Tiêu đề 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 2. PHYSICAL EXAMINATION: A) GENERAL/IPPA:  Inspection  Auscultation  Palpation  Percussion PATIENT DATA ANALYSIS
PHARMD GURU Page 2 B) VITAL SIGNS:  Temperature  Heart rate  Blood pressure  Respiratory rate c) HEENT:  Oral mucosa  TM Eyes (Ophthalmoscopy, Swinging-flashlight test)  Hearing (Weber, Rinne) D) RESPIRATORY:  Respiratory sounds  Cyanosis Clubbing E) CARDIOVASCULAR:  Precordial examination  Peripheral vascular examination  Heart sounds  Other Jugular venous pressure, Abdominojugular test, Carotid bruit Ankle- brachial and pressure index F) ABDOMINAL:  Digestive  Liver  Span  Rectal Murphy's sign  Bowel sounds  Urinary  Murphy's punch sign G) EXTREMITIES/JOINT:  Back (Straight leg raise)  Knee (McMurray test)  Hip Wrist (Tinel sign, Phalen maneuver)
PHARMD GURU Page 3  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 J) GYNAECOLOGICAL:  Well-woman examination  Vaginal examination  Breast examination  Cervical motion tenderness 3. ASSESSMENT:  Medical diagnosis  Differential diagnosis. 4. PHARMACEUTICAL CARE PLAN
PHARMD GURU Page 4 COMMON MEDICAL TERMS AND ABBREVIATIONS USED IN CLINICAL PRACTICES