By Lynn S Bickley; Peter G Szilagyi; Barbara Bates
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Additional resources for Bates' pocket guide to physical examination and history taking
Find out the patient’s preferred method of communicating. Patients may use American Sign Language, a unique language with its own syntax, or various other communication forms combining signs and speech. Determine whether the patient identifies with the Deaf or Hearing culture. Handwritten questions and answers may be the best solution. When patients have partial hearing impairment or can read lips, face them directly, in good light. If the patient has a unilateral hearing loss, sit on the hearing side.
See Plan. qxd 26 9/3/08 2:29 PM Page 26 Clinical Reasoning, Assessment, and Recording Your Findings A SSESSMENT AND P LAN 1. Migraine headaches. A 54-year-old woman with migraine headaches since childhood, with a throbbing vascular pattern and frequent nausea and vomiting. Headaches are associated with stress and relieved by sleep and cold compresses. There is no papilledema, and there are no motor or sensory deficits on the neurologic examination. The differential diagnosis includes tension headache, also associated with stress, but there is no relief with massage, and the pain is more throbbing than aching.
If needed next visit, begin prophylactic medication, because patient is having more than three migraines per month. 2. Elevated blood pressure. Systolic hypertension with wide cuff is present. May be related to obesity, also to anxiety from first visit. No evidence of end-organ damage to retina or heart. Plan: ● ● ● ● ● Discuss standards for assessing blood pressure. Recheck blood pressure in 1 month, using wide cuff. Check basic metabolic panel; review urinalysis. Introduce weight reduction and/or exercise programs (see #4).
Bates' pocket guide to physical examination and history taking by Lynn S Bickley; Peter G Szilagyi; Barbara Bates