CLINICAL HISTORY TAKING (STRUCTURE), Mauren Michelle Lopez Martinez 26988…
CLINICAL HISTORY TAKING (STRUCTURE)
History of present complaint/illnes (HPC)/(HPI)
the nature of the complaint
You should ask
open and closed
clarify the complaint
The HPC/HPI is
the key part
of the history
Taking a good
(acronym used for any type of pain history)
Does it iradiate or move anywhere?
Is there anything associated with the pain?
(breathlessness (SOB), sweating, nausea, vomiting)
Can you describe the pain?
Is it sharp, burning, tight, dull, cramping?
What is the pain like?
Does it follow any time pattern?
How long does it last? (seconds, days, weeks)
Was (is) it counstant or intermitent?
Was it gradual or sudden?
When did it start / beging?
XACERBATING / REALIVING FACTORS:
Does anything make it worse?
(worse on lying down)
Does anything make it better?
Where exactly is the pain?
Show me where it hurts
In a scale from 1 to 10, how severe is your pain?
How is the pain affecting your life?
Now please sit on the examination table
Ok... lets start with taking your vitals
Can you change into the robe, please
Iam going to take your pulse and blood pressure
the next thing we will do is the physical examination
lets take your temperature
Lift your arm up please, I will put the thermometer under your arm
Open your mouth please, stick out your tongue
Ok, now lets continue with the exam
Now please lean forward, Iwill listen to your
Take a deep breath please
Breathe normally now
Breathe like you were tired, please
Ok... Now lay down please we will listen to your
Try and relax please
5 areas for listening to the heart
Now lets move down to the
Ok.. now you tell me if it hurts please
Ok now... please sit up
Lets us listen first
You can get dessed now please, then come back and have a seat
Mauren Michelle Lopez Martinez
INGLES II T2