Bates' pocket guide to physical examination and history by Lynn S Bickley; Peter G Szilagyi; Barbara Bates

By Lynn S Bickley; Peter G Szilagyi; Barbara Bates

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Extra resources for Bates' pocket guide to physical examination and history taking, Edition: 6th ed

Example text

Think about the order and readability of the record and the amount of detail needed. Use the following checklist to make sure your record is clear, informative, and easy to follow. C HECKLIST FOR Y OUR P ATIENT R ECORD Is the order clear? Order is imperative. Make sure that future readers, including you, can find specific points of information easily. Keep the subjective items of the history, for example, in the history; do not let them stray into the physical examination. Did you . . ● Make the headings clear?

Suggest dental care for mild gingivitis. Advise patient to move medications and caustic cleaning agents to locked cabinet—if possible, above shoulder height. APPROACHING THE CHALLENGES OF CLINICAL DATA As you can see from the case of Mrs. N, organizing the patient’s clinical data poses several challenges. The following guidelines will help you address these challenges. ● Clustering data into single vs. multiple problems. The patient’s age may help. Young people are more likely to have a single disease, while older people tend to have multiple diseases.

Family Violence. Many authorities recommend routine screening of all female patients for domestic violence. ” Consider physical abuse in the following settings: ● If injuries are unexplained, seem inconsistent with the patient’s story, are concealed by the patient, or cause embarrassment ● If the patient has delayed getting treatment for trauma ● If there is a past history of repeated injuries or “accidents” ● If the patient or a person close to the patient has a history of alcohol or drug abuse ● If a partner tries to dominate the interview, will not leave the room, or seems unusually anxious or solicitous Death and the Dying Patient.

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