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    Survival in Long Case

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    Rapid Medicine
    This document provides guidance on performing a long case examination in the following 3 steps: 1) Preparation with necessary equipment like a stethoscope and examination tools. 2) Performing a structured history and physical examination covering all body systems through methods like vital signs, examination of major organ systems, and neurological assessment. 3) Presenting the case by forming a problem list, differential diagnosis, investigations needed, and treatment plan.

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    Survival in Long Case

    Uploaded by

    Rapid Medicine
    3K views7 pages
    This document provides guidance on performing a long case examination in the following 3 steps: 1) Preparation with necessary equipment like a stethoscope and examination tools. 2) Performing a structured history and physical examination covering all body systems through methods like vital signs, examination of major organ systems, and neurological assessment. 3) Presenting the case by forming a problem list, differential diagnosis, investigations needed, and treatment plan.

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    This document provides guidance on performing a long case examination in the following 3 steps: 1) Preparation with necessary equipment like a stethoscope and examination tools. 2) Performing a structured history and physical examination covering all body systems through methods like vital signs, examination of major organ systems, and neurological assessment. 3) Presenting the case by forming a problem list, differential diagnosis, investigations needed, and treatment plan.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3K views7 pages

    Survival in Long Case

    Uploaded by

    Rapid Medicine
    This document provides guidance on performing a long case examination in the following 3 steps: 1) Preparation with necessary equipment like a stethoscope and examination tools. 2) Performing a structured history and physical examination covering all body systems through methods like vital signs, examination of major organ systems, and neurological assessment. 3) Presenting the case by forming a problem list, differential diagnosis, investigations needed, and treatment plan.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    The document outlines the structure and components of a long case examination in medical school, including history taking, physical examination, presentation, and discussion.

    The steps include: introducing yourself, taking history, physical examination, presentation, and discussion/question and answer.

    The components of history taking include: chief complaint, present illness, past history, family history, and review of systems.

    Survival In Long Case

    Chinadol MD. Preparation before exam Hair / Nail / Dressing Stethoscope / Watch / Pen / A4 X2 Flashlight / Snellen chart / Opthalmoscope / Jerk / Tooth prick / Tuning fork Vital signs tool General information 75 min / case History taking + Physical examination 30 min Presentation 10 min Discussion-Question and answer 35 min Problem list Diagnosis / Differential diagnosis Investigation for diagnosis / treatment Final diagnosis Plan of treatment Advice Consequence Step approach Introduce myself History taking General information Sex / Age / Native Habitat Occupation Occupational disease Contact vector Right of treatment Chief complaint : Defined symptom Choose to approach 1st except non sp.

    Present illness : Characteristic Causes Effect (time sequence) Co-morbid disease Complication Contraindication for INV / TX Pain syndrome Onset Duration Interval Characteristic Variation of symptom Aggravating factors Alleviating factors Severity Associated symptom Constitutional symptom Performance status FC / NYHC / ECOG / PS Staging Past history Underlying disease Previous treatment and outcome Side effect of treatment Growth and development Mental status and vaccine Previous drug allergy Classified type of hypersensitivity

    Previous operation Brain : Seizure Heart : Palliative shunt / Dz. Intra-abd : Adhesion Appendices : R/O appendicitis Pituitary : Panhypopituitarism Thyroid : HypoTH-PTH Traveling and Tropical disease History drug and substance use Steroid Duration for suppress axis Effect and withdrawal effect NSAIDs Antibiotics Alcohol : degree / addict-withdrawal Smoking : pack-year Substance : Amphetamine / Cocaine Oral contraceptive pills History unsafe sex / multiple partner Intravenous drug use (IVDU) Blood transfusion Family history Transmitted disease Genetic disease : AD / AR / X-linked

    ROS Fatigue / Dyspnea / Chest pain PND-Orthopnea / Claudication / Cyanosis Palpitation / Syncope Cough / Hemoptysis / Pleurisy Dysphagia / Odynophagia Abdominal pain / Dyspepsia / Diarrhea Heartburn / Bowel habit change Malena / Hematochezia / Hematemes Jaundice / Pale stool / Pruritus Hematuria / Dysuria / Oliguria / Polyuria Flank pain / Air bubble / Pass stone Headache / Seizure / Weakness Numbness / Conscious change Ataxia / Dementia / Movement Autonomic dysfunction Dizziness / Vertigo Blurred vision / Double vision Anemia / Bleeding / Mass-LN+ / Hburia Edema Nutritional status Polyuria / Polydipsia / Polyphagia Libido / Erectile dysfn : morning erection Galactorrhea / Lactation Hisutism : frequency for shave Menstruation : menarche / menopause Pregnancy / Abortion Back pain / Athralgia / Arthritis Skin lesion Oral ulcer / Alopecia / Photosense

    Physical Examination General appearance Dysmorphic features Cyanosis Cachexia Vital signs BP 4 extremities PR rate / rhythm / volume RR pattern BT HEENT Pale / Jaundice / Injected Subconjunctival hemorrhage Salivary gland Oral mucosa / Tongue Thyroid and bruit Neck mass / CLN / SCLN Carotid bruit Heart (CVS) Peripheral pulse Jugular venous wave form Precordium Heaving / Thrill S1 / S2 Extra sound / Gallop Murmur / Maneuver Pericardial friction rub Subclavian bruit Lungs (Chest) Thoracic cage Pectus E/C Scoliosis Gynecomastia Superficial vein dilatation

    Spider nevi Trachea Lung expansion / VF-VR Percussion Breath sound Rhonchi / Wheezing Generalized / Localized Crackle / Crepitation Fine / Medium / Coarse Abdomen Distended / Scaphoid abdomen Superficial vein dilatation Direction by Harvey test Sister-Joseph node Bowel sound Abdominal and hepatic bruit Superficial and deep palpation Liver / Spleen / GB Mass Size / Site / Shape / Surface Surrounding tissue Consistency / Movable Intra-abd or Extra-abd Intra / Retroperitoneum Bowel mass / Mesentery Bimanual palpation Kidney Per rectal Examination Musculoskeleton Back Spine : C / T / LS Joint : Peripheral / Axial

    Extremities Skin and skin appendage Edema Clubbing finger Palmar erythema Gangrene / Raynauld / Digital pitting scar Sclerodactyly / Dilated capillary nailfold Neurosigns

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