History Taking

See, Treat & Discharge/ Refer Case Studies expose 1 The Problem Scenario Example Jo Bloggs presents to the ……. with a history of ……... His occupation is……..divorced with two young children. provisional diagnoses Based on the information above, and that initially received on the MDT what was your provisional diagnoses? What were the red flags that you cannot afford to miss? Diagnosis Rationale 1. 2. 3. 4. History hirer Complaint History of Symptom Analysis Timing Has been experiencing ……………….for the past week, ……….. lasting for approximately ……. hours. Has had interchangeable episodes several times over the years but they usually go away. Provocative Pallative Region/Radiation Pain is …………. Quality Describes pain as ……. Severity sum up of (scale 1-10) Past Medical History Current Health status Allergies None known Medication Multi Vitamins OTC Ibrufen OTC Smoking Alcohol Family history set out and Father alive and well Psychosocial history Works as ……………… Lives in …………….

recap of systems CNS Nil of note ENT CVS Nil of note Resps GI GU MS Were you able to confirm or disprove any of your tentative diagnoses at this stage? If so which? What separate Questions did you ask? What pathophysiological processes were occurring? What physical examination did you / would you carry out if you feature the clinical examination skills required ? Are there any investigations you want to do and why? Are they available to you? Part 2 - Physical Findings Vital signs BP - Pulse RR T oecumenical Appearance Alert but appears tired Skin warm and dry No areas of ecchymosis, bird of passage angioma No pallor, cyanosis or jaundice Head and eyes ENT Lungs Clear Cardiac S1 and S2 normal CNS CN 11 X11 intact Strength/ mavin intact bilaterally Gait steady Romberg... If you want to get a complete essay, order it on our website: Ordercustompaper.com

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