Subjective&Data • Patient!demographic: name!(use!initials!or!pseudonym) age sex reliable!historian? • Chief!complaint (Brief!description) • History!of!present!illness (“OLD!CARTS”!onset,!location,!duration,!character,! aggravating/associated!factors,!relieving!factors,!temporal!factors,!severity!of!symptoms).!! Include!pertinent!negatives. • Past!medical!history: 1.! General!health!and!strength 2.! Childhood!illnesses 3.! Major!adult!illnesses/diagnosis 4.! Immunisations • Past!surgical!history 1. Transfusions • Current!medications • Allergies • Family!history!(genogram).!! • Social!history 1.! Personal!status!(may!include:!birthplace,!where!raised,!home!environment,!education,!,! general!life!satisfaction,!hobbies,!sources!of!stress U as!appropriate). 2.! Habits:!(nutrition!and!diet,!regularity!of!eating!and!sleeping habits,!exercise,!alcohol use,!coffee,!tea,!tobacco;!illicit!drugs;!breast!or testicular!selfUexam) 3.! Sexual!hx 4.! Home!conditions 5.! Occupation!(description!of!work;!exposure!to!occupational!hazards/risks – as! appropriate). 6.! Religious!preference 7.! Financial!concerns (family) • Review!of!systems (this!is!a!list!of!current complaints!not!related!to!history!of!present!illness,! not!medical!history!or!diagnosis). 1.! General!constitutional!symptoms 2.! Appetite,!weight!loss 3.! Skin,!hair,!nails 4.! Musculoskeletal;!pain,!functional!changes,!falls 5.! Head!and!neck: 5.1! Eyes;!visual!changes!etc 5.2! Ears 5.3! Nose 5.4! Throat!and!mouth;!dysphagia,!difficulty!chewing!etc 6. Endocrine!(heat!or!cold!intolerance,!weight!changes,!hx!diabetes,!polydypsia,!polyuria,! changes!in!facial!or!body!hair,!skin!striae) 7. Chest!and!lungs;!SOB,!cough!etc. 8. Heart!and!blood!vessels;!angina,!chest!pain 9. Hematologic;!easy!bruising,!bleeding 10. Lymph!nodes 11. Gastrointestinal;!appetite,!bowel!functions,!dyspepsia 12. GenitoUurinary;!urgency,!frequency,!nocturia 13. Neurologic;!headaches,!dizziness,!syncope!memory!etc. 14. Psychiatric;!depression,!anxiety!etc. • Concluding!questions:!(Is!there!anything!else!that!you!think!is!important!for!me!to!know?!! What!concerns!you!the!most?!!What!do!you!think!is!the!matter?) • Physical!exam 1. Head!to!toe,!organised!by!systems 2. Accurate!terminology!and!abbreviations 3. Accurate!description!of!abnormal!findings • Assessment 1. List!all!health!problems!in!order!of!priority.!!Include!if!problem!is!new!onset,!controlled,! or!resolved. • Plan 1. DX!– justify!tests,!evidence!based,!costs,!pt.!comfort 2. RX!– Medications!– why 3. Education 4. FollowUup!plan View Less >>
Chief complaint: Kaira experiences difficulty in breathing. She experienced several coughing, wheezing and breathlessness episodes during previous days and began to cough while playing with her friends. Furthermore, the attack was so severe that she coughed even more when she cried. The young girls’ chest retracted severely on inspiration. Her mother informs that she has had an upper respiratory tract infection (URI). These recurrent attacks of breathlessness and wheezing vary in severity in different episodes •Past medical history   General health and strength  Childhood illnesses: Kaira has no history of childhood illness  Major adult illnesses  / diagnosis  Immunisations: She has completed all her childhood immunizations     Get solution

Place a new order
Pages (550 words)
Approximate price: -