Beruflich Dokumente
Kultur Dokumente
GENERAL EXAMINATION........................................................................................................................... 2
Examine the face .......................................................................................................................................... 2
Examine the eyes.......................................................................................................................................... 2
Examine the neck ......................................................................................................................................... 2
EXAMINE THE CARDIOVASCULAR SYSTEM ........................................................................................... 2
EXAMINE THE RESPIRATORY SYSTEM.................................................................................................... 3
EXAMINE THE ABDOMEN........................................................................................................................... 3
EXAMINE THE NERVOUS SYSTEM ............................................................................................................ 3
Higher Cerebral Functions............................................................................................................................ 3
Examine Cranial Nerves............................................................................................................................... 4
Examine the Arms Neurologically ................................................................................................................ 4
Examine the Legs Neurologically ................................................................................................................. 4
Examine the Arms or Legs ........................................................................................................................... 4
EXAMPLE OF PATIENT ENCOUNTER NOTES........................................................................................... 5
Complains of ................................................................................................................................................ 5
History of Present Illness (PI) ....................................................................................................................... 5
Past History (PH) .......................................................................................................................................... 5
Family History (FH)...................................................................................................................................... 5
Personal and Social History (SH) .................................................................................................................. 5
Physical Examination ................................................................................................................................... 5
EXAMPLE OF MINIMAL STATEMENTS ..................................................................................................... 5
General......................................................................................................................................................... 5
Cerebrovascular System:............................................................................................................................... 6
Respiratory System: ...................................................................................................................................... 6
Abdominal System: ...................................................................................................................................... 6
Central Nervous System: .............................................................................................................................. 6
Summary of Minimal Statements.................................................................................................................. 6
HISTORY IN DETAIL..................................................................................................................................... 6
1. Identification & Vital Statistics................................................................................................................. 6
2. Chief Complaints (CC) ............................................................................................................................. 7
3. Present Illness (PI).................................................................................................................................... 7
4. Current Activity........................................................................................................................................ 7
5. Current Medication................................................................................................................................... 7
6. Past History (PH) ...................................................................................................................................... 7
7. Social History (SH) ................................................................................................................................... 8
9. Family History (FH).................................................................................................................................. 8
10. SUMMARY............................................................................................................................................ 8
11. WORKING PROBLEM LIST. ................................................................................................................ 8
12. DATE, TIME, NAME & SIGNATURE .................................................................................................. 8
SPECIMEN HISTORY .................................................................................................................................... 8
HISTORY OF PRESENT ILLNESS (or PI) .................................................................................................. 8
Functional Inquiry ........................................................................................................................................ 9
Respiratory System (RS) ........................................................................................................................... 9
Gastrointestinal (GI) ................................................................................................................................. 9
Genitourinary (GU)................................................................................................................................... 9
Nervous System (NS) ................................................................................................................................ 9
Past Medical History (PH) ............................................................................................................................ 9
Family History (FH)...................................................................................................................................... 9
Personal and Social History (SH) .................................................................................................................10
Medication ..................................................................................................................................................10
COMMONLY USED IMAGING TECHNIQUES AND CLINCAL INVESTIGATIONS.................................10
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GENERAL EXAMINATION
• hands: splinter hemorrhages (seen in endocarditis or more frequently in people doing manual work like
carpenters.)
• radial pulse: rate, rhythm, waveform, volume, state of artery
• Measure blood pressure, but before you begin, ask “I would normally measure the blood pressure now,
would you like me to do so?” This is supposed to make the patient feel a little more comfortable and avoid
the famous “white coat effect.”
• eyes: anemia
• tongue: a blue-purple tongue may indicate central cyanosis, whereas a dry mouth with a dry tongue can be
seen in dehydration and mouth-breathing.
• JVP: height, waveform
• apex beat: site of apex beat, and it’s character
• auscultate:
• at apex (keep thumb on carotid artery for timing)
• normal heart sounds (S1 and S2)
• added sounds (S3 and S4)
• murmurs
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• hands: clubbing, signs of increased carbon dioxide (warm hands, bounding pulse, coarse tremor)
• tongue: central cyanosis
• trachea
• supraclavicular nodes
• inspection
• shape of chest
• chest movements
• respiratory rate / distress?
• palpitation: check for equal (or unequal) movement of chest using hands
• percussion: upper segments, middle segments, lower segments
• auscultation:
• breath sounds
• added sounds: crepitations, bronchospasm, pleural rub, stridor, (vocal fremitus)
• if obstructive airway disease:
• expiration time (In the absence of obstructive airway disease, one should be able to blow out the fire
of a match from approximately 15 centimeters with the mouth open. You can use this as a bedside
test.)
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• attention / calculation
• memory – short term, long term
• reasoning – understanding of proverb
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• ulcers
• wasting (are both arms and legs involved?)
• joints
• palpate:
• temperature, pulses
• lumps
• joints
• active movements
• feel for crepitations
• passive movements
• reflexes
• sensation
Complains of
• list, in patient’s words
Physical Examination
• general appearance, etc.
• then record findings according to systems
General
Healthy, well-nourished woman.
Afebrile, not anemic, icteric or cyanosed.
No enlargement of lymph nodes.
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No clubbing.
Breasts and thyroid normal.
Cerebrovascular System:
Blood pressure, pulse rate and rhythm.
JVP not raised.
Apex position.
Heart sounds 1 and 2, no murmurs or additional sounds.
Respiratory System:
Chest and movements normal.
Percussion note normal.
Breath sounds vesicular.
No other sounds.
Abdominal System:
Tongue and fauces normal.
Abdomen normal, no tenderness.
Liver, spleen, kidneys, bladder impalpable.
No masses felt.
Hernial orifices normal.
Rectal examination normal.
Vaginal examination not performed.
Testes normal.
Pulses (Carotid, Brachial, Radial, Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis) palpable.
HISTORY IN DETAIL
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• Name (Full)
• Sex
• Residence (Complete address)
• Birthdate & Age
• Place of birth
• Nationality & Race
• Marriage Status : Single, Married, Divorced or Widowed
• Occupation
• Informant : Patient or other (Explain relationship)
• CLARIFICATION : Question until you have sufficient details to categorize the symptom
in medical terms.
• QUANTIFICATION : One big exception is pain which can’t be measured. Try to asses
severity of pain by learning how it affects the patient.
4. Current Activity
• How the disease has diminished the patient’s quality of life and if therapy has improved it
5. Current Medication
• All drugs, doses, effects, and etc.
• If available, prescription bottles may help
b) INFECTIOUS DISEASES
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d) PREVIOUS HOSPITILIZATION
10. SUMMARY.
SPECIMEN HISTORY
C/O severe chest pain for 2 hours. (C/O for Complains Of, or CC for Current Complaint)
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The patient was perfectly well until 6 months ago. He then began to notice central, dull chest ache,
occasionally felt in the jaw, coming on when walking about 1 km (1/2 mile), worse when going uphill and
worse in cold weather. When he stopped, the pain went off after 2 minutes. The patient found that glyceryl
trinitrate spray relieved the pain rapidly. In the last month the pain came on with less exercise after 100 yards.
Today at 10 a.m. while sitting at work the chest pain came on without provocation. It was the worst
pain he had ever experienced in his life and he thought he was going to die. The pain was central, crushing in
nature, radiating to the left arm and neck and with it a feeling of nausea and sweating. The patient was rushed
to hospital where he received an intravenous injection of diamorphine, which rapidly relieved the pain, and
intravenous streptokinase. An electrocardiogram confirmed a myocardial infarction and the patient was
admitted to coronary care unit.
The patient has noticed very mild breathlessness on exertion for 3 months, but had not experienced
palpitations, dizziness, breathlessness on lying flat, ankle swelling or coughing. On one occasion, however, 2
weeks ago the patient had woken with a suffocating feeling and had had to sit on the edge of bed and
subsequently open the window to get his breath. This had not recurred and he did not report it to his doctor.
Functional Inquiry
Gastrointestinal (GI)
• occasional mild indigestion
• bowels regular
• appetite normal
• no other abnormalities
Genitourinary (GU)
• no difficulties with micturition
• normal sex life
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Medication
Other than glyceryl trinitrate spray, no drugs currently being taken.
• Ultrasound Examination
• Liver, gallbladder, pancreas, kidneys, spleen, ovaries, uterus, aorta, bowel, pleura, blood vessel
aneurysms & stenoses, thyroid, scrotum, joints, soft-tissue masses . . .
• Endoscopy
• Gastroscopy, Proctoscopy, Sigmoidoscopy, Colonoscopy, Bronchoscopy, Laparoscopy, Cystoscopy,
Colposcopy
• Needle Biopsy
• Core Biopsy (Liver, Kidney, Lung)
• Fine-needle Aspiration (Tumors / Bacteriological investigations)
• Radiography
• Chest Radiograph “PA Chest Radiograph”
• Abdominal Radiograph “Supine AP Radiograph” and “Erect Abdominal Radiograph”
• Computerized Tomography
• Organs & Masses in abdomen and thorax, tumors-infarcts-bleeds in brain, posterior fossa lesions,
disc prolapse and neoplasm in spinal cord
• Arteriography and Venography
• Coronary, cerebral, carotid, pulmonary, renal, aortography and ilofemoral angiography, leg
venogram
• Background Subtraction Angiography
• Nuclear Medicine Studies (Technetium 99m Scan - Scintigraphy)
• Skeletal, pulmonary, cardiovascular (myocardial perfusion scintigraphy), urogenital, cerebral,
thyroid, adrenal, reticuloendothelial system
• MRI
• Excellent in brain
• Electrocardiography
• Exercise Electrocardiography
• Echocardiography
• Radionuclide Ventriculography (Multiple Gated Acquisition – MUGA Scan)
• Assesses ventricle function
• Pyrophosphate Scanning
• Demonstrates recent myocardial infarction (1-10 days)
• Doppler Ultrasound Cardiography
• Multigated Doppler / Color-flow Doppler
• Cardiac Catheterization
• 24 Hour ECG Tape Recording (Holter)
• 24 Hour Blood Pressure Recording
• pH and Blood Gases
• Peak Flow
• Spirometry
• Skin Testing for Allergens
• Ventilation / Perfusion Scan
• Endoscopic Retrograde Cholangiopancreaticography
• Visualizes the biliary tree and pancreatic ducts
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