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1. Diagnose disease
a. Anamnesis
1. Auto anamnesis
Auto anamnesa: interview with the client directly. Patients
alone answer all the doctor's questions and tell the problem. This is the
best history way because the patient is the best person to tell what he
really feels.
Patient : I am tini
Nurse : The pain in the stomach next to mam? Does the pain spread
or in one area?
Patient : Scale 6
Nurse : Usually to relieve pain, what do you do? Eg let it go, or take
medicine or sleep for a while?
Nurse : So since yesterday yes mam, upset stomach after school about
the child's mother is upset because of what?
Family : yes.
Family : Not nurse, just check with your doctor and give medication.
Nurse : Okay mam, I think is enough, if there is data that I still need I
will contact mother again. Thank you for your cooperation
mam.
The main and most important note when making anamnesis for
the success of disease diagnosis is to try to ask about the main
complaints that cause or cause the patient's treatment or admission to
the hospital or health care.
a. Family
b. Residence
"Is there all right?" "Is your housing solid?" "How is the
ventilation of your house?" "Use of a private bathroom or use a
public bathroom?" "Are your houses affected by floods?" "near the
factory with?"
c. Work
d. Hobby
e. Alcohol
f. Smoke
g. Drugs
"Did you take any other medication in the last few months?"
Start with light and general questions about each system. This focuses
on the attention of the patient and allows us to think of more specific
questions about the system that we want to pay more attention to. Examples
for starting a question are:
We can also add and vary questions depending on the patient's age,
patient complaints, the patient's general state, and our temporary clinical
diagnosis. We can also review this system at the same time as physical
diagnostics, ask about the eyes, ears, and others when we check. If the patient
has few symptoms it can be effective. When there are many symptoms, the
diagnostic and diagnostic history and history will be disturbed and the
important things become undetected and recorded.
If at the time of reviewing these systems a positive answer is obtained,
details should also be given. The (*) indicates questions that are almost
always asked.
Common Questions
*Weight
*Appetite
2. Physical examination
a. Inspection
1. Definition
2. How to check
- The patient's position can sleep, sit or stand
- The part of the examined body should be open (the patient
should open his / her own clothes.) It should not be opened at
the same time, but opened as necessary for inspection while the
other part is covered by a blanket).
- Compare the opposite body parts (symmetry) and abnormality.
- Record the result
b. Palpate
1. Definition
2. How to check
- The patient's position may sleep, sit or stand depending on
which part is examined and the body part being examined
should be open
- Make sure the patient is in a relaxed state with a comfortable
position to avoid muscle tension that can interfere with the
results of the examination
- The nails of the examiner's fingers should be short, warm and
dry hands
- Ask the patient to take a deep breath to increase muscle
relaxation.
- Palpate with a touch of slowly with light pressure and
intermittently.
- Palpasil of suspected areas, the presence of tenderness
indicates abnormalities
- Palpate cautiously in case of bone fracture.
- Avoid excessive pressure on blood vessels.
- Perform Palpate lightly when examining the organ / tissue is
less than 1 cm deep.
- Perform deep Palpation when examining the organ / tissue with
a depth of 1 - 2.5 cm.
- Perform bimanual Palpation when performing an examination
with a depth of more than 2.5 cm. That is by using both hands
where one hand is relaxed and placed at the bottom of the
organ / tissue, while the other hand presses towards the hand
below to detect the characteristics of the organ / tissue.
- Thoroughly feel the abnormalities of the organ / tissue, the
presence of nodules, tumor moves / not with consistency solid /
chewy, is rough / soft, its size and the presence / absence of
vibration / trill, and the pain touch / tap.
- Record the results of the examination obtained.
c. Percussion
1. Definition
2. How to check
- The position of the patient may sleep, sit or stand depending on
which part will be examined and the body part being examined
should be open
- Make sure the patient is in a relaxed state and comfortable
position to avoid muscle tension that can interfere with
percussion results.
- Ask the patient to take a deep breath to increase muscle
relaxation.
- The nails of the examiner's fingers should be short, warm and
dry hands.
- Perform a thorough and systematic percussion by:
a. The direct method is to do the percussion or direct the
fingers directly by using 1 or 2 fingertips.
- The indirect method is as follows:
a. The middle finger of the left hand (which is not dominant)
as the flexymeter is placed gently on the surface of the
body, strive the palms of the hands and other fingers do not
stick to the surface of the body.
b. The tip of the middle finger of the right hand (dominant) as
the flexor, to hit / tap the distal joints of the middle finger
of the left hand.
c. The blow must be fast, sharp with fixed / fixed arm and
wrist rilek.
d. Give the same blow power to every area of the body.
e. Compare the frequency sound accurately.
f. Compare or notice the sound produced by percussion.
g. The sound caused saa
3. Investigations.
The third way and step to determine the diagnosis of disease of patient
is by doing investigation. This investigation is generally performed if the
diagnostic checking steps above have not been able to definitively diagnose a
disease suffered by the patient so that investigation is needed for a definitive
diagnosis of the disease.
In an English conversation with a doctor, we can use several ways to explain our
condition. All you have to do is make the sentences easy by using common words to
describe a particular medical condition or illness. For example:
I am… + gejala.
Patient: Lately, I feel nauseous, especially at night and around the afternoon.
Sometimes, I also vomit. My stomach also feels bloated (Akhir-akhir ini, saya merasa
mual, terutama saat malam dan sekitar siang hari. Kadang-kadang, saya juga mintah.
Perut saya juga terasa kembung).
Doctor: Do you feel pain in the stomach? (Apakah Anda merasa sakit di perut?).
Doctor: How long have you had these symptoms? (Sudah berapa lama Anda
memiliki gejala-gejala ini?).
Patient: About a week, and they are very annoying (Sekitar seminggu, dan mereka
sangat mengganggu).
Doctor: Do you have ulcer before? (Apakah Anda punya maag sebelumnya?).
Patient: No (Tidak).
Doctor: Do you drink coffee? Eat spicy foods? (Apakah Anda minum kopi? Makan
makanan pedas?).
Patient: I drink coffee every morning, and I like spicy foods (Saya minum kopi
setiap pagi, dan saya suka makanan pedas).
Doctor: I think you have ulcer symptoms. I will prescribe you some medications, and
you must stop coffee and spicy foods for a while (Saya pikir Anda punya gejala
maag. Saya akan resepkan beberapa obat, dan Anda harus menghentikan kopi dan
makanan pedas untuk sementara).
Patient: Can I still drink tea? (Bisakah saya minum teh?).
Doctor: Yes, you can drink green tea, milk, and fresh juice. Cut down coffee, soda,
and alcohol. Water is the best drink, of course (Ya, Anda bisa minum teh hijau, susu,
dan jus segar. Kurangi kopi, soda dan alkohol. Air putih adalah minuman terbaik,
tentu saja).
Kosakata penting: symptom (gejala), pain (rasa sakit), prescribe (meresepkan), for
a while(untuk sementara).
Berikut ini adalah contoh yang lebih spesifik, yaitu percakapan antara pasien
kecelakaan yang dirawat di rumah sakit dengan dokter yang merawatnya:
Doctor: Hello, how are you today? (Halo, bagaimana kabar Anda hari ini?)
Patient: I feel better than yesterday (Saya merasa lebih baik daripada kemarin)
Doctor: Do you still feel pain? (Apakah Anda masih merasa sakit?)
Patient: Yes, my head still hurts a little bit, and I have headache. But my leg is better
(Ya, kepala saya masih sakit sedikit, dan saya sakit kepala. Tapi kaki saya lebih baik)
Doctor: What about your eyes? Can you see clearly? (Bagaimana dengan mata
Anda? Apakah Anda bisa melihat dengan jelas?)
Patient: My eyes were a little bit blurry yesterday, but they are fine now (Mata saya
sedikit kabur kemarin, tetapi baik-baik saja hari ini).
Doctor: Good, I will give you painkiller later. I will check on you again (Bagus, saya
akan memberi Anda obat penghilang rasa sakit. Saya akan memeriksa Anda lagi
nanti)
Kosakata penting: blurry (kabur, tidak jelas), painkiller (obat penghilang rasa sakit)