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Comprehensive Patient Case Assessment

This document presents a case for discussion and analysis. It begins with objectives of providing a thorough patient assessment based on history and examination. The document then includes sections for general data, review of systems, physical examination, salient features, initial impression, and planned case discussion covering epidemiology, pathophysiology, clinical manifestation, differential diagnosis, diagnostics, and treatment options. The case discussion will analyze the patient's presentation and management.

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Bernamai Calam
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77 views26 pages

Comprehensive Patient Case Assessment

This document presents a case for discussion and analysis. It begins with objectives of providing a thorough patient assessment based on history and examination. The document then includes sections for general data, review of systems, physical examination, salient features, initial impression, and planned case discussion covering epidemiology, pathophysiology, clinical manifestation, differential diagnosis, diagnostics, and treatment options. The case discussion will analyze the patient's presentation and management.

Uploaded by

Bernamai Calam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

Bernamieh O.

Calam, MD
Objectives
■ To present a thorough general assessment of the patient
base on complete history and physical examination
■ To understand the etiology along with the
pathophysiology and clinical manifestations of the case
presented
■ To discuss the clinical management of the case being
presented
General Data
Chief complaint
History of Present Illness
Past Medical History
Family History
Social History
Review of Systems
(-)chest pain, (-)palpitations, (-)orthopnea

(-)fever, (-)weight loss, (-) loss of appetite, (-)


night sweats
(-)diarrhea, (-)constipation, (-)melena,
(-)hematochezia, (-)abdominal pain
(-)skin rash, (-) pruritus
(-)polydipsia, (-)polyphagia, (-)heat/cold
intolerance, (-)polyuria,
(-)dizziness, (-)blurring of vision, (-)diplopia, (-)dysuria, (-)urinary incontinence, (-)urgency
(-)hearing loss, (-)ear discharges, (-)tinnitus,
(-)epistaxis, (-) hoarseness, (-)dysphagia, (-)joint pains, (-)myalgia, (-)limitation of
(-)nasal discharge movement

(-)cough, (-)dyspnea, (-)hemoptysis, (-)tremors, (-)sensorium change, (-)memory


(-)pleurisy loss, (-)decrease in coordination,
(-)headache, (-)body weakness, (-)loss of
consciousness
Physical Examination ℃

kg cpm

cm bpm

mmHg
kg/m²

%
Physical Examination
Salient Features
Initial Impression
CASE DISCUSSION
Epidemiology
Incidence/ Prevalence
Anatomy
Pathophysiology
Clinical Manifestation
Differential Diagnosis
*table
Differential Diagnosis
Diagnostics
Treatment
At the ER..

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