the art of presenting a patient byfalcon

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2009 Falcon Reviews. By Physicians For Physicians.

The art of presenting a patient | 1


Copyright 2009 by Falcon Reviews All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from Falcon Reviews, except by a reviewer who may quote brief passages in a review. First edition




Contents

History and Physical Exam ......................................................................................................... 4 Review of Systems ..................................................................................................................... 6 Physical Examinations ............................................................................................................... 6 Labs and Studies ...................................................................................................................... 12 Assessment and Plan ............................................................................................................... 14 Problem #1 ........................................................................................................................... 13 Problem #2 ........................................................................................................................... 13 Problem #3 ........................................................................................................................... 13 Problem #4 ........................................................................................................................... 14 Problem #5 ........................................................................................................................... 14 Problem #6 ........................................................................................................................... 14



FalconReviews.com | 866.516.9991 | Score HigherPatient: Record Number: Date: Location:

History and Physical ExamIdentification/Chief Complaint: Mr./Ms. past medical history of who presents to is a year old with complaint(s) of . History of Present Illness: The patient was in his/her usual state of health until when he/she experienced . with a

1. Principal Symptom: Onset: Duration: Frequency: Palliating/Provoking Factors: Quality: Radiation: Severity: Other: 2. Associated Symptom: Onset: Duration: Frequency: Palliating/Provoking Factors: Quality: Radiation: Severity: Other:

3. Associated Symptom: Onset: Duration: Frequency: Palliating/Provoking Factors: Quality: Radiation: Severity: Other: 4. Associated Symptom: Onset: Duration: Frequency: Palliating/Provoking Factors: Quality: Radiation: Severity: Other:

Narrative:




Past Medical History: (when diagnosed, severity, diagnostic tests, treatments, status)

Past Surgical History: (date, reason, also injuries and trauma/accidents)

Medications: (dose, frequency, when started, last taken, why taking, who prescribed? OTC, herbals)

Allergies: (include reaction)

Patients Physicians:

Patients Pharmacy:

Family Medical History: (diabetes, hypertension, heart disease, include st sick contacts, focus on 1 degree relatives )

Social History: (living situation, activities, occupation, diet, exercise)

______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ___________________________________________________________________ Immunizations(flu, pneumo, childhood):

__________________________________ __________________________________ __________________________________ __________________________________ __________________________________Substance History: (alcohol, tobacco, illicit drugs, caffeine use)

______________________________ ______________________________Screening: (pap, mammo, colonoscopy, selfexaminations)

__________________________________ __________________________________ __________________________________ __________________________________ __________________________________Sexual History: (menarche, LMP, contraception, HIV risk factors, recent partners, sexual preference)

______________________________ ______________________________Safety: (home, auto)

______________________________ ______________________________

__________________________________ __________________________________ __________________________________ __________________________________




Review of SystemsConstitutional Fevers, chills, sweats, weight gain/loss, insomnia, hypersomnia, fatigue? _______________________________________________ _______________________________________________ Skin Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes, decubitus ulcers? _______________________________________________ _______________________________________________ Eyes/Ears/Nose/Mouth/Throat Lightheadedness, vertigo, headaches? Acoustic trauma, hearing loss, tinnitus, drainage, pain, infection, discharge, hearing aids, last exam? Visual changes, diplopia, excessive tearing, pain, discharge, injection, light halos, trauma, photophobia, glaucoma, cataracts, last eye exam, glasses/contacts? Olfactory changes, stuffiness, drainage, itching, obstruction, hx of trauma, hay fever, nosebleeds, sinus problems? Hoarseness, dysphagia, enlarged tonsils, bleeding gums, sores, leukoplakia, tooth condition, caries, tongue changes, dry mouth, sore throat? _______________________________________________ _______________________________________________ Neck Goiter, pain, masses, nodules, adenopathy, thyroid problems, stiffness, crepitus, hx of injury? _______________________________________________ _______________________________________________ Cardiovascular Chest pain, palpitations, syncope, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, edema, cyanosis, hx of hypertension, heart murmurs, last ekg? last stress? stents/surgeries? Varicose veins, phlebitis, deep venous thrombosis, claudication? ________________________________________________ ________________________________________________ Respiratory Cough, dyspnea, pleurisy, sputum(amt, type, color), hx of asthma, bronchitis, COPD, emphysema, effusion, TB exposure or disease, last CXR, last PFT? ________________________________________________ ________________________________________________ Gastrointestinal Heartburn, dysphagia, appetite, indigestion, belching, flatulence, hematemesis, stool changes, hematochezia, melena, diarrhea, constipation, nausea, regurgitation, vomiting, hx of gallbladder, liver, pancreatic disease, ulcers? ________________________________________________ ________________________________________________ Genital (male) Hernias, sores, lesions, penile discharge, pain, testicular/mass discomfort, scrotal mass/discomfort, hx of STD's, sexual dysfunction? _______________________________________________ _______________________________________________ Genital (female) Birth control, sexual hx/function, STD's, itching, sores, discharge, dyspareunia, last pap/pelvic exam, menopause, menses (regularity, frequency, duration, amt), dys/amenorrhea, Gs and Ps, abortions/miscarriages? _______________________________________________ _______________________________________________ Urinary Dysuria, polyuria, frequency, stones, pattern change, incontinence, nocturia, hesitancy, dribbling, hematuria, infections, flank discomfort? _______________________________________________ _______________________________________________ Endocrine Thyroid, adrenal, hormonal problems, heat/cold intolerance, edema, hirsutism, sweating, excessive thirst, hunger, polyuria, pigment changes? _______________________________________________ _______________________________________________ Musculoskeletal Myalgia, stiffness, gout, arthritis, backache. swelling, pain, erythema, tenderness, decreased ROM, hx of trauma, overuse injury? _______________________________________________ _______________________________________________ Neurologic Syncope, vertigo, seizures, blackouts, paresthesias, paralysis, tremors, weakness, involuntary movements, changes in equilibrium? _______________________________________________ _______________________________________________ Hematologic Bleeding, bruising, petechia, blood clots, hx of transfusions, anemia, sickle cell, thalassemia? _______________________________________________ _______________________________________________ Psychiatric Hx of anxiety, mood swings, mania, depression, memory loss, insomnia, suicidal ideations, delusions, hallucinations? _______________________________________________ _______________________________________________



FalconReviews.com | 866.516.9991 | Score Higher Physical ExaminationVitals: Temperature: current___ max___ min___ Pulse:_____ Respirations:___________ Blood Pressure:________ Intake/Output:__________ Orthostatics:______________________ Gen: -Well-nourished or thin/cachectic?______________ -No distress? In distress? Short of breath, pain, anxiety? ______________ Skin: -Bronzing, cyanosis, jaundice, erythema, hypo/hyperpigmentation, telangiectasia? _________________ -Moisture, warmth, coldness, edema, texture, turgor? ___________________ -Lesions/Rash?_______________________________________________________________________Primary - Macules, patches, papules, plaques, nodules, tumors, wheals, vesicles, bullae, pustules. Secondary - Erosion, ulcer, fissure, crust, scale, lichenification, atrophy, scar, keloid.

-Auspitz sign (bleeding with psoriasis), Nikolskys sign (blister fragility)? ______________________ Nails: Hair: -Look for infections, pitting, clubbing? Cap refill < 2sec? ____________________________________ -Quantity, texture and distribution. Look for infections. ______________________________________

Head/Face:

-Edema, ecchymosis, lesions, trauma, lacerations?_________________________________- masses, nodules, lymph nodes, salivary glands, sinus tenderness, temporal artery tenderness?___________________________________________________________________ -mastoid tenderness, facial symmetry, periorbital edema, TMJ, sinus tenderness__________

Eyes:

-Pupils, extraocular movements, visual acuity, lid lag, nystagmus? ______________________________ 20/____ OS 20/____OD

-Fundoscopic Exam (cup to disc ratio, margins, AV nicking, copper wiring, tapering, banking , exudates, wool spots, neovascularizations, papilledema, retinal detachment, drusen?______________________ -Injection/erythema/discharge (color, amt, type)______________________________________________ -Ciliary flush (red/violet ring around cornea seen in glaucoma/ iridocyclitis), hyphema, strabismus(Hirschberg Test)? _____________________________________________________________ -Foreign body, abrasions, ulcers, keratoconjunctivitis?________________________________________ -Anterior chamber depth (glaucoma), proptosis (thyrotoxicosis)?________________________________

Front

Back

R

L




Physical Examination (contd)

Ears:

-Edema, erythema, abrasions, cerumen, foreign body, masses, lymphadenopathy, hematoma, drainage (color, amt, type), tenderness (where), hearing acuity? ________________________________________________________________________________________ -Weber Test (fork to forehead)- lateralizes towards conductive hearing loss________________________ -Rinne Test (fork to mastoid)- confirms conductive hearing loss_________________________________ -TM condition (color, intact, mobile, landmarks), anterior cone of light, air fluid level?_______________

Nose:

-Symmetry, patency, ecchymosis, edema, exudate , bleeding, drainage (color, amt, type), polyps, foreign body___________________________________________________________________________

Throat:

-Uvula (midline?), trismus (inability to open mouth), peritonsillar abscess?________________________ -Erythema, edema, exudates, pustules, vesicles, breath odor, ulcers, plaques?_____________________

Neck:

-Meningeal signs (Kernig- pain with knee extension, Brudzinski-involuntary knee bending with head lift), rigidity, tenderness, range of motion?_______________________________________________________ - Masses, nodules, edema, erythema, ecchymosis?___________________________________________ -Lymph nodes (location and character, smooth, mobile, size)?___________________________________ -Thyroid masses, goiter, tenderness?_______________________________________________________

Lungs:

-Wheezes (expiratory), crackles (inspiratory, coarse or fine), egophony, bronchophony, whispered pectoriloquy, pleural rub, tactile fremitus?____________________________________________________ -Respiratory expansion, work of breathing, tachypnea, diaphragmatic excursion, percussion? ________________________________________________________________________________________

Heart:

-Visualize/palpate precordium for heave, thrill, visible carotid pulse, jugular pulse___________________ -Auscultate all 4 listening posts (A) - RUSB at the 2nd ICS, (P) - LUSB at the 2nd ICS, (M) - LMCL at the 5th ICS, (T) - LLSB at the 5th ICS for murmurs/rubs/gallops. Listen for physiologic S2 split or fixedsplit.____________________________________________________________________________________ -Does the murmur radiate to the apex or carotid, is it systolic or diastolic, decrescendo or crescendo, low-pitched or high-pitched? Is there a mid-systolic click or opening snap? Machine-like murmur? Grade the murmur 1-6. ____________________________________________________________________

Vasc:

- Hepatojugular reflux, manual compression (saphenous), Allen's test (radial/ulnar patency), Adson's test (thoracic outlet), thrombophlebitis, DVT(Homans sign, edema), varicosities, peripheral pulses? ________________________________________________________________________________________




Physical Examination (contd)GI: -Inspect and auscultate the abdomen first! Masses, distention, aneurysms, bruits, bowel sounds, telangiectasia, caput medusa, Cullen's (periumbilical hematoma), Grey-Turner's sign ( flank hemorrhage - hemorrhagic pancreatitis)?________________________________________________________________ -Palpate all 4 quadrants light, then heavy. Masses, tenderness, rigidity, guarding, rebound, pelvic shake, ascites (fluid wave), Murphys Sign, Rovsings Sign (LLQ pain)____________________________ -Percuss for hepatosplenomegaly, tympany, dullness__________________________________________ -If tender, perform psoas sign, obturator sign_________________________________________________ -Rectal Exam -sphincter tone, hemoccult , fissure, fistula, hemorrhoids, ulceration, excoriation, infection, lesions, prostate: size, shape, consistency, boggy, hard, firm, enlarged, nodules, masses, tenderness?_____________________________________________________________________________ Genital(m) -Lesions (painful vs. non), rash, erythema, discharge/drainage, tenderness, hernias, masses, nodules, cysts (scrotal, penile, testicular)?___________________________________________ ________________________________________________________________________________ -Cremasteric reflex, lymphadenopathy (inguinal), symmetry, Phrens Sign(epididymitis), transilluminate any masses with flashlight. ___________________________________________ Genital(f) -External genitalia- vaginal/introitus condition/lesions/discharge, lymphadenopathy?________ ________________________________________________________________________________ -Pelvic exam- Cervical Motion Tenderness (PID) (Chandelier Sign), discharge/drainage (color, amt, type), cervical os condition, bleeding, Chadwicks sign (bluish cervix with pregnancy, vaginal lesions?__________________________________________________________________ -Bimanual exam- Ectopic preg, ovarian cyst or mass, adnexal or uterine masses, tenderness? ________________________________________________________________________________ Low Back -Range of motion, muscle strength, tenderness? ______________________________________ -Reflexes (patellar (L4), Achilles (S1), sphincter (S5)____________________________________ -Edema, ecchymosis, erythema, deformity, spasms?____________________________________ -Step off (spondylolisthesis, bifida, Gauchers, sickle cell disease, injury)?_________________ -Lordosis, scoliosis, tenderness?___________________________________________________ -Straight Leg Raise / crossover SLR (herniated disk)?__________________________________ -Hoover Test (exaggeration of leg weakness)?_________________________________________ -Sacroileitis tests (Pelvic rock, Patrick test, Yeomans test, Gaenslens test)?_______________



FalconReviews.com | 866.516.9991 | Score HigherPhysical Examination (contd)Knee: -Edema, erythema, ecchymosis, effusion, tenderness?_________________________________________ -ROM, (active/passive) muscle strength?_____________________________________________________ -Neurovascular check (L4, L5, S1), distal pulses, proprioception, discrimination?___________________ -Deformity (valgus, varus), stability, masses, tenderness?______________________________________ -Ant. Drawer Sign, Lachmans Test (ACL dmg)?________________________________________________ -Post. Drawer Sign (PCL dmg), Posterior Sag (PCL)?___________________________________________ -Apley's compression, McMurrays Test (meniscus), Apley's distraction (collaterals)?________________ -Ballotment, bulge sign (effusion), Patellar grind (PFS, chondromalacia)?__________________________ -Lateral knee/femoral tenderness(ITB syndrome)?______________________________________________ Ankle: -Edema, ecchymosis, erythema, effusion , tenderness?__________________________________________ -Lesions, rashes, masses, nodules, deformity?_________________________________________________ -Neurovascular ( L4, L5, S1 ), proprioception?_________________________________________________ - ROM, muscle Strength (active/passive)?_____________________________________________________ -Stability and tenderness (ATFL, CFL, PTFL, deltoid ligament)?___________________________________ -Metatarsal squeeze (morton's neuroma), plantar fasciitis?_______________________________________ -Squeeze test (Achilles tendon), Homans Test?________________________________________________ Shoulder: -Neurovascular testing first! Pulses?________________________________________________ T1-C8- medial arm, 4 and 5 digits_________________________________ C7- middle finger, tricep reflex______________________________________ C6-1 and 2st nd th th

digits, brachiorad. reflex_______________________________

C5-lateral arm, biceps reflex________________________________________ -Edema, erythema, ecchymosis, effusion, deformity, tenderness?_________________________ -Drop arm test (rotator), winging (long thoracic n.)?_____________________________________ -Active and passive ROM, strength testing?___________________________________________ -Fowlers Test(re-location)?_________________________________________________________ Hand/Wrist: -Neurovascular check ( C5, C6, C7, C8, T1, T2, pulses)?_________________________________ -Edema, erythema, ecchymosis, effusion?_____________________________________________ -Deformity, nodules, tenderness , crepitus?___________________________________________ -ROM, muscle strength (active/passive)?______________________________________________ -Tenosynovitis, fracture, sprain, strain, overuse syndrome, tendonitis, ganglion cysts, Snuff box tenderness (scaphoid fracture)?_________________________________________________ -Look for fractures-(volar plate (fingers), boxer's (5 metacarpal neck), bennett's (1th st

metacarpal), colle's (distal radius), nightstick (ulnar shaft))______________________________ -Nodules (DIP Hebeden's, PIP Bouchard's) (osteoarthritis)?______________________________



FalconReviews.com | 866.516.9991 | Score HigherPhysical Examination (contd)Neuro: -In all patients, assess:Level of consciousness______________________________________ Posture and motor activity____________________________________________ Dress, grooming and personal hygiene___________________________________________ Facial Expression, Speech and Language __________________________________________ Manner and affect Mood ____________________________________________________ Insight and judgment_______________________________________________________ Thought content: Perceptions, interpretation of external stimulus________________________ Thought Process: Sequence, logic, coherence, relevance of thought_____________________ Consider mini-mental status exam in patients with perceived abnormalities: One point for each correct answer: Day, Date, Month, Year, Season:______________________________________ State, City, County, Building, Room:___________________________________ Say Horse, Book, Chair slowly, have pt repeat:______________________ Serial 7s, count backwards from 100, 5 subtractions:____________________ Spell the word WORLD backwards:__________________________________ Remember Horse, Book, Chair______________________________________ Have pt identify a watch and a pen or pencil____________________________ Instruct pt to 1. Pick up paper, 2. Fold in half, 3. Put on floor________________ Write close your eyes on a piece of paper, pt follows written command____ Instruct pt to write any sentence on piece of paper_______________________ Draw 2 intersecting polygons and have patient copy them_________________ A score of 20 or less is indicative of moderate to severe cognitive impairment. If the patient is not awake and alert, consider Glasgow Coma Scale. -Cerebellar Function: -Station simply stand straight____________________________________________ -Romberg close eyes and stand straight__________________________________ -Pronator sign (drift)_____________________________________________________ -Heel to toe walk________________________________________________________ -Heel to shin drag (while supine)___________________________________________ -Rapid alternating movements (RAM's)_____________________________________ -Finger to nose movements_______________________________________________ -Cranial nerves : Olfactory Sensory smell (by history)__________________________________________________ Optic Sensory - Visual Acuity, Peripheral vision by confrontation.__________________________ Oculomotor Motor- EOM, accommodation.(lateral rectus, superior oblique)__________________ Trochlear Motor - EOM (superior oblique)_______________________________________________ Trigeminal Motor- clench teeth (palpate)_______________________________________________________ Sensory- bilateral 3 sections of face-light touch V1, V2, V3______________________________ Reflex- corneal use cotton swab__________________________________________________ VI Abducens Motor- EOM (lateral rectus) _________________________________________________ VII Facial Motor- raise eyebrow, frown, smile, puff cheeks, show teeth, shut eyes tightly_____________ Sensory: taste to anterior of tongue (by history) ______________________________________ VIII Vestibulocochlear- Sensory- watch tick, rub fingers, hearing acuity. ________________________ IX/X Vagus/Glossopharyngeal Motor- Listen to voice, say "AH___________________________________________________ Sensory- Taste to Posterior tongue (by history)_______________________________________ Reflex- gag, using tongue blade to back of throat_____________________________________ XI Spinal accessory- Motor- Turn head, shrug shoulders_____________________________________ XII Hypoglossal- Motor- Stick out tongue and move side to side_______________________________ IIIIIIIVV____/5 ____/5 ____/3 ____/5 ____/5 ____/3 ____/2 ____/3 ____/1 ____/1 ____/1 ____/30



FalconReviews.com | 866.516.9991 | Score HigherPhysical Examination (contd)Neuro (contd): Peripheral Nerve Exam:-Muscular Strength- Flexors and extensors at all major joints. (1-4) -Deep Tendon Reflexes scored 0-5+. 2+ is normal. C5 - Biceps ____________________________________ C6 - Brachioradialis______________________________ C7 - Triceps ____________________________________ L4 - Patellar ____________________________________ S1 - Achilles ___________________________________ -Babinski_______________________________________________

Sensorium:-Sharp/dull/pain__________________________________________________________________ -2 point discrimination____________________________________________________________ -Temperature____________________________________________________________________ -Vibratory_______________________________________________________________________ -Light touch- dermatomes on upper and lower extremities (diabetics) ____________________ -Proprioception toe up/down test bilaterally ________________________________________ -Stereognosis ability to recognize an object by holding it______________________________ -Graphesthesia ability to recognize writing words on the skin__________________________

Labs and Studies:Labs:

Radiology/Ultrasound/Echo:

EKG:

Rate_______Rhythm________ Regularity__________ Axis____________ P waves-positive in leads 2 and V1? ________________ Sinus, AV, junctional, ventricular origin _________________ PR interval()_________QRS interval()___________QT interval()______________ Hypertrophy________________________________________________ Q's, ST changes____________________________________________ BBB's, hypertrophy, hemiblock________________________________

Other Tests/Consults:




Assessment and Plan:Mr./Ms. past medical history of who presented to with complaint(s) of found to have . Problem #1: Likely diagnosis: Rationale: Alternative diagnoses: Rationale: Plan/Treatment: is a year old with a

Problem #2: Likely diagnosis: Rationale: Alternative diagnoses: Rationale: Plan/Treatment:











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