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Task 1: relevant data gathering and examination -------…
Task 1: relevant data gathering and examination
------------------------------------- Dr. Sabahat Adeel
(a) What important points should be asked in history?
weight loss history
over what time period?
how much weight has been lost?
weakness
does it interfere with daily activities?
is the fatigue profound?
Fever
duration - acute or persistent?
response to antipyretics?
pattern - continues, limited or relaxing?
onset - sudden or gradual?
bumps & lumps
location of lump?
are they painful or painless?
when did the lump first appear?
any change in size or number?
cough
duration?
character - dry or productive?
sputum - colour, amount, blood-stained?
timing - is it worse at certain times or after activity?
travel history?
duration of stay(s)?
time of onset of symptoms in relation to travel?
details of geographical locations visited?
activities during travel - swimming, hiking, animal contact?
accommodation type?
food and water consumption details?
menstrual and sexual history?
STIs
contraception use details
irregular period?
medical history?
recent procedures or surgery?
current medication?
immunization status?
pre-existing conditions?
history of exposure?
sexual contact?
freshwater exposure?
animal contact?
consumption of unpasteurised dairy products or undercooked meat?
contact with an ill individual?
insect bites?
associated symptoms?
skin - any itchiness and/or rash?
night sweats or malaise?
abdominal discomfort?
pain - any pain in bone, joint or muscle?
loss of appetite?
respiratory - cough, shortness of breath, sore throat?
neurological - lethargy, irritability, confusion?
(b) Which physical exams should be conducted?
general appearance
signs of toxicity
hydration status
level of consciousness
system examination
abdominal
hepatosplenomegali, tenderness, masses
muculoskeletal
joint swelling, tenderness, range of motion
head and neck
conjunctival injection, pharyngeal erythema, cervical lymphadenopathy
neurological
mental status, meningal signs, focal deficits
skin
rashes(maculopapular, petechial, vesicular), scar, purpura, jaundice or lump
respiratory
sign of lung infection or tuberculosis
vital signs
heart rate, respiratory rate, blood pressure
oxyen saturation
body temperature
(c) Investigation - What appropriate tests should be done?
blood culture
malaria film and rapid diagnostic test
blood tests - CBC, ESR
renal function test
liver function test
HIV, tuberculosis (montox test, gene expert)
ultrasound abdomen
chest x-ray (for tb / lung disease)