Clinical History Documentation in Hospital and Primary Care
Clinical History Documentation
Hospital Care
Clinical history is a comprehensive record of patient information gathered during hospital care, including outpatient and inpatient services. It should contain all relevant documentation.
Structure and Order
- Patient Identification and Statistical Data: Collected upon admission, this section includes name, address, contact information, date of birth, sex, and a unique patient history number.
- Admission Sheet, Case History, and Clinical Exploration: Completed
Cardiac Conditions: A Paramedic’s Guide
Module 1: Cardiac Basics
Cardiovascular Disease (CVD)
CVD is an umbrella term encompassing coronary artery disease, heart failure, stroke, peripheral artery disease, and others.
History Taking (CVD)
- Current event history (e.g., hypertension, hypercholesterolemia, or diabetes)
- Past medical history
- Family and social history (smoking)
- Surgical and medication history
Common Cardiac Complaints
- Chest pain
- Dyspnea (SOB)
- Dizziness/syncope/fatigue
- Unexplained nausea with or without vomiting
- Swollen ankles, abdominal
Delirium: Assessment and Management in the Emergency Department
Delirium
Definition
Delirium is characterized by:
- Disturbance of consciousness: Reduced clarity of environmental awareness, with diminished ability to focus, sustain, or shift attention.
- Change in cognition: Memory deficit, disorientation, language disturbance, or perceptual disturbance.
- Presence of a general medical condition: This is usually assumed rather than specified.
- Clinical subtypes: Hypoactive, hyperactive, and mixed.
Key Features
- Recent onset of fluctuating awareness
- Impairment of memory and attention
- Disorganized
History of Drug Use and the Controlled Drugs and Substances Act
A Brief History of Drug Use
Early Therapeutic Drugs
In approximately 1500 B.C., opium and castor oil were first documented as therapeutic drugs. This period saw the rise of centralized religions in Egyptian and Babylonian societies, a decline in shamanism, and an increased emphasis on formal rituals and rules.
The Ebers Papyrus (approx. 1500 B.C.) is the earliest known collection of prescriptions. It contains over 800 prescriptions for various ailments, many containing ingredients we wouldn’t consider
Read MoreTuberculosis & Cystic Fibrosis: Epidemiology, Diagnosis & Treatment
Tuberculosis (TB)
Epidemiology
- 1/3 of the world population is infected
- 8.8 million new cases annually
- Mostly in developing countries
- MDR-TB and XDR-TB are increasing due to poor treatment (not following protocols)
Etiology
Causative Agents:
- Mycobacterium Tuberculosis
- Other: M. Bovis, M. Africanum, M. Microti
Transmission:
- Airborne particles spread from people with active TB
- Risk factors: Overcrowded areas
Clinical Presentation
Active Disease
- 10% of immunocompetent individuals with latent TB become active
- 90% of
Cardiovascular Diseases: Diagnosis and Treatment
Dilated Cardiomyopathy
Diagnosis
- Enlargement of ventricles
- Left systolic dysfunction
- Dyspnea
- Pulmonary edema
- Leg edema
- Hepatomegaly
- Ascites
- Angina pectoris
- Fatigue, dizziness
- Thromboembolic complications
ECG Findings
- Sinus tachycardia
- ST changes
- Left bundle branch block
Echocardiogram Findings
- Increased chamber dimensions
- Decreased left ventricular ejection fraction (LVEF)
- Valvular abnormalities
- Increased left ventricular end-diastolic pressure
Other Diagnostic Tests
- Coronary angiography
- Endomyocardial biopsy
X-ray Findings
- Cardiomegaly
- Pulmonary