m – Chart Note (FULL)

Nov 21, 2019 admin KỸ NĂNG LÂM SÀNG 0

Chart Note (FULL)

HPI:

  1. Elements of C/C (use mnemonic OLDCARTS)
  2. Association
  3. PMH: childhood, immunization, adult
    • (m): Preventive Health (cần cho primary care)
  4. PSH
  5. All / Meds
  6. FM
  7. SH: x3 (EtoH, drug, smoking), sexual, others
  8. ROS: Nhớ từ cơ quan HEENT/Neck/CV/Resp/GI/GU) đến tổng quát từ ngoài vào (mẹo nhớ từ ngoài vào: Skin/Allergy/Immunization -> MS -> Neuro/Endo -> Hemo/Lymphatic -> Psycho -> HEENT/Neck -> CV/Resp -> Abd/GU)
    1. Skin
    2. Allergic / Immunization
    3. Hemato / Lymphatic
    4. HEENT / Neck
    5. Resp
    6. CV
    7. Abd
    8. Genital – Urinary (GU)
    9. MS
    10. Nervous
    11. Endo
    12. Psy

Physical

(ROS thì đi từ cơ quan đến tổng quát, Physical thì từ tổng quát đến cơ quan: Vital/General/Skin/Hemo/Lymph -> Đầu cổ/ngực/bụng/lưng -> Sinh dục / extremities or MS –> Neuro)

  1. Vitals
  2. General appearance
  3. Skin
  4. HEENT / Neck / Nodes
  5. Chest / Breast / CV / Lungs
  6. Abd / Back / Spine / Genitals / Rectal
  7. Extremities with pulses
  8. Neuro: mental status, cranial nerves, motor, sensory, cerebellar, posterior column (vibratory, position, Romberg), reflexes

Labs/Tests Review

Problem List

  • List of All abnormal findings from H&P (mark MSAP (most significant active problem) relation)

Summary or Problem Statement

A/P

TEMPLATE

History and Physical Examination

  • Identifying Data: Patient’s name; age, race, sex. List the patient’s significant medical problems. Name of informant (patient, relative).
  • Chief Compliant: Reason given by patient for seeking medical care and the duration of the symptom.
  • History of Present Illness (HPI): Describe the course of the patient’s illness, including when it began, character of the symptoms, location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives. Describe past illnesses or surgeries, and past diagnostic testing.
  • Past Medical History (PMH): Past diseases, surgeries, hospitalizations; medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction, cancer. In children include birth history, prenatal history, immunizations, and type of feedings.
  • Medications:
  • Allergies: Penicillin, codeine?
  • Family History: Medical problems in family, including the patient’s disorder.
  • Asthma, coronary artery disease, heart failure, cancer, tuberculosis.
  • Social History: Alcohol, smoking, drug usage. Marital status, employment situation. Level of education.

Review of Systems (ROS):

  • General: Weight gain or loss, loss of appetite, fever, chills, fatigue, night sweats.
  • Skin: Rashes, skin discolorations.
  • Head: Headaches, dizziness, masses, seizures.
  • Eyes: Visual changes, eye pain.
  • Ears: Tinnitus, vertigo, hearing loss.
  • Nose: Nose bleeds, discharge, sinus diseases.
  • Mouth and Throat: Dental disease, hoarseness, throat pain.
  • Respiratory: Cough, shortness of breath, sputum (color).
  • Cardiovascular: Chest pain, orthopnea, paroxysmal nocturnal dyspnea; dyspnea on exertion, claudication, edema, valvular disease.
  • Gastrointestinal: Dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena (black tarry stools), hematochezia (bright red blood per rectum).
  • Genitourinary: Dysuria, frequency, hesitancy, hematuria, discharge.
  • Gynecological: Gravida/para, abortions, last menstrual period (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding, breast masses.
  • Endocrine: Polyuria, polydipsia, skin or hair changes, heat intolerance.
  • Musculoskeletal: Joint pain or swelling, arthritis, myalgias.
  • Skin and Lymphatics: Easy bruising, lymphadenopathy.
  • Neuropsychiatric: Weakness, seizures, memory changes, depression.

Physical Examination

  • Vital Signs: Temperature, heart rate, respirations, blood pressure.
  • General appearance: Note whether the patient looks “ill,”well, or malnourished.
  • Skin: Rashes, scars, moles, capillary refill (in seconds).
  • Lymph Nodes: Cervical, supraclavicular, axillary, inguinal nodes; size, tenderness.
  • Head: Bruising, masses. Check fontanels in pediatric patients.
  • Eyes: Pupils equal round and react to light and accommodation (PERRLA); extra ocular movements intact (EOMI), and visual fields. Funduscopy (papilledema, arteriovenous nicking, hemorrhages, exudates); scleral icterus, ptosis.
  • Ears: Acuity, tympanic membranes (dull, shiny, intact, injected, bulging).
  • Mouth and Throat: Mucusmembrane color andmoisture; oral lesions, dentition,pharynx, tonsils
  • Neck: Jugular venous distention (JVD) at a 45 degree incline, thyromegaly, lymphadenopathy, masses, bruits, abdominojugular reflux.
  • Chest: Equal expansion, tactile fremitus, percussion, auscultation, rhonchi, crackles, rubs, breath sounds, egophony, whispered pectoriloquy.
  • Heart: Point of maximal impulse (PMI), thrills (palpable turbulence); regular rate and rhythm (RRR), first and second heart sounds (S1, S2); gallops (S3, S4), murmurs (grade 1-6), pulses (graded 0-2+).
  • Breast: Dimpling, tenderness, masses, nipple discharge; axillary masses.
  • Abdomen: Contour (flat, scaphoid, obese, distended); scars, bowel sounds, bruits, tenderness, masses, liver span by percussion; hepatomegaly, splenomegaly; guarding, rebound, percussion note (tympanic), costovertebral angle tenderness (CVAT), suprapubic tenderness.
  • Genitourinary: Inguinal masses, hernias, scrotum, testicles, varicoceles.
  • Pelvic Examination: Vaginalmucosa, cervical discharge, uterine size, masses, adnexal masses, ovaries.
  • Extremities: Joint swelling, range of motion, edema (grade 1-4+); cyanosis, clubbing, edema (CCE); pulses (radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses).
  • Rectal Examination: Sphincter tone, masses, fissures; test for occult blood, prostate (nodules, tenderness, size).
  • Neurological: Mental status and affect; gait, strength (graded 0-5); touch sensation, pressure, pain, position and vibration; deep tendon reflexes (biceps, triceps, patellar, ankle; graded 0-4+); Romberg test (ability to stand erect with arms outstretched and eyes closed).
  • Cranial Nerve Examination:
  • I: Smell
  • II: Vision and visual fields
  • III, IV, VI: Pupil responses to light, extraocular eye movements, ptosis
  • V: Facial sensation, ability to open jaw against resistance, corneal reflex.
  • VII: Close eyes tightly, smile, show teeth
  • VIII: Hears watch tic; Weber test (lateralization of sound when tuning fork is placed on top of head); Rinne test (air conduction last longer than bone conduction when tuning fork is placed on mastoid process)
  • IX, X: Palette moves in midline when patient says “ah,” speech
  • XI: Shoulder shrug and turns head against resistance
  • XII: Stick out tongue in midline
  • Labs: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine),
  • CBC (hemoglobin, hematocrit, WBC count, platelets, differential); x-rays,
  • ECG, urine analysis (UA), liver function tests (LFTs).

Assessment (Impression): Assign a number to each problem and discuss separately. Discuss differential diagnosis and give reasons that support the working diagnosis; give reasons for excluding other diagnoses.

Plan: Describe therapeutic plan for each numbered problem, including testing, laboratory studies, medications, and antibiotics.

 

 

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