Title 10. PATIENT DATA ANALYSIS.pdf ✅

PHARMD GURU Page 1 THE PATIENT’S CASE HISTORY: DEFINITION: A case history is defined as a planned professional conversation that enables the patient to communicate his/her symptoms, feelings and fears to the clinician so as to obtain an insight into the nature of patient’s illness & his/her attitude towards them. THE STRUCTURE OF PATIENT’S CASE HISTORY: 1. Medication history:  Chief complaint  History of the present illness  Systems review  Nursing assessment  Allergies  Medications  Past medical history  Family history  Social history  Psychiatric history  Progress notes  Mnemonics: a) SAMPLE b) OPQRST c) SOAP d) COAST MAP PATIENT DATA ANALYSIS

PHARMD GURU Page 3 f) Abdominal: ▪ Digestive (a) Liver (b) Span (c) Rectal Murphy's sign (d) Bowel sounds ▪ Urinary (a) Murphy's punch sign g) Extremities/Joint:  Back (Straight leg raise)  Knee (McMurray test)  Hip Wrist (Tinel sign, Phalen maneuver)  Shoulder (Adson's sign)  GALS screen h) Neurological:  Mental state  Mini–mental state examination  Cranial nerve examination  Upper limb neurological examination i) Neonatal:  Apgar score  Ballard Maturational Assessment
PHARMD GURU Page 4 j) Gynaecological:  Well-woman examination  Vaginal examination  Breast examination  Cervical motion tenderness 3. Assessment: • Medical diagnosis • Differential diagnosis. 4. Pharmaceutical care plan. COMMON MEDICAL TERMS AND ABBREVIATIONS USED IN CLINICAL PRACTICES