Radiology History Taking - Dr.Ayesha Mughees . (the best motivational books TXT) 📗

Radiology Rotations CT Scan MRI Flouroscopy - Barium Meal - Mammogram.  Ultrasound X-ray  CT Scan and MRI History Taking On your history taking paper write all details related to the patient, including patient's name, age, gender and phone number. Write the date of presentation. Write their request, which Scan/MRI is to be done/query. Write the presenting complaints (P/c) and their duration since when the signs and symptoms started till the last day.For e.g ask, 'since when?' See whether it's a routine, new, old or a follow up case? Record. Take history of fever and fits of every individual patient.  Take history of pain if present - nature of pain, does it radiate? Towards which part of the body does it radiate to? Which side? Right or left? Or both sides? Towards which limb does it radiate to? Upper or lower? Or both upper and lower limbs? Ask if there's any pain while bending/standing/walking/sitting. Record on paper.  Consider any difficulty in eating? Any vision changes? Hearing loss?

      Headache? Dizziness? Vertigo? Bleeding? Ask, particularly for cancer                    patients. Pen down.

For cancer patients: See the patient's biopsy reports - previous and new, all. Take history of Chemotherapy. Mention the number of cycles completed, with dates of the first and last cycle. Take history of Radiotherapy, likewise. Mention dates. Any history of surgery should be written too. (This should be done for all patients both having or not having cancer.) See for any previous CT scan, MRI, Ultrasound, X-Ray or any other report present.  Record all important and relevant impressions on paper from  all the above-mentioned reports.  Take history of Tuberculosis of all patients. Mention whether the patient is off or on ATT course. Whether or not he has completed the course previously or currently.  Breifly ask about IHD, DM and HTN. Question about any implants within the body. MRI cannot be done if there's any metal implant . Keep all new or old records of Scans, X-rays and photocopies/photos of biopsy and MRI reports in order to form the MRI and CT scan reports. Ask patients to collect their previous records alongside their new reports.

 

Flouroscopy History Taking Write the name, age, gender and phone number of the patient. Write the date of the day. Take a 3 line history, should be brief. For a sinus or fistula locate the site, what O' Clock position is it at ? Take history of any discharge? Blood? Pus? Mixed? From the fistula or sinus site. History of fever, if suffering from? Since when? Duration?

 

Barium Meal:

History of dysphagia. For liquids? solids?or semi-solids? Pain history  Time duration, since when?

 

Mammogram:

Take history for any on lump on either side of the axillae and breast? Is it Palpable? Pain history  Fever associated? For breast cancer history see the biopsy, CT scan and MRI reports. Write the impressions on the history taking paper.  Take history of any redness? Discharge? And site of discharge and redness. Note any change of skin texture or colour? Take history.  For a good history, examine the patient yourself to avoid any errors and for accurate findings. Ultrasound History Taking Write the name, age, gender and date on your Ultrasound form.   Identify the problem.  Write the region of the body for ultrasound. For e.g KUB, Abdomen,Scrotal etc. Go through patient notes, file of the patient for a better understanding of the underlying problem and query.  X-Ray History Taking Write the name, age, gender and phone number of the patient. Write today's date. Identify patient's problem and X-Ray region. See for any fracture and it's site. The limited movements. Take pain history. Write view of the X-Ray. For example, PA view under the mentioned X-Ray.  Go through patient notes and file. Write about the underlying condition. For e.g blunt trauma, RTA etc and it's duration. 

 

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Publication Date: 11-26-2018

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