dr_messo
09-24-2002, 01:34 AM
بسم الله الرحمن الرحيم
this is an example of how to present a case containg complete history & phisical examination ... i love if we interact to gether & discuss the case ask Qs etc. ... & by this way we will improve our skills in these 2 important subjects .
Nesma Al-***** 60 year-old house wife Saudi female patient . Admitted to the hospital through the E.R complaining of 2 month history of right side chest pain & shortness of breath which become sever prior to the admission .
History of Presnting Illness :
Chest pain :
· Right side .
· Sudden .
· Intermittent for half an hour duration .
· On moderate exertion .
· Relived by rest .
· Not associated with palpetation or PND .
Shortness of breath :
· Gradual .
· Intermitenet for ½ hour duration .
· On moderate exertion .
· Relived by rest .
· Associated with chest pain .
No H/O : cough , sputum , hemoptesis , wheezing , night sweats , nasal discharge , orthopnia or PND .
Past medical history :
· No history of previous hospital admission , D.M , HTN , T.B , rheumatic fever , surgery , or ischemic heart disease .
Medication :
· No H/O chronic medications .
· Current medication (( given at hospital )) ; lasix , bacteram , mucolytic syrup , claforan , zantac & maximit .
Allergies :
· No H/O drug , food , animal or occupational allergy .
Social history :
· Divorced with one daughter ( 30 year-old ) .
· House wife .
· X-smoker for 10 years 1 pack per day , she stops smoking one year ago .
· Living alone at home .
· No H/O alcohol or drug abusing .
Family history :
· No family history of HTN , DM , C.V.A , ischemic heart disease , asthma , malignancy or death of young relatives .
Review of systems :
· HEENT (head , eye , ear , nose , throught ) :
· Headache .
· No H/O visual disturbance , red eye , ear discharge , hearing problems , sore throat or horseness of voice .
· C.V.S :
· Shortness of breath .
· No H/O palpitation , syncope , lower limb edema , swilling , cyanosis or intermittent claudication .
· G.I.T :
· Loss of appetite .
· No H/O heart burn , dysphagia , odenophagia , nausea , abdominal pain , vomiting or any other GIT symptoms .
· C.N.S :
· No history of dizziness , syncope , seizures , tremor , numbness , weakness or disturbances of sphincter control .
· GUT ( GenetoUrinary Tract ) :
· Little change in urine color ( I asked about the color but the patient didn’t know how to describe it I helped her but finally she says its only a little change ) .
· No H/O loin pain , dysurea ,polyurea , nocturea , hematourea , hesitancy, dripling or vaginal discharge .
· Rhumatic :
· Joints pain .
· No H/O stiffness , weakness , malignancy or backpain .
· Endocrine :
· No H/O polyurea , polydepsia , polyphagia , nocturea , cold-heat intolerance , neck swelling or hair disturbances .
· Skin :
· No H/O rashes , pruritis or pigmentation changes .
· Hematology :
· No H/O anemia , ease of brusing or bleeding tendency .
On examination:
· The patient was conscious , cooperative , oriented to time, person & place .
· Look well , mormal body built , ling comfortably on bed .
· Not jaundice , cyanosed .
· Afebrile .
· Vitals :
o P.R = 85 /min . regular , normal volume , no femoral delay , collapsing pulse ,syncronus also blood vessel wall was not palpable .
o R.R = 16/ min .
o B.P = 110 / 70 mmHg .
o Temp. = 36.9 C .
· Head :
o Eyes were normal no pallor or jaundice .
o Tounge was normal , no central cyanosis or abnormal coloration .
o Lips were also normal color , no perephral cyanosis .
· Neck :
o No lymph node enlagment , normal J.V.P , normal thyroid , normal carotid , trachea was not displaced .
· Hands :
o No clubbing , leuconychia , koilonychias , splinter hemorrhage , palmar erythema , tremor , waisting , swilling or deformity .
· Respiratory system :
o On inspiction : Chest expansion was a little reduced in the left side , no scars , lesions , chest deformity .
o No tracheal displacement .
o On percussion bilateral effusion ( dullness bilaterally )
o mainly in the lower lobes .
o On auscultation ; there was lung crepitation
o Vesicular sound are a little reduced mainly in left side .
o No bronchial , bronchovisicular sounds .
o reduced vocal fremitus & vocal resonance more prominent in the left side .
o No other significant findings .
· C.V.S :
o PMI is displaced to sexth intercostal space anterior axillary line .
o Heart sounds were normal , no murmers or splitting sounds of valves .
o No pericardial rub ,thrill or heave .
· G.I.T :
o No abdominal distension , promenant veins , hernia scar , scrach mark , hair distribution , pigmentation , tenderness , rigidity ,masses , organomegaly or ascitis .
o Normal liver span , spleen was not palpable .
· C.N.S :
o Normal reflexes .
o Normal sensations of pain , tempreture , touch ,position sense , vibration .
o Cranial nerves were normal .
o Coordination : finger nose , pronation-supination , heal-shin all are normal .
o No tremor , chorea , atrophy .
o No significant findings .
o See the attached file for more details about CNS Exam .
this is an example of how to present a case containg complete history & phisical examination ... i love if we interact to gether & discuss the case ask Qs etc. ... & by this way we will improve our skills in these 2 important subjects .
Nesma Al-***** 60 year-old house wife Saudi female patient . Admitted to the hospital through the E.R complaining of 2 month history of right side chest pain & shortness of breath which become sever prior to the admission .
History of Presnting Illness :
Chest pain :
· Right side .
· Sudden .
· Intermittent for half an hour duration .
· On moderate exertion .
· Relived by rest .
· Not associated with palpetation or PND .
Shortness of breath :
· Gradual .
· Intermitenet for ½ hour duration .
· On moderate exertion .
· Relived by rest .
· Associated with chest pain .
No H/O : cough , sputum , hemoptesis , wheezing , night sweats , nasal discharge , orthopnia or PND .
Past medical history :
· No history of previous hospital admission , D.M , HTN , T.B , rheumatic fever , surgery , or ischemic heart disease .
Medication :
· No H/O chronic medications .
· Current medication (( given at hospital )) ; lasix , bacteram , mucolytic syrup , claforan , zantac & maximit .
Allergies :
· No H/O drug , food , animal or occupational allergy .
Social history :
· Divorced with one daughter ( 30 year-old ) .
· House wife .
· X-smoker for 10 years 1 pack per day , she stops smoking one year ago .
· Living alone at home .
· No H/O alcohol or drug abusing .
Family history :
· No family history of HTN , DM , C.V.A , ischemic heart disease , asthma , malignancy or death of young relatives .
Review of systems :
· HEENT (head , eye , ear , nose , throught ) :
· Headache .
· No H/O visual disturbance , red eye , ear discharge , hearing problems , sore throat or horseness of voice .
· C.V.S :
· Shortness of breath .
· No H/O palpitation , syncope , lower limb edema , swilling , cyanosis or intermittent claudication .
· G.I.T :
· Loss of appetite .
· No H/O heart burn , dysphagia , odenophagia , nausea , abdominal pain , vomiting or any other GIT symptoms .
· C.N.S :
· No history of dizziness , syncope , seizures , tremor , numbness , weakness or disturbances of sphincter control .
· GUT ( GenetoUrinary Tract ) :
· Little change in urine color ( I asked about the color but the patient didn’t know how to describe it I helped her but finally she says its only a little change ) .
· No H/O loin pain , dysurea ,polyurea , nocturea , hematourea , hesitancy, dripling or vaginal discharge .
· Rhumatic :
· Joints pain .
· No H/O stiffness , weakness , malignancy or backpain .
· Endocrine :
· No H/O polyurea , polydepsia , polyphagia , nocturea , cold-heat intolerance , neck swelling or hair disturbances .
· Skin :
· No H/O rashes , pruritis or pigmentation changes .
· Hematology :
· No H/O anemia , ease of brusing or bleeding tendency .
On examination:
· The patient was conscious , cooperative , oriented to time, person & place .
· Look well , mormal body built , ling comfortably on bed .
· Not jaundice , cyanosed .
· Afebrile .
· Vitals :
o P.R = 85 /min . regular , normal volume , no femoral delay , collapsing pulse ,syncronus also blood vessel wall was not palpable .
o R.R = 16/ min .
o B.P = 110 / 70 mmHg .
o Temp. = 36.9 C .
· Head :
o Eyes were normal no pallor or jaundice .
o Tounge was normal , no central cyanosis or abnormal coloration .
o Lips were also normal color , no perephral cyanosis .
· Neck :
o No lymph node enlagment , normal J.V.P , normal thyroid , normal carotid , trachea was not displaced .
· Hands :
o No clubbing , leuconychia , koilonychias , splinter hemorrhage , palmar erythema , tremor , waisting , swilling or deformity .
· Respiratory system :
o On inspiction : Chest expansion was a little reduced in the left side , no scars , lesions , chest deformity .
o No tracheal displacement .
o On percussion bilateral effusion ( dullness bilaterally )
o mainly in the lower lobes .
o On auscultation ; there was lung crepitation
o Vesicular sound are a little reduced mainly in left side .
o No bronchial , bronchovisicular sounds .
o reduced vocal fremitus & vocal resonance more prominent in the left side .
o No other significant findings .
· C.V.S :
o PMI is displaced to sexth intercostal space anterior axillary line .
o Heart sounds were normal , no murmers or splitting sounds of valves .
o No pericardial rub ,thrill or heave .
· G.I.T :
o No abdominal distension , promenant veins , hernia scar , scrach mark , hair distribution , pigmentation , tenderness , rigidity ,masses , organomegaly or ascitis .
o Normal liver span , spleen was not palpable .
· C.N.S :
o Normal reflexes .
o Normal sensations of pain , tempreture , touch ,position sense , vibration .
o Cranial nerves were normal .
o Coordination : finger nose , pronation-supination , heal-shin all are normal .
o No tremor , chorea , atrophy .
o No significant findings .
o See the attached file for more details about CNS Exam .