Patient Interview. Chief complaint- subjective statement regarding most significant symptoms or signs of illness Description of general health Description of lifestyle Changes in status since last visit All info is considered confidential!!. Components.
Chief complaint- subjective statement regarding most significant symptoms or signs of illness
Methods include: inspection, palpation, percussion, auscultation, mensuration, manipulationExamination of pt.
Neurological: LOC- level of consciousness and orientation to person, place and time. Motor ability- ambulation. Senses, speech, hearing, vision
Integumentary: wounds, scars, ecchymosis, contracture, rash, lacerations, decubitus ulcers. Color, temp., surgical incisions, stitches, staples
GYN/Reproductive: Date of LMP, breast self-exam, testicular exam, problems
Psychosocial: affect, mood, anxious, angry, conversant, defensive, non-cooperative, combative. Living environment: alone, with spouse, nursing home, etc. Vocation/avocation: jobs, hobbies, interestsExam cont.
Diabetes: inability of pancreas to produce enough insulin resulting in lack of sugar available for cell metabolism.