Resident survival guide examine the patient: Difference between revisions
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Rim Halaby (talk | contribs) No edit summary |
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'''Vitals'''<br> | '''Vitals'''<br> | ||
❑ Temperature <br> | ❑ [[Temperature]] <br> | ||
:❑ [[Fever]] <br> | :❑ [[Fever]] <br> | ||
:❑ [[Hypothermia]] <br> | :❑ [[Hypothermia]] <br> | ||
❑ Pulse <br> | ❑ [[Pulse]] <br> | ||
:❑ Rate <br> | :❑ Rate <br> | ||
::❑ [[Tachycardia]] <br> | ::❑ [[Tachycardia]] <br> | ||
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❑ [[Narrow pulse pressure]] <br> | ❑ [[Narrow pulse pressure]] <br> | ||
❑ Respiratory rate <br> | ❑ [[Respiratory rate]] <br> | ||
❑ [[Tachypnea]] <br> | ❑ [[Tachypnea]] <br> | ||
❑ [[Bradypnea]] <br> | ❑ [[Bradypnea]] <br> | ||
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❑ [[Pulmonary edema]] and [[rales]] <br> | ❑ [[Pulmonary edema]] and [[rales]] <br> | ||
❑ [[Wheezing]] <br> | ❑ [[Wheezing]] <br> | ||
❑ | ❑ Reduced [[breath sounds]] <br> | ||
❑ [[Rales]] <br> | ❑ [[Rales]] <br> | ||
❑ [[Egophony]] <br> | ❑ [[Egophony]] <br> | ||
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❑ [[Heave]] <br> | ❑ [[Heave]] <br> | ||
❑ [[Thrill]] <br> | ❑ [[Thrill]] <br> | ||
❑ [[ | ❑ [[Pericardial friction rub]]<br> | ||
❑ [[Heart sounds]] | ❑ [[Heart sounds]] | ||
:❑ [[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] <br> | :❑ [[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] <br> | ||
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❑ [[Abdominal distention]] <br> | ❑ [[Abdominal distention]] <br> | ||
❑ [[Abdominal tenderness]] <br> | ❑ [[Abdominal tenderness]] <br> | ||
❑ [[Rebound]] <br> | ❑ [[Rebound tenderness]] <br> | ||
❑ [[Abdominal mass]] <br> | ❑ [[Abdominal mass]] <br> | ||
❑ | ❑ [[Abdominal guarding]] <br> | ||
❑ [[Hepatomegaly]] <br> | ❑ [[Hepatomegaly]] <br> | ||
❑ [[Splenomegaly]] <br> | ❑ [[Splenomegaly]] <br> | ||
❑ Genitourinary exam if relevant <br> | ❑ [[Genitourinary exam]] if relevant <br> | ||
'''Extremities''' <br> | '''Extremities''' <br> | ||
Revision as of 16:57, 20 March 2014
Appearance of the Patient
❑ This section should give a general description of what a patient with the disease you are describing may look like. You may include a physical description such as obese, thin, cachectic, well appearing, ill appearing, diaphoretic etc
Vitals
❑ Temperature
- ❑ Fever
- ❑ Hypothermia
❑ Pulse
- ❑ Rate
- ❑ Rhythm
- ❑ Regular
- ❑ Irregularly irregular
- ❑ Regular
- ❑ Strength
- ❑ Weak
- ❑ Bounding
- ❑ Alternating in strength (pulsus alternans)
- ❑ Weak
- ❑ Paradoxical pulse
- ❑ Symmetry
- ❑ Asymmetric
- ❑ Asymmetric
❑ Blood pressure
❑ Hypotension
❑ Hypertension
❑ Wide pulse pressure
❑ Narrow pulse pressure
❑ Respiratory rate
❑ Tachypnea
❑ Bradypnea
❑ Kussmaul respirations
Skin
❑ Cyanosis
❑ Jaundice
❑ Rash
❑ Pallor
❑ Lesions
Head
❑ Abnormalities of the head/hair
❑ Evidence of trauma
Eyes
❑ Icteric sclera
❑ Nystagmus
❑ Abnormal extra-ocular movements
❑ Pupils not reactive to light
❑ Abnormal findings on ophthalmoscopic exam
Ears
❑ Reduced hearing acuity
❑ Positive Weber test
❑ Positive Rinne test
❑ Exudate from the ear canal
❑ Tenderness on movement of the pinnae
Nose
❑ Inflamed nares
❑ Epistaxis
❑ Purulent exudate from the nares
❑ Tenderness to percussion of the sinuses
❑ Congested nares
Throat
❑ Erythematous
❑ Exudate
❑ Petechiae
❑ Tonsillar inflammation
Neck
❑ Elevated jugular venous pressure
❑ Carotid bruits
❑ Lymph nodes
❑ Thyromegaly
❑ Hepatojugular reflux
Lungs
❑ Pulmonary edema and rales
❑ Wheezing
❑ Reduced breath sounds
❑ Rales
❑ Egophony
❑ Asymmetric chest movement
Heart
❑ Heave
❑ Thrill
❑ Pericardial friction rub
❑ Heart sounds
- ❑ Systolic murmur best heard at the base (describe the murmur)
- ❑ Systolic murmur best heard at the apex (describe the murmur)
- ❑ Diastolic murmur (describe the murmur)
Abdomen
❑ Abdominal distention
❑ Abdominal tenderness
❑ Rebound tenderness
❑ Abdominal mass
❑ Abdominal guarding
❑ Hepatomegaly
❑ Splenomegaly
❑ Genitourinary exam if relevant
Extremities
❑ Clubbing
❑ Cyanosis
❑ Edema
Neurologic
❑ Altered mental status
❑ Glasgow coma scale of___
❑ Clonus
❑ Hyperactive reflexes
❑ Deficits in cranial nerves ___