Introduction to Clinical Cases

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30 Νοε 2013 (πριν από 3 χρόνια και 17 μέρες)

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Introduction to Solving Clinical Cases


Steps in a Clinical Encounter

1.

2.

3.

4.



Patient
History

-

Information gained by a healthcare professional by asking
specific questions, with the aim of obtaining information useful in
formulating a
diagnosis and providing medical care.


Symptoms

-



Signs

-




A History
may

include:



Identification and demographics: name, age, sex, height, weight



The "
ch
ief complaint

(CC)
"


the major health problem or concern, and its
time course.



History of pre
sent illness

(HOPI)
-

details about the complaints enumerated in
the CC.



History of past illness

(HP
I) (including major illnesses, any previous
surgery/operations, any current ongoing illness, e.g., diabetes, sickle cell)



Review of systems
(ROS)
-

Systematic questioning about different
organ systems




Family diseases




Childhood diseases

and immunizations



Social history
-

including living arrangements, occupation, drug use (including
tobacco, alcohol, other recreational drug use), recent foreign travel and
exposure to environmental pathogens through recreational activities or pets.



Regula
r medications (including those prescribed by doctors, and others
obtained over the counter or
alternative medicine
)



Allergies




Sex life
, obstetric/gynecological history



and so on as appropriate.



Physical Examination

-

Process by which a healthcare professio
nal investigates
the body of a patient for
signs

of disease.


A physical examination usually starts with first observation of the patient and
systematically covers the patient
head

to
extremities
. It
may

include:



General appearance


mobility, awareness, color, hydration, etc



Basic biometrics


height, weight, pain



Vital Signs


temperature, blood p
ressure, pulse, respiratory rate



Organ systems


cardiovascular, lungs, breast, abdomen, genitalia,
musculoskeletal, nervous, including mental status, HEENT (head, eyes, ears,
nose, throat), skin



History + Physical Examination


Presumptive Diagnosis

(a working theory)
and a
Differential

(in our case,
infectious disease,
a list of
specific
microorganisms
associated with the presumptive diagnosis).


Presumptive + differential will guide your investigation, development of a
strategy

that will allow you
to eliminate (or not) the most likely candidates. Always start
with the idea that this is a “horse” and not a “zebra”.