Bates' pocket guide to physical examination and history by Lynn S Bickley; Peter G Szilagyi; Barbara Bates

By Lynn S Bickley; Peter G Szilagyi; Barbara Bates

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Sample text

4. Timing. When did (does) it start? How long did (does) it last? How often did (does) it occur? 5. Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. 6. Remitting or exacerbating factors. Does anything make it better or worse? 7. Associated manifestations. Have you noticed anything else that accompanies it? Use language that is understandable and appropriate to the patient. Technical language confuses patients and blocks communication.

Tension headaches. Discuss biofeedback and stress management. Advise patient to avoid caffeine, including coffee, colas, and other caffeinated beverages. Start NSAIDs for headache, as needed. 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.

Diet high in carbohydrates. Safety measures. Uses seat belt regularly. Uses sunblock. Medications kept in an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet below sink. Mr. N’s shotgun and box of shells in unlocked closet upstairs. Review of Systems General. *Has gained about 10 lbs in the past 4 years. Skin. No rashes or other changes. Head, Eyes, Ears, Nose, Throat (HEENT). See Present Illness. No history of head injury. Eyes: Reading glasses for 5 years, last checked 1 year ago.

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