It started with a dry cough; however, over the past couple days she has expectorated some clear, and more recently, thicker rust-colored, mucous. You click on these responses and He was given the diagnosis of PE and transferred to our hospital for further evaluation.
If you discover that your patient has not been taking his coumadin, you would tell the story chronologically.
Past Medical History Include all medical problems active or remote. What seems to be the problem? This may be difficult depending on where the interview is taking place.
However, you are already in possession of the tools that will enable you to obtain a good history. Are you ever short of breath?
The emergency room or a non-private patient room are notoriously difficult spots. He was given the diagnosis of PE and transferred to our hospital for further evaluation. It does not take a vast, sophisticated fund of knowledge to successfully interview a patient.
The pain began 1 month ago and only occurs with activity.
If so, what was done at that time? As such, you would ask follow-up questions that help to define a cardiac basis for this complaint e. If the patient is an older adult, ask the patient whether or not he or she has had an annual flu immunization and pneumonia vaccine.
If they are describing pain, ask them to rate it from 1 to 10 with 10 being the worse pain of their life, though first find out what that was so you know what they are using for comparison e. As yet, you do not have the clinical knowledge base to know what questions to ask next.
If it affects their activity level, determine to what degree this occurs. Noncompliance with coumadin, see HPI 3.Intensive Case Study Nursing Health History II Biographic Data Name: Erlinda Ayala Etcubañas Age/sex: 71 y/o, Female Birth date: March 20, Birth place: Pagbilao, Quezon Address: Venus, Bukal by bojums in Types > School Work > Homework5/5(1).
History of Present Illness (HPI): The history of present illness can be viewed as a hypothesis generating statement. The first paragraph should make clear to the reader the primary hypothesis (or hypotheses) that one is considering as an explanation of the patients presenting complaint(s). Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain Questions to include.
Different sources include different questions to be. HISTORY: Mr. Alcot is a 68 year old man who developed a harsh, productive cough four days prior to being seen by a physician.
COURSE OF ILLNESS: Following a chest x-ray PA viewand Lateralwhich revealed an acute pneumonia in the right middle lobe, the patient was treated with antibiotics as an outpatient.
During the 10 days of treatment. Example of a Complete History and Physical Write-up Patient Name: Unit No: History of Present Illness: Her husband died 9 years ago of seizures and pneumonia.
She had one sister who died in childbirth. She has 4 daughters (ages 60, 65, 56, 48) who are all healthy, and had a son who died at the age of 2 from.
Respiratory History and Physical Exam Patients with lung disease often complain of the following symptoms: dyspnea/shortness of breath, cough, sputum production, fatigue, exercise intolerance, chest tightness or chest pain.Download