Professional Documents
Culture Documents
CASE PRESENTATION
Student's Name:
vv
Student Number:
Patient's Initials:
Date of Encounter:
_________________________________________________________________________________
Chief Complaint:
History of Present Illness:
vddd
Surgical history:
Family history:
Social history:
Review of systems:
Yes
No
SYSTEM
General:
Recent weight loss
Recent weight gain
Weakness
Fatigue
Fever
Chills
Skin:
Rashes
Lumps
Sores
Itching
Dryness
Yes
No
SYSTEM
Changes in skin color
Changes in hair
Changes in nails
Changes in size or color of moles
No
SYSTEM
Yes
No
SYSTEM
Cardiovascular
Blurred vision
Double vision
Edema
Gastrointestinal
Loss of hearing
Trouble swallowing
Tinnitus
Heartburn
Vertigo
Loss of appetite
Earache
Ear discharge
Frequent colds
Nasal stuffiness
Nasal discharge
Rectal bleeding
Nosebleeds
Sinus pain
Hemorrhoids
Neck
Constipation
Diarrhea
Goiter
Abdominal pain
Pain
Excessive belching
Stiffness
Excessive flatulence
Breasts
Jaundice
Lumps
Peripheral Vacular
Pain
Intermittent claudication
Discomfort
Leg cramps
Nipple discharge
Varicose veins
Respiratory
Ulcers
Cough
Sputum
Hemoptysis
Dyspnea
Urinary
Wheezing
Increased frequency
Pleurisy
Nocturia
Cardiovascular
Urgency
Palpitations
Flank pain
Dyspnea on exertion
Orthopnea
Hematuria
No
SYSTEM
Yes
No
SYSTEM
Urinary (Male)
Neurologic
Changes in speech
Hesitancy
Changes in orientation
Dribbling
Frequent headaches
Genital (Male)
Dizziness
Hernias
Fainting or blackouts
Weakness
Sores or ulcers
Paralysis
Testicular pain
Testicular masses
Tingling sensation
Scrotal swelling
Tremors
Involuntary movements
Genital (Female)
Seizures
Irregular menses
Hematologic
Prolonged menses
History of anemia
Excessive bleeding
Easy bruising
Excessive bleeding
Dysmenorrhea
Past transfusions
Menopause
Endocrine
Postmenopausal bleeding
Excessive sweating
Vaginal discharge
Vaginal itching
Polyuria
Musculoskeletal
Muscle pain
Joint pain
Backache
Swelling of the joints
Stiffness of the joints
Muscular weakness
Limitation of motion
History of fractures or trauma
Psychiatric
Nervousness
Anxiety
Depressed mood
Health Maintenance:
Vaccinations
Hepatitis B
Influenza
Measles-Mumps-Rubella
Pneumococcal
Tetanus toxoid
Varicella
Last Dose
Last Performed
Screening
Bone densitometry
Lipid profile
Colonoscopy
Mammography
Diabetes screening
Pap smear
Last Performed
Physical Exam:
Vital signs:
Temperature
Weight
Normal
Abnormal
Heart rate
Respirations
Height
BMI
SYSTEM
General: Alert, awake, and oriented. Appropriate grooming
and hygiene. No acute distress.
Skin: Moist skin. No ulcers, rashes, or lumps. Normal hair
and nails. No jaundice.
HEENT: Normocephalic. Sclearea white. Normal visual
acuity. Pupils equally reactive to light. Normal eye fundi.
Normal ear canal. Weber midlince. Rinne AC>BC.
Normal nasal mucosa. No sinus tenderness. Moist oral
muscosa. Good dentition. No erythema or exudates.
Neck: No palpable masses or lumps. No goiter. Neck supple.
No palpable lymph nodes. No jugular venous distention. No
carotid bruits.
Thorax and Lungs: No tenderness to palpation of spinal
processes. Normal lung expansion. Normal tactile fremitus
No egophony or whispered pectoriloquy. Lungs clear to
auscultation with no ronchi, crackles or wheezing.
Breasts and Axillae: No lumps or masses. No discharge.
Heart: Non-displaced apex. Regular rhythm. Normal S1
and S2. No S3 or S4. No audible murmurs. No clicks, rubs
or other sounds.
Abdomen: Normal bowel sounds. No abdominal bruits
No tenderness to palpation. No masses. Normal liver span.
No splenomegaly. No ascites.
Extremities: No ulcers or discoloration. No edema.
Peripheral pulses +2 throughout. No deformities of the
joints. Normal range of motion. Normal muscle bulk and
tone.
Blood pressure
ABNORMAL FINDINGS
Abnormal
SYSTEM
ABNORMAL FINDINGS
Neurologic:
Mental status: Alert, awake, and oriented. Appropriate
speech. Normal mentation, insight, judgement, and memory.
Cranial nerves: Normal sense of smell. Normal visual
acuity, visual fields, and ocular fundi. Normal pupillary
reaction. Normal extraocular movements. Normal corneal
reflex, facial sensation, and jaw movements. Normal facial
movements. Normal hearing. Weber midline. Rinne AC>
BC. Normal swallowing and rise of the palate. Intact gag
reflex. Normal voice and speech. Normal shoulder and
neck movements. Normal tongue symmetry and position
Motor system: Normal muscle tone and bulk. Strength 5/5 in
all muscle groups. Point-to-point movements and rapid
alternating movements intact. Normal gait.
Sensory system: Normal sensation to pain, temperature,
light touch, vibration,and point discrimination.
Reflexes: Normal biceps, triceps, brachioradialis, patellar,
and Achilles deep tendon reflexes.
Laboratory Findings:
Segmented neutrophils
Lymphocytes
Eosinophils
Alkaline phosphatase
Monocytes
Bilirubin, total
Bilirubin, direct
Magnesium
Imaging studies:
Electrocardiogram:
Plan:
References:
STUDENT SIGNATURE: