Professional Documents
Culture Documents
Bed + MRN
Full Name
Gender & Race
DOB
Ht/Wt/BMI
Date/Time Admit
Date/Time Clerk
Husband/Wife
(Name/Age/Occp)
9. Total Income
10. Address/House Type
1.
2.
3.
4.
5.
6.
7.
8.
DDx = Trauma # Infection # Neoplasm # Congenital # Autoimmune # Metabolism # Blood # Endocrine # Drugs
Hx Taking Guidelines Surgery Ver. 3
1.
2.
3.
4.
5.
6.
7.
Fever
1. Type (Cont./Remit/
Intmint./Relapse)
2. Character
3. Duration
(sudden/gradual)
4. Nocturnal Variation
5. Chills/Rigor?
6. Rashes/Joint Pain
7. Frequency/Recurrent
8. Temperature
9. Medication
10. Hx Contact
11. Hx Travel
12. Fits
1.
2.
3.
4.
5.
6.
7.
8.
9.
Vomitting
Frequency
Characteristics
Volume
Projectile/NonProjctle
Hematemesis (colour)
Duration
Exacerbating/Relieving
Timing
Nausea
1.
2.
3.
4.
5.
6.
7.
8.
Diarrhea
Character/Consistency
Colour
Frequency
Amount
Blood/Mucous
Pain
Abd. Distension
Flutulance
1.
2.
3.
4.
5.
Constipation
Onset
Time
Bleeding
Straining/Prolapse
Tenesmus
Loss of Weight
1. How much?
2. Period of time?
3. Diet (type & intake)
Cough
1. Duration
2. Sound
3. SOB?
4. Cyanosis
5. Type (Productive?)
6. Sputum Character
7. PostTussive (Condition)
8. Runny nose
9. Frequency
10. Exacerbating/Relieving
11. Medication
SYSTEMIC REVIEW
RESPI - runny nose, cough,
wheeze, SOB, activity
limitation
ENT throat infections,
snoring, noisy breathing
CVS - sweating, cyanosis,
pallor, SOB, exercise
tolerance, murmur
GIT - appetite, diet,
vomiting, pain, abdominal
distention, bowel habit,
stools,
MSK - gait, limb pain, joint
pain @ swelling,
CNS - headaches, fits,
hearing, vision
GnUr - pain, colour,
frequency, training
H&L - anemia, bleeding
tendency or clotting
tendency.
1.
2.
3.
4.
5.
6.
Social Hx
Smoking/Drink/Drugs
Diet
Occupation
Income
Education
House type &
environment
Prepared & Improved by Group 3 9th Batch UiTM 2013/2014 * Please add on if theres anything missing and improve this guideline
General Examination
Bed 45 Stand @ Right Hand Side of Pt
1.
Appearence, Alertness,
Activity(movements)
2.
Is the patient in pain?
3.
Hydrational/Nutritional Status
Sunken orbits
Dry buccal mucosa
Skin turgor
Capillary refill
Anterior fontanelle
4.
Attachment/Equipment
5.
Temperature
6.
Respiratory Distress
Rate
Nasal flaring
Accesory Muscle Use
7.
BP & Pulses (Rt/Ry/Vol)
Radial
Brachial
Femoral
Popletial
Dorsalis Pedis
Posterior Tibial
8.
Colour
Pink
Blue/Cyanose
Yellow/Jaundice
Pale
9.
Skin
Rash
Bruises
Scratch Marks/Scars
Eczema
10.
Hands
Nails shape & colour
(clubbing,splinter H)
Temperature
Moisture
Colour
11.
Edema
12.
Neck
Trachea
JVP
Thyroid
Lymph Nodes
Cervical
Occipital
Axillary
Inguinal
Abdominal Examination
1.
2.
3.
4.
5.
6.
7.
8.
General Abdominal
Activity
Lie still appndcts/pritonits
Moving acute cholangitis
Inspection
(Supine + Hips Flexed)
Contour, peripheral vasuclar
irregularities, skin markings
Skin (dermatitis
herperiformis, erytherma
nodosum, palmar
eryhterma, spider angioma,
caput madusae)
Abdomen (distention,
schaphoid abdomen,
peristaltic waves, scars,
protrusions in hernia)
Palpate (superficial > deep)
Tenderness, liver, spleen,
kidney, detect masses
Groin adenopathy, inguinal
hernias
Percussion
Hepatomegaly,
Spleenomegaly,
Acites (shifting dullness,
fluid thrill)
Auscultate
P
Abdominal sounds (active,
decreased, absent)
Bruit
CVS Examination
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
General CVS
Pallor Sweating Cyanosis
SOB Palpitations Edema
Dysmorphic features
Vital Signs
(HR,RR,BP,Ht,Wt, Head
Circumfrence)
Inspection
Nails (clubbing, splinter
hemorrhages, cyanosis)
Capillary refill time
Eyes (pallor, scleral
icterus, xanthomata,
senile arcus)
Mouth (central cyanosis,
hydration)
JVP
Chest (shape, precordial
bulge, pectus carinatum/
excavatum, scars, visible
impulse)
PPeripheral Palpation
Pulses brachial & femoral,
Brachial femoral delay
Precordium Palpation
Apex beat & all 4
auscultatory areas
Thrills
Liver
Spleen
Edema
Auscultation
Heart sounds/Murmurs at
4 Areas
- Aortic (2nd R ICS)
- Pulmonic (2nd L ICS)
- Tricuspid (Low L Strnl
Bordr)
- Mitral (Apex)
*Diaphragm (high
pitch:rubs, S1,S2) & Bell
(low pitch: gallop, S2 spilit)
Lungs (pulm congestion)
CNS Examination
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
Respiratory Examination
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
General Respiratory
Respiratory Rate, depth,
ease and rhythm of
respiration
Inspection
Thorax Anterior &
Posterior
(symmetry,retractions,
accessory muscles, shape,
vertebral column)
Nose (nasal flaring)
Lips/Mucus membrane
(cyanosis)
Oropharynx (Inflamed?)
Nail bed (peripheral
cyanosis, clubbing)
PPalpation
Trachea at supra sternal
notch (mobility and
deviation)
Lymph nodes (head &
neck)
Anterior & Posterior
Tactile Fermitus (99 test)
Pulsus Paradoxus
(decrese in systolic BP
during inspiration)
Apex Beat
Percussion
Chest (dull,
hyperresonant,flat)
Auscultation
For each lobes (compare
R&L)
- Air Entry
- Breath Sound
- Additional Sounds
- Vocal Resonance
5.
6.
7.
8.
9.
1.
2.
3.
4.
Describing Lumps
8. Site + Size + Surface
9. Colour + Contour(Shape) + Consistency
10. Tender? + Temperature + Transilluminable
11. Fluid filled + Fixed? + Fields (of lymph drainage)
12. Pulsatile?
13. Expansible?
14. Reducible
CNS Examination
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
1.
2.
3.
Describing Ulcer
4. Base
a. Solid brown/grey
b. Yellow grey
c. Bluish
d. Underlying structures bare
5. Edge
a. Sloping
b. Punched out
c. Undermined
d. Rolled
e. Everted
6. Discharge
7. Relations