You are required to evaluate a patient based on the information
mentioned in the evaluation sheet. If he suffers from any of the
aforementioned diseases, you must clarify this based on the
examination.
You should examine a patient or assume that based on previous
experience
If there is no real patient, please fill in data in the paper
assuming experience and previous cases that have passed you by,
i.e. drawing a scenario from you and taking his medical history and
complaining of diseases and mentioning them if he does not suffer
from a specific thing explaining this, but it is preferable to be
sick
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OBJECTIVE (Physical Exam - sample recordings) Comprehensive Health Assessment Paper Write comprehensive health assessment paper includes: o Chest: Inspect: Expansion/retraction of chest wall/work of breathing and/or accessory muscle use Auscultate: o For breath sounds anteriorly and posteriorly o Apices and bases for any adventitious sounds Palpate: For symmetrical lung expansion o PT identification Chief Complaint Source and Setting History of Present Illness Past Medical History Surgical History Medications Allergies Family History Social History Physical Exam Vitals General Appearance Cardiac system Inspect: o Jugular distension Auscultate: o Apical heart rate Nervous system Sensory Motor DTR's reflex grading Cranial Nerve Evaluation . Problem List Summary
Statement The following list contains criteria that may be used to determine whether or not a report is well written. 1. Document is written using language that is appropriate for the intended audience. Technical vocabulary is used but new or unfamiliar technical terms are defined. 2. Abbreviations and acronyms are used to avoid repeated long descriptions, but they are spelled out and defined the first time they are used 3. Document printed in a professional looking font that is large enough to read easily (A suitable font is Times Roman, 12 pt.). 4. Section headings and subheadings are consistently formatted using bold, upper/lower case, etc. 5. Paragraphs are indicated with a blank line or indentation. Document organized in a logical sequence. Document is free of errors in spelling, grammar, word usage, sentence structure, and punctuation. 8. Avoid copying from another student's work. 9. Avoid using materials not authorized by the institute. 10. Avoid collaborating with another student, without permission. 11. Avoid plagiarism which means presenting another person's work or ideas as one's own, without attribution SUBJECTIVE (Review of Systems) Skin, hair, nails - lesions, rashes, pruritis, changes in moles; change in distribution Lymph nodes - enlargement, pain Bones, joints muscles - fractures, pain, stiffness, weakness, atrophy Blood - anemia, bruising Head - trauma, vertigo, syncope, seizures, memory Eyes- visual loss, diplopia, trauma, inflammation glasses Ears - deafness, tinnitus, discharge, pain Nose - discharge, obstruction, epistaxis Mouth-sores, gingival bleeding, teeth, jaw pain Throat-hoarseness, voice changes Neck - swelling/stiffness, adenopathy, goiter, Breasts - lumps, pain, nipple discharge, last mammogram Endocrine - polyphagia dipsia/via, /fatigue Respiratory - dyspnea, orthopnea, wheezing, cough, sputum, hemoptysis, pain, pleurisy, night sweats, TB, #pillows, pneumonia, asthma CV (cardiovascular) -palpitations, ascites, cold feet, phlebitis, cyanosis GI - appetite/Wgt change, dysphagia, N/V, hematemesis, melena, abd, pain/colic, icterus, diarrhea, constipation, change in bowels, tenesmus, hemorrhoids, rectal pain, hernia GU - polyuria, oliguria, dysuria/strangury, hematuria, pyuria, incontinence, nosturia, pain passage of stones, UTI 6. 7
Health_story Theboprophic tale Name 3 K. Naveen dest: singapore Muliai stalow maried : 23 Both date : 16-09-MM8 Birthplace a singapoor Religion Buddhism Jos taas the main bola level of function under Gretheate Ocupation . student The dala Reason for seeking care less relient ware apparently asymptomatic 6 days ago Then he developed breathlessnese fuce balans, cough stree 6days, folur si sdays. flistory of present Allmeny Brasil onset - (odays) sudlow-acula Duration - bdays- Continan, doesn't worsen on Creation cough - onset - progresive dualion - bdays. + episode produtuke cougla
four NO aggregating so relieving Factors. Factors, onad Productive Quantity - scanty - upper respiratory e Tract with Maramille de Mucopusulant. Appeacomce :- past History: 1: - Not significant SO بنات childhood illnes = No similar complaints in past, For y lo chronic illness i. not present جملفية ww pulloon Immunization - up to date op Allergies :- No allergies to drugs current medication No medications wings steinow ansside entre page, wat and pessonal fistory great to pistole عقلند regular Bladder & Baces appetite & Normal - adequate. be stand Review of system :- All are Normal., iexcept ip respiratory s pescussion - DULL.on left long. Ascultation Oraclor.
Goretel suway Thoras hage - a strape of cak & Regular o Tracheal positions wowwal straight) pe duration apical Impulse coural positions, 5th Inte coastal space mid couscular live Movemente of chart - Normal, on both side srilar palpation :- all Inspectory finding confirmed Vocal Fremutor : Increased on leff bung pescussion - Hype Resonance on offling Wheeze Asculation in on Left lang, crickles. NO NO cussise Hand so mucmurs. GIT organenegaly, to free shid ENT- pocal semiological Deficit . povisioned nlaquests left long precumonia,