The history and_physical_exam
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The document provides guidance on performing a patient history and physical exam, including key components to cover. It recommends using open-ended questions to obtain the patient's chief complaint, history of present illness, past medical history, medications, and other relevant details. It also provides direction on performing a physical exam and documenting the findings in the patient's medical record.
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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.
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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.
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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.
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Ms. Rodriguez is a 38-year-old female presenting with cough and shortness of breath for 2 days, which is worse than previous similar episodes. She has a history of hypertension, COPD, and end-stage renal disease requiring dialysis. On exam, her temperature is 101.3 and lungs have diminished breath sounds and rales in the right lower lobe. The assessment is pneumonia, and the plan is to obtain a chest x-ray to evaluate for infiltrates and start antibiotics.
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