Resident survival guide examine the patient: Difference between revisions
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❑ [[Heave]] <br> | ❑ [[Heave]] <br> | ||
❑ [[Thrill]] <br> | ❑ [[Thrill]] <br> | ||
❑ [[Friction rub]]<br> | ❑ [[Friction rub]]<br> | ||
❑ [[Heart sounds]] | |||
❑ [[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] <br> | :❑ [[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]] <br> | ||
❑ [[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] <br> | :❑ [[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]] <br> | ||
❑ [[Heart sounds#Third heart sound S3|S3]] <br> | :❑ [[Heart sounds#Third heart sound S3|S3]] <br> | ||
❑ [[Heart sounds#Fourth heart sound S4|S4]] <br> | :❑ [[Heart sounds#Fourth heart sound S4|S4]] <br> | ||
❑ [[Heart sounds#Summation Gallop|Gallops]] <br> | ❑ [[Heart sounds#Summation Gallop|Gallops]] <br> | ||
❑ [[Systolic murmur]] best heard at the base | ❑ Murmur | ||
❑ [[Systolic murmur]] best heard at the apex | :❑ [[Systolic murmur]] best heard at the base (describe the murmur)<br> | ||
❑ [[Diastolic murmur]] | :❑ [[Systolic murmur]] best heard at the apex (describe the murmur)<br> | ||
:❑ [[Diastolic murmur]] (describe the murmur)<br> | |||
'''Abdomen''' <br> | '''Abdomen''' <br> | ||
Revision as of 16:46, 20 March 2014
Appearance of the Patient
❑ This section should give a general description of what a patient with the disease you are describing may look like. You may include a physical description such as obese, thin, cachectic, well appearing, ill appearing, diaphoretic etc
Vitals
❑ Temperature
- ❑ Fever
- ❑ Hypothermia
❑ Pulse
- ❑ Rate
- ❑ Rhythm
- ❑ Regular
- ❑ Irregularly irregular
- ❑ Regular
- ❑ Strength
- ❑ Weak
- ❑ Bounding
- ❑ Alternating in strength (pulsus alternans)
- ❑ Weak
- ❑ Paradoxical pulse
- ❑ Symmetry
- ❑ Asymmetric
- ❑ Asymmetric
❑ Blood pressure
❑ Hypotension
❑ Hypertension
❑ Wide pulse pressure
❑ Narrow pulse pressure
❑ Respiratory rate
❑ Tachypnea
❑ Bradypnea
❑ Kussmaul respirations
Skin
❑ Cyanosis
❑ Jaundice
❑ Rash
❑ Pallor
❑ Lesions
Head
❑ Abnormalities of the head/hair
❑ Evidence of trauma
Eyes
❑ Icteric sclera
❑ Nystagmus
❑ Abnormal extra-ocular movements
❑ Pupils not reactive to light
❑ Abnormal findings on ophthalmoscopic exam
Ears
❑ Reduced hearing acuity
❑ Positive Weber test
❑ Positive Rinne test
❑ Exudate from the ear canal
❑ Tenderness on movement of the pinnae
Nose
❑ Inflamed nares
❑ Epistaxis
❑ Purulent exudate from the nares
❑ Tenderness to percussion of the sinuses
❑ Congested nares
Throat
❑ Erythematous
❑ Exudate
❑ Petechiae
❑ Tonsillar inflammation
Neck
❑ Elevated jugular venous pressure
❑ Carotid bruits
❑ Lymph nodes
❑ Thyromegaly
❑ Hepatojugular reflux
Lungs
❑ Pulmonary edema and rales
❑ Wheezing
❑ Consolidation with reduced breath sounds
❑ Rales
❑ Egophony
❑ Asymmetric chest movement
Heart
❑ Heave
❑ Thrill
❑ Friction rub
❑ Heart sounds
❑ Gallops
❑ Murmur
- ❑ Systolic murmur best heard at the base (describe the murmur)
- ❑ Systolic murmur best heard at the apex (describe the murmur)
- ❑ Diastolic murmur (describe the murmur)
Abdomen
❑ Abdominal distention
❑ Abdominal tenderness
❑ Rebound
❑ Abdominal mass
❑ Guarding
❑ Hepatomegaly
❑ Splenomegaly
❑ Genitourinary exam if relevant
Extremities
❑ Clubbing
❑ Cyanosis
❑ Edema
Neurologic
❑ Mental status may be altered
❑ Glasgow coma scale of___
❑ Clonus
❑ Hyperactive reflexes
❑ Deficits in cranial nerves ___