Tää on aika tiukka lista käydä läpi jokaisen potilaan kohdalla.
1. Patient’s name, age
2. Date come hospital (count how many day patient treatment in hospital)
3. Reason: main symptoms so patient come to hospital.
4. Pathological process: You presented of the disease of the patient in order of time, from patient have the first symptoms untill when you exam patient.
- When did patient have first symptoms, how to pain, where did they pain, moved or don’t move.
- Method reduce pain at home: use drugs( buy in pharmacy themself , from other clinic…), what kind of drugs, how long use it,…
- How about Patient’s state when come hospital: consciousness (alert or coma), vital sign…
- Doctors diagnose: depend on patient’s document
- Treatment when patient hospitalized: oral drugs, infusion, injection, blood transfusion…
- During times patient has treated in hospital:
+ Disease’s state improve or don’t improve
+ What symptoms decreased, what symptoms increase, what new symstoms appear,…
5. Medical history:
- Patient’s medical history:
+ Other diasease before, when, how about treatment,…
+ Smoking
+ Alcohol
+ Eating habbit
+ Exercise
- Patient’s family:
- Epidemiology: For disease able to spread to other people.
6. Examination:
6.1. Total body state:
- consciousness
- Tied or no
- skin, mucosa, hair, fingernail, toenail
- Edema or no edema
- vital sign
6.2. exam organs: from organs have symptoms to normal organs, follow in the order: from syptoms you ask patient to entity symptoms ( see, touch, knock, listen) For example:
* Circulatory system
+ Pain chest, in front of sternum, nervous,..
+ Listen heart beat
* Respiratory system
+ Dyspnea, pain lung position, sore throat,…
+ Cough( sputum?)
+ Listen lung sound
* Digestive
+ Eat: how much, compare before
+ Dink: how much
+ Stomachache: belching, heatburn, pain abdomen, nausea, vomit….
+ Defecation ( give stool): colour, how much,…
+ Observe form abdomen
+ Touch and exam abdomen
+ Listen bowel sound
* Urinary system
+ painful urination, uncomfortable, how much, urine colour
+ Exam kidney
* Nervous System
+ sleep?
+ worry?
* Musculoskeletal: able to walk and move, normal joint,…
7. Subclinical: somes test
8. Drugs:
9. Patient’s need: summary from exam patient ( May be give nursing diagnose)
10. What do you do when you take care patient
11. Patient's teaching.
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