IMEC-Medizin ©

When interviewing the patient, it is essential in establishing a relationship of trust between the patient and caregiver.

Talking with the patient and obtaining their health histories is usually the first and often the most important part of the health care process

This enables a clinician to accurately assess the potential risks presented by a patient, prior to the start of treatment

When taking a Medical History A clinician should ask: 1. “Are you having pain or discomfort at

this time?” 2. “Do you feel nervous about having to

see a physician ?” 3. “Have you ever had a bad experience in

reference to your healthcare?”

Recent physical or psychological concerns

Family History Medications (recent changes) Allergies Weight gain or loss Sleep pattern disturbances Sexual appetite/companionship Exercise Tobacco and Alcohol Use

1. Medical history

2. Dialogue history

3. Physical examination

It is important to get a clear understanding of medications, past and present and what the patient and previous physician were attempting to achieve.

Again, have there been recent medication changes?

High blood pressureDiabetesHeart disease or attackAngina pectorisHeart failure

TuberculosisAsthmaCOPD/Emphysema Hay fever Sinus troubleThyroid diseaseChemotherapy or Radiation therapy due to

malignancy

Renal diseaseStrokeUlcersSeizure disorderLiver diseaseSickle Cell diseasePregnancy

History- Does the patient have any previous episodes of anxiety or mental illness

Observation:◦ Shaking◦ Itching◦ Sweating ◦ Dilated pupils◦ Cold and sweaty palms◦ Nervous appearance

"White Knuckle" Syndrome  Trembling

During the initial exam, certain things must be done!!

1) To determine whether a treatment modification is required, and whether to seek other medical consultation, if indicated.

THEN IN CONSIDERING THE PATIENT:A. To determine patient's ability to

physically tolerate any treatment, and

B. To determine patient's ability to psychologically tolerate any treatment.

Blood pressure – BP (both arms)

Heart rate / rhythm – along with abnormal Heart sound

Respiratory rate – Rales/rhonchi/crackles

Check O2 Saturation and/or dyspnea on exertion, at all if possible

Radial - Medial wrist Brachial - Antecubital fossa Carotid - Groove between trachea & sternocleidomastoid muscle

Femoral - Femoral triangle Pedal - Top of the foot (dorsal pedis)

Determine if pulse beats are evenly spaced, if so, record as regular,

If pulse beats are uneven, record as irregular

You can get a better idea if an EKG is available

Monitor respiratory rateObserve movement of chest wall. Is it symetrical.

Is there cough◦Is it a productive cough

Initial examination of the skin may reveal a lot of pertinent information.

Sores, moles, (bacterial) impetigo, various fungal (tinea), and inflammatory (erythema) & histimine reactions (uticaria) ,etc. the dermatologic list goes on and on.

Even looking at the skins physical age can tell a lot, via amount of wrinkles and pigments (vitiligo) and in learning if the patient has spider veins

Rotation of the head is very important, as well as upward/downward movements

Look at the eye sockets and the midline symmetry of the nose.

Have them give a chewing motion to check the buccinator and masseter muscles.

But remember we are doing more than just checking the cranial nerves!!!

Ask if the patient has had headaches, and/or head injuries in the past? What type? 

The first part of the eye exam is an assessment of acuity. This can be done with either a standard

Snellen Hanging Wall Chart read with the patient standing at a

distance of 20 feet or a specially designed pocket card (held at 14 inches).

Each eye is tested independently