History and General Physical Examination

History

Introduce your self

Make consent from the patient or from his/her attendant

1.History
i.Biodata
-Name
-Age
-Sex
-Occupation
-Religion
-Marital status
-Mode of admission
-Date of admission
ii. Presenting Complaint:(words by client) Issue/problem with the patient of which he/she wanting to get rid of seeking a cure from it.
iii. History of presenting complaint:(words by health care person) Making scenario from the whole discussion with the utilization of presenting complaint.
iv.Other histories:
-family
-drug
-Past
-Social
-Travel
if female then obs/gyne history about pregnancy and menstrual cycle
if the child then immunization history
General Physical examination:

1… Consent of the patient must be taken
2… Be on the right side of the patient
3…The patient should be having proper exposure for examination,
4…. Make a general assessment by viewing the whole body of the patient

History
History

Examination

1. Four vitals should be checked
-Blood pressure
-Temperature
-Heart rate/Pulse
-Respiratory rate
certain findings:

Examination of the Parts of body
Hands
1.Anemia:
i.Yellowish palmer creases of hands
ii. Koilonychia:(Spoon nail) sign of Anemia
2.Splinter hemorrhage: Tiny blood spots underneath the nail due to ruptured capillaries
3.eficient Moisture in hands: a sign of hyperthyroidism
4.Noded
I.heberdens node: swelling od distal interphalangeal joint
ii.Bouchard’s node: Swelling of middle interphalangeal joint
5.Clubbing: Angle b/w nail and skin are lost. it occurs most commonly in Lung cancer.
6.deputrine contracture
7.Wasting of thenar and hypothenar

Axillary lymph node are examined especially in women cause they can have breast cancer
Head:
-The hand is moved over the scalp so that any swelling or sink should be noticed
Eye:
Binocular vision is examined
I.Anemia: Pale conjunctiva
ii.Jaundice: Yellowish Sclera
iii.cranial nerves to the eyes should be checked
Nose:
Dribbling of the nose is noticed
the cavity is examined with light
Mouth:
tongue teeth and palate are examined
with tongue depressor sides walls and roof of the mouth is examined and viewed up to oropharynx
Ear:
examined by pulling it superio-posteriorly
Any dribbling is noticed and
cyanosis: Bluish-purple color
Lips:
Cyanosis: Blue
Regional lymph nodes are examined
1.submendibular 2.submental 3.preauricular 4.postauricular 5.mastoid

Neck:
Examined with hand properly and any swelling must be noticed especially cervical lymph nodes
Supraclavicular lymph nodes are examined
Thyroid enlargement……

Chest and Abdomen
1.inspection
2.Palpation
3.Percussion
4.Auscultation
texture, color, and pulsation should be examined
Any deformity/swelling is noticed

Back:
The hand is moved over back

Certain findings
Dehydration:
skin turgor: Time is taken by skin to maintain its position after stretching
Dry tongue
Edema: Swelling at medial melleous

Hitory and general Physical Examination

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