New PDF release: Bates' pocket guide to physical examination and history

Diagnosis

By Lynn S Bickley; Peter G Szilagyi; Barbara Bates

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Extra resources for Bates' pocket guide to physical examination and history taking

Example text

Thought coherent. Oriented to person, place, and time. Cranial Nerves: II–XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout (see p. 321 for grading system). Cerebellar: Rapid alternating movements (RAMs), point-to-point movements intact. Gait stable, fluid. Sensory: Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative. Reflexes: RT LT Biceps Triceps Brachioradialis Patellar Achilles Plantar 2+ 2+ 2+ 2+ 2+ 2+ 2+ 2+/2+ 1+ 1+ ↓ ↓ OR ++ ++ ++ ++ + + +_+ +_+ + + ++ ++ ++ ++ + Laboratory Data None Currently.

Qxd 9/3/08 2:30 PM Page 51 Interviewing and the Health History 51 Also ask about blackouts (loss of memory for events during drinking), seizures, accidents or injuries while drinking, job loss, marital conflict, or legal problems. Ask specifically about drinking while driving or operating machinery. Questions about drugs are similar. “How much marijuana do you use? Cocaine? Heroin? ” Use the CAGE questions but relate them to drug use. With adolescents, it may be helpful to ask about substance use by friends or family members first.

Speak directly to the patient. Bilingual written questionnaires are valuable. qxd 48 9/3/08 2:30 PM Page 48 Interviewing and the Health History G UIDELINES FOR W ORKING W ITH AN I NTERPRETER ● Choose a professional interpreter in preference to a hospital worker, volunteer, or family member. Use the interpreter as a resource for cultural information. ● Orient the interpreter to the components you plan to cover in the interview; include reminders to translate everything the patient says. ● Arrange the room so that you and the patient have eye contact and can read each other’s nonverbal cues.

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