IB CSL ORTHO

HISTORY - BEDSIDE

Dr Kwok

Ortho

Fri 20-09-02

Presenting Complaint

Hung Mei Li is a 65 yo female who presented to hospital with L thumb and R palm swelling

Hx of Current Complaint

3 weeks ago she pricked her thumb with a [clean/ dirty] needle at [home/ work]

Immediate cause?

Tx seeked - eg. Drainage efficacy under GA > LA

Underlying cause + risk factors - thyoma (when, where, Tx afterward, immunocompromised?)

Progress of disease - local / generalised ® rest of hand/ generalised?

Don't just present information, have intention

Effect of disease on Pt's function ® ie. Severity

  1. ADL
  2. Occupation - need leave?
  3. Leisure
  4. Pain - ongoing, episodic, aggravating/ relieving factors, etc.

Past Med Hx

Past surgery failed?

Comorbidity ® DM, HT, bleeding tendencies, CVS, RS, CHD ® ­ surgical risk

Fam Hx

Enriches information, may affected Tx

  1. Familial
  2. Genetic
  3. Congenital

Social Hx

­ Rapport ® Pt more forgiving if surgery/ Tx fails

  1. Occupation / $
  2. Home conditions ® life, stairs (rehab)
  3. Smoke/ drink/ drugs

Allergies

Food, meds

SUMMARY