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Clinical history

By Cindy Henry,2014-04-28 01:23
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Clinical history

    Volunteers for Intercultural and Definitive Adventures

    Med Team Manual

    University of Georgia

    ththMay 14-29, 2008

    Medical texts compiled by Dr. Arabela Paniagua

    Spanish lessons and vocabulary organized by Karina Páez

Welcome

Dear Volunteer,

    We couldn’t be more excited to have the students of the University of Georgia with us in our first year offering these amazing volunteer adventures. This should prove to be a great trip thanks to the effort of many people, including all our local staff, volunteers in the U.S. and Costa Rica, and the students of UGA.

    VIDA was born last year, with its goal being the creation of a humanitarian, not-for-profit, secular, nonpolitical, grassroots organization that empowers individuals and benefits communities. At the same time, we offer volunteers hands-on, eye-opening, mind-enriching experiences. Those goals are now being reached, and VIDA is turning out to be a great organization.

    You are now a part of this organization, and we are thrilled to have you in our family. These adventures don’t end in Central America; they provide a lifetime of memories, lessons learned, and a connection between all the people who participate to help make the world a better place.

    After this adventure, we encourage you to stay in touch with all the people you meet, and of course we’d love to have you again next year.

    Sincerely,

    Curtis & Sondra

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    Table of Contents

Welcome.....................................................................1

    Table of Contents.........................................................2

    Clinical History.............................................................3

    Physical Exam………………………………………………………………….……5 Common Signs and Symptoms……………….…………………………10

    Abdominal…………………………………………..…………….…10

     Cardio-respiratory……………………………….………………12

     Urinary…………………..………………………….…………..…..14

     Hematological……………………………………………………..15

    Common Diseases………………………………………………………………16 Ear and Throat Diseases………………………………………………….…21 Eye Diseases…………………………………………………………………….…24 Skin Disorders…………………………………………………………………….30 Urinary Tract Infections……………………………………………………..37 Sexually Transmitted Diseases……………………………………….…38 Chronic Diseases………………………………………………………………..40 Intestinal Parasites…………………………………………………………....44 External Parasites……………………………………………………………….52 Protozoan Infections…………………………………………………………..55 Viral Infections……………………………………………………….…………..66 Spanish Lessons………………………………………………………………….67 Patient Interview Questions in Spanish………………………….…71 Medical Spanish Vocabulary……………………………………………….88

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    Clinical History

    The interview is used to obtain a series of data about the patient’s medical history, actual illness, and personal and family clinical antecedents as well as psychological aspects. The doctor-patient relationship is one of the most important keys to obtaining all the possible information from the patient. It is important to listen carefully and stimulate a spontaneous narration from the patient always directing the interview without suggesting an answer.

    Two fundamental objectives have to be followed during the interview:

    1. Obtain as much information as needed from the patient regarding the

    present illness (clinical diagnosis) and as much information as possible

    about the patient’s personality (psychological diagnosis).

    2. Establish an appropriate doctor-patient relationship.

    A good clinical history will be characterized by the following aspects:

    1. Trustworthy data

    2. No useful information omitted

    3. Concise data

    4. Objective data

    A clinical history should include the following information:

    1. Name

    2. Sex

    3. Age

    4. Academic degree

    5. Profession

    6. Place of birth

    7. Place of residence

    8. Actual illness

    ; “what can I do for you?”, “how can I help you?”, “why did you

    come here today?”: Chief complaint

    ; Since when?

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    ; How did it start?

    ; Associated symptoms

    ; Treatments that are being taken: homeopathy, allopathic, and

    natural medications

    ; Changes in patient’s life because of illness

    9. Previous diseases

    ; A chronological order is of main importance

    ; It has to include accidents, hospitalizations and surgical

    interventions

    ; In this part of the history the gynaecological history has to be

    included: menarche, menstrual cycles, pregnancies, deliveries,

    abortions, contraceptives

    10. Family history

    ; Regarding chronic illnesses as diabetes, hypertension, allergies,

    cancer, mental disturbances, endocrine problems, etc 11. Personal and social history

    ; Family group and the patient’s role in it

    ; Job: what is it, schedule, stability

    ; Sports: how often, what kind, alone or with family and friends

    ; Hobbies

    ; Habits: Smoking, alcohol consumption, and drug use

    ; Psychological problems: alimentary disorders, Frequent job

    changes, family relationships

    Finally a quick exam by systems has to be done including skin, eyes, ears, nose,

    and thorax, breast, cardiovascular, respiratory, gastrointestinal, genitourinary,

    muscular, nervous, and psychological

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    Physical Exam

    After a thorough clinical history is established, a methodical and careful physical exam proceeds. Ideally, before examining the region or organ related to the chief complaint, a general exam is done first, unless the patient’s anxiety does not permit this. The examiner has to learn how to use her/his sense of sight, touch, and smell. He/She must then coordinate or interpret all the findings adequately.

The physical exam consists of four basic elements:

    1. Inspection: This begins the moment the patient enters the office; the

    doctor should be able to see how the patient walks, her/his position while

    seated, physiognomy, gests or tics, skin color, etc. A detailed inspection

    by zones will also have to be made, and to aid this, instruments, such as

    an otoscope, ophthalmoscope, flashlight, or speculums can be used.

    2. Palpation: This permits corroboration of all the findings of the inspection,

    such as local temperature changes, pulsations, edema, crackles, and

    tumors. Excessive pressure must be avoided and palpation must start

    away from the place that is painful.

    3. Percussion: This consists of softly tapping the area where the patient

    complains of pain using both hands as follows: Apply slight pressure on

    the skin with the second or third left fingers and tap the area with the

    third right finger.

    4. Auscultation: The stethoscope was introduced by René-Théophile-

    Hyacinthe Laennec in France in 1819. For optimal results, the clinician

    should be in a quiet area, and he/she must focus on the analysis of every

    single noise heard. A biauricular stethoscope with a diaphragm and bell

    is preferably used. The diaphragm is used to listen to high frequency

    noises (cardiac and pulmonary noises, heart murmurs and intestinal

    noises). The bell is used to hear grave noises (diastolic murmurs,

    vesicular murmur).

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Vital signs

Arterial Pulse

    The most important aspects to take into account while taking the arterial pulse are:

    1. frequency

    2. rhythm

    3. tension

    4. breadth

    5. shape

    The arterial pulse may be taken in the radial artery with the second and third fingers of the examiner. The pulse may also be taken in the humeral or preferably in the carotid artery. Enough pressure has to be made over the artery to almost suppress the pulse; then pressure is slowly released until the examiner can feel clearly every beat. Whenever possible, the pulse should be taken symmetrically. If the rhythm is regular, the pulse should be measured for 15 seconds. If this is not the case, the pulse has to be taken for 60 seconds.

    Normal pulse oscillates between 60 and 100 beats per minute (bpm). These ranges change in kids, depending on the age. Pulses less than 60 bpm are considered bradycardia, and pulses more than 100 bpm are considered tachycardia. If a fever is present, every centigrade increased, will elevate pulse between 15 and 20 bpm. Athletes’ pulses are slower than sedentary people’s pulses.

Blood Pressure

    The measurement of blood pressure was first introduced in the clinical practice

    that the beginning of the 20 century; however, the sphygmomanometer was

    invented in 1896 in Italy by Scipione Riva-Rocci. Blood pressure is the vascular peripheral resistance exerted by the blood flow and is affected by the strength in the contraction of the left ventricle of the heart and the arteriolar resistance; it reaches its maximum during the systolic period and its minimum during the

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    diastolic period. The ratio of systolic pressure to diastolic pressure is the blood pressure.

    A sphygmomanometer should be in good condition to accurately measure blood pressure. The patient should be comfortably seated with her/his forearm resting horizontally on a table. In order to obtain an accurate blood pressure, the patient should rest at least 10 minutes before taking the measurement. The cuff must be collocated 2cm above the cubital fosse (the elbow fold) and the cuff needs to be completely deflated, with the stethoscope placed over the brachial artery. If the patient is very obese, blood pressure might be taken on the forearm and the stethoscope over the radial artery. Using the bulb (or bladder), the cuff should be inflated until the gauge measures 30mmHg after the last heart beat is heard; then pressure should be slowly released until the first regular noises (heart beats) appear. This is the systolic pressure. The pressure should be continued to be released until all noises are completely unheard. This is the diastolic pressure.

Normal ranges of blood pressure:

    ; Systolic pressure: between 90 and 135mmHg

    ; Diastolic pressure: between 60 and 85mmHg

    Blood pressure less than 90/60mmHg is considered hypotension and is not dangerous, unless it is produced by bleeding, or if it is accompanied by fainting, vertigo, or dizziness. Readings over 135/85mmHg are considered pre-hypertension. In this case, the patient must be instructed in necessary life-style changes, such as exercise, low-salt diets, increased consumption of fruits and vegetables and decreased protein intake. Measurements more than 140/90mmHg are considered hypertension; however, a single measurement is not sufficient to diagnose a patient as hypertensive, so at least three measurements on separate days have to be done in order to diagnose high blood pressure. If a patient is diagnosed with hypertension, he/she needs to be instructed about life-style changes, and an adequate treatment may need to be.

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Respiratory Rate

    Breathing is made possible by use of the thoracic and abdominal muscles; in men, the diaphragm and abdominal muscles are mainly involved during the respiration, and in women, thoracic muscles.

    When the respiratory rate is been taken the patient must not know it, because respiration is always involuntary and will turn voluntary if is known, because of that once the pulse is taken the examiner must pretend to steal be taking it but instead take the respiratory rate.

Frequency

    In newborns, the respiratory rate can oscillate between 40 and 50 breaths per minute and gradually decreases to a range between 12 and 18 breaths per minute in adults, slightly faster in women.

    ; Newborns: Average 40-50 breaths per minute

     Infants: 20-40 breaths per minute ;

    ; Preschool children: 20-30 breaths per minute

    ; Older children: 16-25 breaths per minute

    ; Adults: 12 to 18 breaths per minute

Temperature

    An adequate corporal temperature is absolutely necessary to maintain all the biological processes that occur in the body.

    Temperature can be measured with a mercury or digital thermometer. The thermometer has to be in position between 3 to 5 minutes in order to obtain an accurate reading.

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Measurements vary depending on where they are taken:

    1. The arm pit (axillary temp) is the easiest place to take the temperature,

    but it is lower than any other place in body (37.0?C).

    2. The oral temperature is a little bit higher than under the arm pit (37.3?C).

    3. The anus (rectal temp) gives the highest measurement (37.6?C).

    Body temperature is lower at the beginning of the day than at the end of it, even in cases where a fever is present.

Temperature can be measured in Celsius or Fahrenheit:

    ; ?C= (?F- 32)x0.556

    ; ?F= (?Cx1.8)+32

    ; 0?C=32?F

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