topic sentence, chronology, pertinent negatives, and concluding remarks. Common mistakes include omitting pertinent negatives, discussing related complaints separately, using long narrative descriptions, and incomplete assessment and plans.
This document outlines the key components of taking a patient's history and performing a physical examination. It discusses obtaining demographic information, chief complaints, history of present illness, review of systems, past medical history, medications, family history and social history. It also covers performing a general exam including vital signs and a systems-based physical exam using inspection, palpation, percussion and auscultation. The document stresses developing a provisional diagnosis followed by appropriate investigations, treatment and management of the patient's condition.
This document outlines the key components of conducting a physical examination, including:
- The purposes of a physical exam are to identify health issues and monitor a patient's condition over time. Exams can be comprehensive, focused on a specific issue, or ongoing.
- Proper preparation includes explaining the exam to the patient, ensuring privacy and comfort, and using appropriate exam techniques like inspection, palpation, percussion, and auscultation.
- A full exam involves a health history, assessment of each body system, and documentation of findings. Key steps are outlined for assessing things like the eyes, ears, nose, and neurological system.
Health assessment By - Jitendra Bokha.pptxJitendra Bokha
Health assessment is defined as systematic and dynamic process by which nurse through interaction with client, significant others and health care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
This document provides information on case history taking in dentistry. It discusses the objectives, steps, and components of obtaining a patient's medical history. The key methods of history taking are interviews, health questionnaires, and a combination approach. Important parts of the case history include the patient's statistics, chief complaint, medical/dental history, examination findings, diagnosis, and treatment plan. Thoroughly understanding a patient's history is essential for establishing a diagnosis and appropriate treatment.
History taking involves gaining information from patients through directed questioning to aid medical diagnosis and care. It is critical for determining the cause of a patient's illness, as diagnosis is often based on clinical history alone. An accurate history is obtained by addressing key components in order: chief complaint, history of present illness, past medical history, family history, and personal history. Open-ended questions allow patients to provide their own perspective, while closed questions clarify specific details chronologically. History taking is an essential medical skill developed through focused practice and attention to patient communication.
The document provides guidance on conducting an effective patient history. It emphasizes the importance of the history in making an accurate diagnosis in many cases. The summary should include the key components of a patient history: chief complaint, history of present illness, past medical/dental history, social history, and review of systems. The document also describes different methods for obtaining the history and important factors to address for different chief complaints like pain, swelling and ulcers.
Pediatrics History Taking and Physical Examination.pptxAJAY MANDAL
This document outlines the components and steps for taking a pediatric history and conducting a physical examination for newborns, infants, children, and adolescents. It discusses obtaining a thorough history, including chief complaint, history of present illness, review of systems, past medical history, family history, and social history. The document also provides guidance on performing a complete physical exam for newborns, assessing vital signs, appearance, and examining each body system.
Here are the key differences between the 1995 and 1997 E/M examination guidelines:
1995 Guidelines:
- Based on extent of exam (problem focused, expanded problem focused, detailed, comprehensive)
- Defines extent by number of body areas/organ systems examined
1997 Guidelines:
- Based on organ systems/body areas examined and elements documented
- Defines extent by minimum number of elements documented across organ systems/body areas
- More flexibility in choice of organ systems/areas examined
So in summary, 1995 based on scope of exam, 1997 based on documentation of exam elements.
This document provides information on history taking and physical assessment in nursing. It discusses the components of history taking, including patient profile, chief complaint, history of present illness, past medical history, family history, and system review. It also describes the four techniques of physical assessment: inspection, palpation, percussion, and auscultation. The nurse's role in maintaining privacy, lighting, patient comfort, and preparing equipment for physical examination is also outlined.
This document provides care plans for various medical conditions and procedures. It includes care plans for a neonate with hyperbilirubinemia, risk of overdose from drug toxicity, appendicitis post-operation, and sickle cell crisis. The care plans identify problems, goals, and interventions related to fluid balance, pain management, infection risk, and other common issues for each condition.
MN552 Advanced Health Assessment Unit 4 Comprehensive SOAP Note .docxannandleola
This guide provides instructions for completing a comprehensive SOAP note by documenting all elements of the patient's history and physical exam in an organized manner. The guide outlines the subjective, objective, assessment, and plan sections of the SOAP note and provides examples of what to include under each system of the physical exam. It emphasizes performing a full exam of all body systems rather than just those relevant to the chief complaint. Students are to use this guide to document a sample patient encounter and SOAP note.
Assessment and management of Airway for BSc Nuursing StudentsAme Mehadi
The document discusses airway assessment. It defines the upper and lower airways and describes components of each. It then defines a difficult airway and lists factors that can make mask ventilation and intubation difficult. The document outlines tools for assessing airway difficulty, including individual indices, group indices with or without scoring, laryngoscopy grading, tests of mandibular space, and advanced radiographic assessments. It emphasizes that a thorough airway assessment is critical for airway management and difficult intubations cannot always be predicted.
Principles of Anesthesia for Nursing StudentsAme Mehadi
This document provides an overview of anesthesia, including definitions, types, stages of general anesthesia, and mechanisms of action. It discusses local anesthesia, general anesthesia, and the routes of administering each. The stages of general anesthesia are induction, excitement, relaxation, and danger. Inhalational agents like nitrous oxide, halothane, and isoflurane as well as intravenous agents like thiopental sodium and ketamine are reviewed. The document aims to educate about the basics of anesthesia.
First Aid for management of Specific Injuries.pptxAme Mehadi
This document provides information on first aid for specific injuries written by Ame Mehadi. It covers injuries to the eyes, head, face, jaw, nose, neck, chest, abdomen and skin burns. For eye injuries, it describes treating foreign objects and blows to the eye. For head injuries, it discusses scalp wounds and signs of brain injury, advising to call for medical help. Face and jaw injuries can obstruct breathing, so the first aid is to maintain an open airway. Nosebleeds are also addressed. The document aims to inform first responders on appropriate first aid for different types of injuries.
Nursing Ethics for nurses in clinical settingAme Mehadi
The document outlines an agenda for a national training on nursing ethics conducted by the Federal Ministry of Health. The 7-session training covers topics such as the introduction to nursing ethics, ethical principles, nursing values, ethical dilemmas, ethical decision-making, legal aspects of nursing practice, and the nursing code of ethics. Session 1 defines nursing ethics and describes theories of ethics. Session 2 identifies ethical principles like beneficence, non-maleficence, respect for autonomy, and others. Session 3 explains ideal nursing competencies such as moral integrity, communication skills, and concern for patients. Session 4 discusses ethical dilemmas and moral distress in nursing.
pneumothorax for Emergency and critical care nursing studentsAme Mehadi
A tension pneumothorax occurs when air enters the chest cavity during breathing but cannot escape, causing the lung to collapse with each inhalation. This puts pressure on the heart and pushes the trachea away from the affected side, compressing the heart and potentially stopping breathing if not treated by releasing the trapped air.
WOUND CARE for Public health professionals .pptAme Mehadi
This document provides guidance on wound care, including differentiating between types of wounds and describing various wound healing processes. It outlines the objectives and equipment needed for cleaning and dressing clean wounds, septic wounds, and wounds with drainage tubes. Procedures are provided for dressing changes, wound irrigation, and ensuring aseptic technique is followed to prevent infection. The goal of wound care is to keep wounds clean and promote healing.
The document provides information about operating room organization and design. It discusses the objective of describing specific OR areas, equipment, environmental layout, personnel, and aseptic technique principles. It defines key terms like operating department, operating suite, and operating theater. It describes the major considerations for OR design which include doors, lighting, ventilation, humidity, and heating. The basic design principles are outlined, including having a simple cleanable design, separate clean and soiled instrument rooms, and sufficient space. Specific organizational areas in the OR are also detailed.
The document provides an outline for a lecture on communicable disease control nursing. It covers several topics including the definition and features of communicable diseases, classification methods, and the chain of disease transmission. The chain of transmission involves an infectious agent, reservoir, portal of exit, mode of transmission, mode of entry, and successive host. Reservoirs can be humans, animals, vectors, or the environment. Five factors that play a role in fecal-oral disease transmission are also defined.
Surgical Conscience and Informed ConsentAme Mehadi
This document discusses informed consent and surgical conscience. It defines informed consent as permission obtained from a patient to perform a specific medical test or procedure. Surgical conscience is defined as surgical ethics, principles, or a sense of right and wrong. The document outlines the purposes of informed consent, circumstances requiring consent, essential elements of informed consent, and requisites for validity of informed consent such as obtaining written permission and signature without pressure or duress.
CASH Clean and Safe Health facilities Initiative_Ethiopia.pptAme Mehadi
The Clean and Safe Health Facilities Initiative (CASH) aims to make healthcare facilities clean, safe, and comfortable for patients, visitors, staff, and the community. It focuses on cleaning, safety, and infection prevention. The objectives are to increase awareness of cleaning and safety, engage all staff in cleaning activities, and create accountability. The scope includes clinical areas, utilities, buildings, and waste management. Principles emphasize that clean care is safer care and cleanliness is a shared responsibility. Strategies include governance structures, advocacy, collaboration, and recognition of best practices. Action points involve assessments, infrastructure improvements, campaigns, and monitoring/evaluation. Measures center on attitudes, standards implementation, satisfaction, and infection rates. Responsibilities
This document discusses proper hand hygiene techniques for healthcare workers. It covers the importance of hand hygiene in reducing infection spread, different hand hygiene methods like hand washing, hand antisepsis, antiseptic hand rubs and surgical hand scrubs. The techniques for each method are described in detail. Barriers to hand hygiene compliance and strategies to improve practices are also reviewed.
This document discusses personal protective equipment (PPE) used in healthcare settings. It covers various types of PPE like gloves, masks, gowns and drapes. It describes when each type should be used and how to correctly put on and remove PPE like gloves and masks. The key learning objectives are to list different PPE, describe their uses and limitations, and demonstrate proper donning and doffing of equipment.
This document discusses iron poisoning, including its stages, signs and symptoms, diagnostic tests, differential diagnosis, management, follow up, complications, and prognosis. Iron poisoning can cause gastrointestinal toxicity within 6 hours, then apparent improvement before systemic injury sets in from 12-48 hours with potential hepatic injury, hypoglycemia, bleeding, and other effects. Management involves supportive care, gastric emptying, whole bowel irrigation, and chelation therapy with deferoxamine. Complications can include hypotension, metabolic acidosis, hemorrhage, and organ failure. Prognosis depends on serum iron levels with higher levels carrying more risk.
This document discusses various types of bone injuries including fractures, sprains, strains, and muscle cramps. It provides details on closed and open fractures, as well as green stick and complicated fractures. Signs and symptoms of fractures are outlined. First aid principles for fractures include immobilization, splinting, controlling bleeding if open, and seeking immediate medical help. Specific fractures of the skull, face, shoulder blade, collarbone, upper arm, elbow, and forearm are also described with appropriate first aid treatments.
THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...Nursing Mastery
Title: Unlocking the Wonders of the Special Senses: Sight, Sound, Smell, Taste, and Balance
Introduction:
Welcome to our captivating SlideShare presentation on the Special Senses, where we delve into the extraordinary capabilities that allow us to perceive and interact with the world around us. Join us on a sensory journey as we explore the intricate structures and functions of sight, sound, smell, taste, and balance.
The special senses are our primary means of experiencing and interpreting the environment, each sense providing unique and vital information that shapes our perceptions and responses. These senses are facilitated by highly specialized organs and complex neural pathways, enabling us to see a vibrant sunset, hear a symphony, savor a delicious meal, detect a fragrant flower, and maintain our equilibrium.
In this presentation, we will:
Visual System (Sight): Dive into the anatomy and physiology of the eye, exploring how light is converted into electrical signals and processed by the brain to create the images we see. Understand common vision disorders and the mechanisms behind corrective measures like glasses and contact lenses.
Auditory System (Hearing): Examine the structures of the ear and the process of sound wave transduction, from the outer ear to the cochlea and auditory nerve. Learn about hearing loss, auditory processing, and the advances in hearing aid technology.
Olfactory System (Smell): Discover the olfactory receptors and pathways that enable the detection of thousands of different odors. Explore the connection between smell and memory and the impact of olfactory disorders on quality of life.
Gustatory System (Taste): Uncover the taste buds and the five basic tastes – sweet, salty, sour, bitter, and umami. Delve into the interplay between taste and smell and the factors influencing our food preferences and eating habits.
Vestibular System (Balance): Investigate the inner ear structures responsible for balance and spatial orientation. Understand how the vestibular system helps maintain posture and coordination, and explore common vestibular disorders and their effects.
Through engaging visuals, interactive diagrams, and insightful explanations, we aim to illuminate the complexities of the special senses and their profound impact on our daily lives. Whether you're a student, educator, or simply curious about how we perceive the world, this presentation will provide valuable insights into the remarkable capabilities of the human sensory system.
Join us as we unlock the wonders of the special senses and gain a deeper appreciation for the intricate mechanisms that allow us to experience the richness of our environment.
Test bank advanced health assessment and differential diagnosis essentials fo...rightmanforbloodline
Test bank advanced health assessment and differential diagnosis essentials for clinical practice 1st edition myrick.
Test bank advanced health assessment and differential diagnosis essentials for clinical practice 1st edition myrick.
Test bank advanced health assessment and differential diagnosis essentials for clinical practice 1st edition myrick.
Emotional and Behavioural Problems in Children - Counselling and Family Thera...PsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Basics of Electrocardiogram
CONTENTS
●Conduction System of the Heart
●What is ECG or EKG?
●ECG Leads
●Normal waves of ECG.
●Dimensions of ECG.
● Abnormalities of ECG
CONDUCTION SYSTEM OF THE HEART
ECG:
●ECG is a graphic record of the electrical activity of the heart.
●Electrical activity precedes the mechanical activity of the heart.
●Electrical activity has two phases:
Depolarization- contraction of muscle
Repolarization- relaxation of muscle
ECG Leads:
●6 Chest leads
●6 Limb leads
1. Bipolar Limb Leads:
Lead 1- Between right arm(-ve) and left arm(+ve)
Lead 2- Between right arm(-ve) and left leg(+ve)
Lead 3- Between left arm(-ve)
and left leg(+ve)
2. Augmented unipolar Limb Leads:
AvR- Right arm
AvL- Left arm
AvF- Left leg
3.Chest Leads:
V1 : Over 4th intercostal
space near right sternal margin
V2: Over 4th intercostal space near left sternal margin
V3:In between V2 and V4
V4:Over left 5th intercostal space on the mid
clavicular line
V5:Over left 5th intercostal space on the anterior
axillary line
V6:Over left 5th intercostal space on the mid
axillary line.
Normal ECG:
Waves of ECG:
P Wave
•P Wave is a positive wave and the first wave in ECG.
•It is also called as atrial complex.
Cause: Atrial depolarisation
Duration: 0.1 sec
QRS Complex:
•QRS’ complex is also called the initial ventricular complex.
•‘Q’ wave is a small negative wave. It is continued as the tall ‘R’ wave, which is a positive wave.
‘R’ wave is followed by a small negative wave, the ‘S’ wave.
Cause:Ventricular depolarization and atrial repolarization
Duration: 0.08- 0.10 sec
T Wave:
•‘T’ wave is the final ventricular complex and is a positive wave.
Cause:Ventricular repolarization Duration: 0.2 sec
Intervals and Segments of ECG:
P-R Interval:
•‘P-R’ interval is the interval
between the onset of ‘P’wave and onset of ‘Q’ wave.
•‘P-R’ interval cause atrial depolarization and conduction of impulses through AV node.
Duration:0.18 (0.12 to 0.2) sec
Q-T Interval:
•‘Q-T’ interval is the interval between the onset of ‘Q’
wave and the end of ‘T’ wave.
•‘Q-T’ interval indicates the ventricular depolarization
and ventricular repolarization,
i.e. it signifies the
electrical activity in ventricles.
Duration:0.4-0.42sec
S-T Segment:
•‘S-T’ segment is the time interval between the end of ‘S’ wave and the onset of ‘T’ wave.
Duration: 0.08 sec
R-R Interval:
•‘R-R’ interval is the time interval between two consecutive ‘R’ waves.
•It signifies the duration of one cardiac cycle.
Duration: 0.8 sec
Dimension of ECG:
How to find heart rhytm of the heart?
Regular rhytm:
Irregular rhytm:
More than or less than 4
How to find heart rate using ECG?
If heart Rhytm is Regular :
Heart rate =
300/No.of large b/w 2 QRS complex
= 300/4
=75 beats/mins
How to find heart rate using ECG?
If heart Rhytm is irregular:
Heart rate = 10×No.of QRS complex in 6 sec 5large box = 1sec
5×6=30
10×7 = 70 Beats/min
Abnormalities of ECG:
Cardiac Arrythmias:
1.Tachycardia
Heart Rate more than 100 beats/min
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REVISION ON HISTORY TAKING.ppt
1. REVISION ON ADULT AND PEDIATRIC HEALTH HISTORY
BY AKLILU GETACHEW (MD)
1
2. REVISION ON HISTORY TAKING
Objectives
◦ To clarify about clinical evaluation of a patient
◦ To revise on basic techniques of hx taking
◦ To revise on contents & relevance of all components of comprehensive
health history
◦ To see difference b/n Adult & pediatrics hx taking
2
3. Clinical evaluation
Comprises of health history & P/E
Core of patient evaluation
Made based on Hx taking & P/E skills
Importance of clinical evaluation
70%-80% of diagnosis is made by it.
Guides next step or it is base for investigation based evaluation.
3
4. THE HEALTH HISTORY
Is a record of clinical event
Concerned with symptoms
Symptoms; are subjective complaints noted & told by a
patient.
e.g. cough, chest pain, shortness of breath, vomiting,
diarrhea constipation
fever, loss of appetite, loss of weight
Guides physical examination.
4
5. Hx Taking/ Conducting an Interview
Has four main components
1. Greeting the patient and Establishing Rapport
2. Skilled Interview (supportive interview)
3. Taking Notes
4. The Closing
5
6. 1. Greeting the patient establishing Rapport
◦ Greet the patient and introduce yourself
◦ Maintain Confidentiality
◦ Arrange the room
◦ Give your undivided attention
2. Making skilled Interview
◦ Interview should be more flexible, focused & problem
oriented.
◦ Should be more fluid & will follow patients leads & cues.
6
7. Components of the techniques of Skilled History
taking
a) Adaptive Questioning ; based on patients verbal and non
verbal cues
uses d/t options to clarify patients story
Directed Questioning; from general to specific & should be open
ended.
N.B avoid leading questions.
Questioning to elicit graded response
Asking series of questions one at a time
Offering multiple choices for answer
7
8. 8
b) Adaptive listening; process of fully attending what a patient
is communicating
-it needs practice
c) Facilitation; maintaining the flow of the patient’s story
- made by actions (nodding head, leaning forward) or
words (Go.. on. ”I’m listening’’)
d) Echoing ; simple repetition of patient’s word
e) Empathic Response; sharing patient’s feelings & responding
accordingly.
9. 9
f)Validation; making the patient feel his/her emotions are
understandable
g) Reassurance; should be made at the end.
h) Summarization; giving summery of the story.
-it indicates to the patient that u’r listening
-helps to know what you know & don’t know
-allows to organize clinical reasoning
10. 10
3. Taking Notes
-Jot down short phrases, specific dates or words.
-don’t let note taking distract you from the patient.
-keep good eye contact
4. The Closing
-a time to encourage the patient to discuss any additional
problems, or to ask any question.
-but, don't answer questions if you aren’t sure.
11. Components of Comprehensive Health History
Listed in standard format of CASE REPORT
Structure patient’s story & format of written document.
N.B - order shouldn’t dictate sequence of interview (technique of
history taking should be flexible)
Preferably organization of information in to formal written format
should be after the interview & examinations are completed.
11
12. Order of Case Recording.
1. Identification of the patient
2. Previous Admissions
3. Chief complaints
4. History of the present Illness
5. Past Illness
6. Functional Inquiry ( System Review)
7. Personal &Social History
8. Family History
12
13. 1. Identification of the patient
-Date Time -Full Name
-Date of Admission
-Age & Sex -Ward
-Address -Bed No
-Occupation
-Religion
2. Previous Admissions; list of hospitalization in the order
they occurred.
-Specify the date, name & location of the hospital. the
disease that led to admission & the outcome.
13
14. 3. Chief complaint (s)
Is the main complaint that brought the patient to seek medical
care.
Should be simple, brief,& recorded with duration of each
symptoms using patients word.
If there are >2 C/C ,should be listed in order of occurrence.
The question can be put as “what is the main problem that has
brought you to hospital?”
e.g. shortness of breath / 3 weeks
Not dyspnea
chest pain / 1 week
14
15. 4. History of present Illness
It is detailed description of the chief complaint in relation to its
mode of onset &development of illness in chronological order.
Details of the chief complaint should include;
1. Date of onset :- it is often useful to start the HPI with a
phrase “the patient was relatively well until…” from then on ,the
development of signs & symptoms, expressed as chief
complaint, should be traced in detail to the present time.
2. Mode of onset
-Sudden/Abrupt
-Insidious/Gradual
15
16. 3. Character (elaboration or analysis of symptoms)
Examples
1.common complaints
a. Pain (PQRST)
-Place (location)
-Quality (dull aching,sharp,burning or stabbing)
-Radiation
-Severity (mild ,moderate, sever)
-Temporal
b. Fever – Grade (low/high)
_Course (Intermittent/Persistent)
16
17. 2.Common cardio-respiratory symptoms
a. Shortness of Breath
-How does it come on?/what degree of exertion produce it?
-Does it wake up the patient at night? (PND)
-Does the patient has to sit up/require more pillows while lying supine?
(Orthopnea)
b. Cough
-Quality (Dry/Productive of sputum)
-Character (Hacking, Barking, Whooping)
-Timing (Morning/Nocturnal)
C. Sputum
-Color &Consistency (Serous, Purulent ,Mucoid, Frothy & Mucopurulent)
-Odor (foul smelling, or Not)
17
18. 18
d . palpitation
-What brings it ?(Exertion/Spontaneous)
-How long it lasts ?
e. Chest pain (PQRST)
f. Body Swelling (edema)
-Pattern of spread
-Time interval
3. Common GI & Renal Complaints
a. Vomiting
-Pattern ( Projectile/ Non Projectile )
-Amount & Color (Bilious /Non Bilious )
-Content (Blood, Feculent, Ingested food)
-Frequency
19. 19
b. Diarrhea
-Consistency & Color (watery, Bloody, mucous containing)
-Frequency
c. Abdominal Swelling (Distension)
-Initial Site
-Progression (rapid/gradual)
-Associated symptoms
d. Urinary Symptoms
Urine
-amount
-Color
-Frequency
-Pain during urination
20. 20
4. Aggravating & Relieving factors
5. Course of symptoms
-persistent /continuous
-Short lived /constant
-Intermittent / on-off
-Steady /Increasing in severity
6. Effect of Treatment & Medications
-Mode of treatment
Conservative (Life style modification)
Medications (Name, dose,Frequency)
Allergies
-Effect of Treatment
21. 7. “Negative-Positive Statement”
Includes completion of review of affected / suspected system (s) ,&
inquiry in to other related system, as well as, medicinal, hereditary,
environmental, & other conditions related to the C/C.
Aim is to construct DDX.
Positive statements include
-associated symptoms
-risk factors
-precipitating factors
-predisposing factors
Negative statements:-used to rule out DDx.
21
22. 8. Strength & Weight Changes
- Stated in the last paragraph of HPI
-Strength-how the patient came
-Weight change
22
23. 5.Past illness
Lists childhood illnesses
Lists adult illnesses with dates for at least
four categories: medical; surgical; obstetric/
gynecologic; and psychiatric
Includes health maintenance practices such
as: immunizations, screening tests,
23
24. 6. Functional Inquiry ( System Review)
Is a detailed account of symptoms referable to each system of the
body.
Can be made while examining the patient.
Has the following main advantages
-Uncover problems that the patient overlooked---Gives Clear
understanding of the HPI.
-Allows to group important symptoms that need to be considered
with the present complaint.
-it also helps to include important Negative statement.
Standard series of review of system Questions
24
25. 1. Head, Eyes, Ears, Nose, Throat (HEENT).
Head: Headache, head injury, dizziness lightheadedness
Eyes: Vision, glasses or contact lenses, last
examination, pain, redness, excessive tearing, double vision,
blurred vision,.
Ears: Hearing, tinnitus, vertigo,
earaches, infection, discharge. If hearing is decreased, use or
nonuse of
hearing aids.
25
26. 26
. Nose and sinuses:, nasal stuffiness, discharge, or itching, bleeding
per nose
Throat (or mouth and pharynx):
Condition of teeth, bleeding gums,
sore tongue, frequent sore throats.
. Neck. Lumps, “swollen glands,” goiter, pain, or stiffness in the neck.
Breasts. Lumps, pain or discomfort, nipple discharge,
Respiratory. Cough, sputum (color, quantity), hemoptysis,
dyspnea,wheezing.
27. 27
, Cardiovascular
chest pain or discomfort, palpitations, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea,edema
Gastrointestinal., nausea, vomiting, excessive belching ,heartburn,
loss of appetite, Pain up on swallowing
change in bowel habits, (diarrhea constipation ) rectal bleeding or
black or tarry stools, hemorrhoids,,. Abdominal pain passing of gas.
Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or
pain on urination, hematuria, hesitancy,
dribbling.
28. 28
Integumentary System (skin, hair & Nail)
Dry or Moist Skin, rashes, ulcers, hair distribution & pigementary
changes, changes in finger nails
Musculoskeletal. Muscle or joint pains, stiffness, swelling,
redness,,, weakness, or limitation of motion or activity backache.
history of trauma.
Neurological. Fainting, blackouts, seizures, weakness, paralysis,
numbness
or loss of sensation, tingling or “pins and needles,” tremors or
other involuntary movements.
29. 29
. Genital. Male:, discharge from or sores on the penis, testicular
pain or masses, history of sexually transmitted diseases and their
treatments.
Female: Gynecologic Hx
Vaginal discharge, itching, ulcer ,dyspareunia ,birth control methods, &
Exposure to HIV.
.Age at menarche; regularity, frequency, and duration of periods;
amount of bleeding, bleeding between periods or after intercourse,
dysmenorrhea, age at menopause, menopausal symptoms,
Obstetric Hx
. No of pregnancies, No & type of deliveries, abortions
30. 30
7.Personal History
Early development:-place of birth, child hood development,
activities, social & economic status.
Education
Environment
Social Activities &Habits
Marital Status:- Health of husband (wife), No
Of Children &their health.
8. Family History
-father & mother’s; Age, health (if dead, cause of
death)
-Siblings list with ages, health (if dead, cause of
death)
-Familial disease (hypertension, Diabetes, Asthma)
31. PEDIATRIC HEALTH HISTORY
Similarities with Adult Health
History
In Basic Techniques of history
Taking.
In most of the contents of
comprehensive health history.
Differences from Adult Health
History
History is obtained Indirectly from
care taker.
The History has some peculiar
components
-Immunization Hx
-Nutritional Hx
-Developmental Hx 31
32. Contents of pediatric history
1. Personal Details
2. Chief complaint
3. Chief Complaint
4. History of Present Illness
5. Past Medical Illness
6. Family History
7. Immunization History
8. Nutritional History
9. Developmental History
10. Review of Systems
32
33. 33
1.Personal details (ID)
Patients Identification
-Name
-Age
-Sex
-Address
-Ward & Bed No
Historian’s Identification
- Name
-Age
-Sex
-Occupation
-Religion
34. 34
2. Chief Complaint
3.History of present Illness
4.Past Medical Illness
-Mother’s` Prenatal, Labor &Delivery Hx
-Child’s Neonatal, Infancy & Childhood’s Hx
-Medical Illnesses Measles, Pertussis, Mumps, Chickenpox
-Surgical conditions & Medications
5.Family History
-Social History Housing, family size, Income, water supply &
waste disposal.
35. 35
6. Medical Hx:- list of siblings & their health statu----Familial Disease
7.Immunization History
-when started?, types, time interval & route of Administration
- Should be assed based on EPI Schedule
8.Nutritonal History
-Breast feeding (EBF/not, frequency & total duration)
-Complementary feeding ( when started? ,type of meal, frequency &
duration)
-Exposure to sun Light
-Current diet (type & frequency)
36. 8.Developmental History
Assessed based on the four Spheres of development
(Developmental Milestones) for that Particular age
-Gross Motor dev’t:-includes control of head, trunk &
extremities
-Fine Motor dev’t:-includes the dev’t of finger movements
-Language dev’t:- production of sounds, words,&
understanding others.
-Social Dev’t:- identification of objects,& persons ,ability to play
with others
9.Review of Systems
36