University:
Michigan State University
Course:
MED 492 | Basics and Methods in Biomedical Research
Academic year:

2023
Views:

458

Pages:

8
Author:

Campbell Wagner

Case sheet in medicine Identity: Name: Age Sex: Occupation Nationality Date of Birth: Address Marital Status: Religion: Source of Hx: Source of Referral Date of admission Date of Examination: Respiralury Cough Sputom Hemoptesis Chief Complaint & Duration: History of presenting illness: Known case of Review of axstem: GIT CVS Taste Change Chest pain Appetile PND Dyaphasia Palpitation Analysis of CC Managements that the patient received for. Healach GUS CNS Endocrine Lom Pain J.Pain Hintoler, at wh Freque soy Dizzness J. Swelling CIntoler.cl Dysurin Vertigo Sweating Odynophagia Syncope Chest Pain Hematuria Syncope M.Stiffness Fleck Swe Heartburn Inter Chaadic Wheezy Polyuria Fit M.Pala Retrotter. P. Orthopenia Orthopnin Nocturia Fanits M. Weak. Hiccap Dyspnia Dyspuia Incontinenc Alm. Μov. Naumia, Vom. Abdl.prin Dizzness Hesitancy Parasthesia Ank. Odema Urgency Numbness Stash Hem melena Genet. Uloer Weakness iching Const. Diarh U.Discharge Vision Abm.Color WLChanges Menst. Hx. Hearing Ulcer Abdi Disten Speech Other Past History: Childbood He: Disease & hospitalization Past Medical Hx Chr. Dz. Hospitalization (date& duration), Blood Transfusion. Past Surgical Hx.: Operation (date & type). Druz History: • Dose, Frequency, Dumtion, Allergy to food & drug. Famile History: Parenia, Sibling & Childrentany systemic D. & death (ags & cause)). Social History: • Occupation, living circumstanem (type of housing & with whom), marital status. • Smoking (No. of cigarette & duration), alcohol Hx. de drug. **GI Examination** 1. **Introduce** / Consent / Chaperone 2. **Position** of the Pt. - Front and side of the bed 3. **Expose** * Upper body * Lower body * Abdomen * Perineum **Hand:** * **Skin:** * Clubbing - IHD, bronchiectasis, cyanotic heart disease * Koilonychia - Iron deficiency * Palmar erythema - Chronic liver disease (alcoholic liver disease) * Dupuytren's contracture - Alcoholic liver disease * Flapping tremor - Hepatic encephalopathy * **Nails:** * Leukonychia - Hypoalbuminemia, chronic renal disease * Koilonychia - Iron deficiency **Face:** * **Eyes:** * Jaundice - Iron deficiency * **Mouth:** * Angular cheilitis - Iron deficiency * Aphthous ulcers - IBD, Crohn's disease * Odor of mouth - Alcoholic liver disease **Neck:** * Bilateral parotid swelling - Alcohol liver disease **Chest** * Spider nevi - Chronic liver disease (excessive estrogen) * Gynaecomastia - ↓ break estrogen * Breast atrophy (in women) **4. Abdomen** **Inspection** * From xiphisternum to the symphysis pubis * Skin: * Color * Striae * Bruising * Scratch marks * Visible Veins * Poor liver obstruction * Portal hypertension * Abdominal swelling * Localized mass * Abdominal scars **Palpation** * Warm hand & clean * Observe the pt's face * Superficial palpation * Tenderness & Rebound tenderness * Deep palpation * No mass * Hepatomegaly * Splenomegaly **Enlarged organs**

Case Sheet in Medicine

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