Handbuch 2013 (pdf, 736KB) - Berner Institut für Hausarztmedizin ...

Skills
History taking
S 1
S 2
S 3
S 4
S 5
S 8
S 11
S 12
S 13
clarifying the patient’s expectations and requests for the encounter
taking detailed, systematic history of somatic and psychological aspects of symptoms and
complaints, the patient’s situation, his/her understanding and concerns, social and cultural
background and illness experience
taking targeted, hypothesis-directed history
taking history from third party
noting and reacting to nonverbal cues
taking history in patients with special communication needs, e.g. language or speech problems
taking occupational and workplace history
identifying hazardous behavior and dangerous lifestyle
taking psychoactive substance history
Information / management
S 19
recording findings in patient file
Examination
S 34
S 35
S 37
S 38
S 46
S 47
S 48
S 77
S 79
S 80
S 81
S 84
S 85
S 86
S 87
S 88
S 90
S 91
S 92
S 93
S 94
S 95
assessment of general condition (habitus and posture, symmetry and mobility of body, nutritional
state, mood and mental status)
assessment of vital functions (body temperature, respiration, pulse rate, blood pressure, venous
pressure)
recording of anthropometric data (height, weight, body mass index [BMI], waist and hip
circumference)
assessment of skin and mucous membranes (signs of anemia, cyanosis, jaundice, edema,
dehydration)
examination of peripheral and central arterial pulses, detection of arterial bruits
examination of lymph node areas
detailed description of skin lesions
assessment of voice and speech including recognition of aphasia
inspection, palpation and auscultation of cervical structures, thyroid, carotid arteries and lymph
nodes
palpation of head and cervical spine, testing for mobility, tenderness and neck stiffness
inspection of shape and movement of chest and testing for tenderness on compression and/or
percussion
palpation of tactile fremitus
palpation of apex beat (heart)
percussion of lungs including respiratory shifting of diaphragm
auscultation of lungs
auscultation of heart
inspection of abdomen
auscultation of abdomen (bowel sounds, bruits)
percussion of abdomen (liver, Traube's area, bladder dullness)
palpation of abdomen (abdominal wall, colon, liver, spleen, aorta, abdominal masses)
eliciting abdominal tenderness, rebound tenderness and guarding
eliciting shifting abdominal dullness