Professional Documents
Culture Documents
1
II. Chief Complaint 4. Associations with:
a. Other symptoms
One or more symptoms causing the patient b. Posture
to seek care c. Movement
verbatim patient’s own words d. Physiologic functions
Avoid diagnostic words e. Aggravating/alleviating factors
2
iv. Duration of stay Living arrangements
v. Condition @ discharge Physical and social aspects of home and
7. Relief of symptoms environment
8. Recurrences
Personal interests
9. Pertinent positives & negatives
a. Do not repeat what has been written Lifestyle
b. Not mentioned by the patient
VII. Obstetrical and Menstrual History
IV. Past Medical History menarche
o Age of onset
Childhood diseases o Duration
Adult illnesses categorized as medical, surgical, o Amount (no. of napkins)
obstetric/ gynecologic or psychiatric With dates o Associated symptoms
Immunization status subsequent menses
Note for screening tests undergone by patient o Regularity
Maintenance medications o Duration
History of trauma/accidents o Amount
History of hospitalizations, operations, illnesses pregnancies
History of allergies & adverse drug reaction o G_P_(T-P-A-L)
G – no. of pregnancies
P – No. of live births
V. Family History
(term – preterm – abortions – living)
Peripartum events
heredo-familial diseases
Delivery, place, attending personel,
member of the family
complications
- Age and state of health
Menopause
- Age and cause of death
Age of onset
*If sick: age of onset of illness and treatment
Associated symptoms
marital history
o Duration of marriage
o Occupation of partner PHYSICAL EXAMINATION
o Health of spouse – sick/dead Do’s
no. of children Pay attention to physician/patient’s comfort
o Ages Avoid unnecessary exposure and
o Health of children embarrassment
Avoid expressions of disgust, alarm and
V. Personal, Social &Environmental History distaste
Keep the patient informed as to what you
Education, military service and religious intend to do or are doing
activity Avoid distasteful of unhygienic sequence in
Occupation doing PE
o Present & past Avoid reassuring the patient prematurely
o Income, social standing
o Occupational hazards Preparing for the Physical Examination- Bates
o Places of travel, residence
Alcohol intake ● Reflect on your approach to the patient.
o Kind, amount, frequency, duration ● Adjust the lighting and the environment.
Drugs ● Make the patient comfortable.
Sexual preferences ● Determine the scope of the examination.
3
● Choose the sequence of the examination. PE Maneuvers (Note: this is in order!)
● Observe the correct examining position (the Inspection
patient’sright side) and handedness. Palpation
Percussion
PE Overview Auscultation
General Survey - The General Survey begins with *the sequence of PE in the abdomen is usually
the first moments of the patient encounter. How do different from the conventional sequence :
you perceive the patient’s apparent state of health, Inspection, Auscultation, Percussion, Palpation
demeanor and facial affect or expression, grooming,
posture, and gait? Height and weight, usually
recorded before the patient enters the examining A. Inspection
room, add important detail to the General Survey. General
Local (certain anatomic region)
Bates: Continue this survey throughout the patient
visit. Observe general state of health, height, build, B. Palpation
and sexual development. Note posture, motor Act of feeling by sense of touch
activity, and gait; dress, grooming, and personal Structure examined by palpation
hygiene; and any odors of the body or breath. All external structure
Watch facial expressions and note manner, affect, Accessible through body orifices
and reactions to persons and things in the
environment. Listen to the patient’s manner of Qualities elicited by palpation
speaking and note the state of awareness or level of texture (skin and hair)
consciousness. temp.
Development masses
Nourishment moisture
General Appearance precordial thrust
Mental Style (Alertness, affect, intellect) crepitus (air in subcutaneous)
Motor (Ambulant, bed-ridden, posture, tenderness
abnormal movements) thrills (murmurs or repulses from the heart)
fremitus (tactile vibration on the chest upon
Vital Signs talking)- polytactile fremitus
Blood Pressure
Heart Rate Palpation
Pulse Rate Tactile sense = Tips of fingers
Respiratory Rate Temp. sense = Dorsum of hands and fingers
Temperature Vibratory sense = Palms
Height- if not ambulant don’t use tape Position and Consistency = Grasping fingers
measure
Weight – rapid change is a good indicator of
changes in body fluids Maneuvers
*usually only TPRBP (temperature, pulse rate, Light
respiratory rate, BP) are being taken in the real Deep
setting, but there are journal updates at present Bimanual
want to include PAIN as the fifth vital sign Ballotement- for mass inside the fluid,
bouncing feeling after palpation
4
C. Percussion the connecting metal band to a comfortable
Percussion Methods tightness.
Bimanual (mediate or indirect) Thick-walled tubing as short as feasible to
Immediate or Direct maximize the transmission of sound:
Sonorous – to ascertain the density of approximately 30 cm (12 inches), if possible, and
underlying structures no longer than 38 cm (15inches)
A bell and a diaphragm with a good changeover
Notes of Percussion mechanism
Tympany – abdomen ● Gloves and lubricant for oral, vaginal, and rectal
Resonance – lungs examinations
Dullness – solid organs (muscle tissues) ● Vaginal specula and equipment for cytological and
Flatness – Bone (sternum) perhaps bacteriological study
Hyperresonance – exaggerated resonance in ● A reflex hammer
the lungs (ex. Emphysema, COPD) ● Tuning forks, ideally one of 128 Hz and one of 512
Hz
Definitive Percussion – to map out the area of ● Q-tips, safety pins, or other disposable objects for
greater density to ascertain the size of the testing two-point discrimination
underlying structure or the extent of its border {ex. ● Cotton for testing the sense of light touch
Dull=Liver, Tympany=intestine} ● Two test tubes (optional) for testing temperature
sensation
D. Auscultation - hearing through stethoscope ● Paper and pen or pencil
5
tissue or organs. This sound wave also generates a
tactile vibration against the pleximeter finger.