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Medicine Pearls

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HISTORY

IDENTIFYING DATA:
Patients name, age, race, sex; referring physician or clinic.

SOURCE AND RELIABILITY:
Name and reliability of informant (patient, old chart, relative).

HISTORY OF PRESENT ILLNESS (HPI):
Describe the course of the patients illness, including when it began, character of the symptoms; location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives, other related diseases; past illnesses or surgeries, past diagnostic testing.

PAST MEDICAL HISTORY (PMH):
 
Past diseases, surgeries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, COPD, MI, Cancer, TB. In children include birth history, prenatal history, immunizations, type of feedings.

MEDICATIONS:

ALLERGIES:
Penicillin?

FAMILY HISTORY:
Medical problems in relatives; specifically ask about problems similar to patients illness. Asthma, MI, heart failure, hypertension, CA, TB, diabetes, kidney diseases, hemophilia.

SOCIAL HISTORY:
Alcohol, smoking, drug usage. Marital status and children; employment and home situations; exposure to carcinogens or environmental agents. In children include: Sleep, play habits, grade in school.

REVIEW OF SYSTEMS (ROS):

General: Weight gain or loss, appetite loss, fever, chills, fatigue, night sweats.


Skin: Rashes, bruising, skin discolorations.

Head: Headaches, dizziness, tenderness, lumps or masses; history of seizures, head trauma.

Eyes: Visual changes, visual acuity, visual field deficits, diplopia, inflammation.

Ears: Tinnitus, vertigo, pain, discharge.

Nose: Nose bleeds, discharge, sinus diseases.

Mouth & Throat: Dental diseases, hoarseness, sore throat, pain.

Respiratory: Cough, shortness of breath, sputum (color, amount), chest pain; history of PTB; vaccination for influenza or pneumococcus. Positive Purified Protein Derivative (PPD Testing).

Cardiovascular: Chest pain, orthopnea, paroxysmal nocturnal dysonea; dyspnea on exertion, claudication, extremity edema.

Gastrointestinal: Odynophagia, dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, melena, hematochezia, constipation, bloody stool, change in bowel habits, jaundice.

Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge, impotence, testicular masses, penile discharge.

Gynecological:

Gravida/para, abortions, LMP (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding; last pelvic exam and pap smear, breast masses, self-examination, mammography.

Endocrine: Polyuria, polydipsia, polyphagia, skin or hair changes, cold or heat intolerance, hormonal therapy.

Musculoskeletal: Joint pain or swelling, arthritis, myalgias.

Skin: Easy bruising, bleeding tendencies.

Lymphatics: Lymphadenopathy.

Neuropsychiatric: Weakness, seizures, paresthesias, memory changes, emotional depression disturbances.

PHYSICAL EXAMINATION

Vital Signs:

Temperature, heart rate, respiratory rate, blood pressure (right and left arm, sitting and standing height), weight.

Skin:

Rashes, scars, moles; capillary refill (in seconds).

Lymph Nodes:

 Cervical, supraclavicular, auxiliary, inguinal nodes; size, mobility, tenderness, consistency.

Head:

Bruising, tenderness. In pediatric patients check fontanelles.

Eyes:

 Pupils equal round and react to light and accommodation (PERRLA); extra ocular movement intact (EOMI); visual fields and acuity. Fundoscopy (fundi, papilledema, arteriovenous nicking, hemorrhages, or exudates), conjunctiva; scleral icterus, ptosis.

Ear:

Discharge, acuity, tympanic membranes (dull, shiny, intact, injected, bulging).

Nose:

Discharge, exudates, polyps. Pediatrics: Nasal flaring.

Mouth & Throat:

Mucus membrane color and moisture level; oral lesions, dentitions, tonsils, erythema.

Neck:

Jugular venous distention (JVD), thyromegaly, lymphadenopathy; range of motions, masses, bruits, hepatojugular reflex (HJR).

Chest:

Equal expansion, tactile fremitus, percussion, auscultation, rhonchi, crackles, rubs, breath sounds, egophony, whispered pectoriloquy.

Heart:

Point of maximal impulse (PMI), thrills (palpable tubulance); regular rate & rhythm (RRR), first & second heart sounds (S1 & S2); gallops, murmurs (grade 1-6), pulses (grade 0-2+).

Breast:

Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia.

Abdomen:

Contour (flat, scaphoid, obese, distended); scars, bowel sound, tenderness, organomegaly, masses, liver span; splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle tenderness (CVAT), inguinal masses.

Genitourinary:

External lesions, hernias, scrotum, testicles, varicoceles.

Pelvic Exam:

Vaginal mucosa, cervical discharge; uterus size & masses, adnexa, ovaries, suprapubic tenderness.

Extremities:

Joint swelling, range of motions, edema (grade 1-4+); cyanosis, clubbing, edema (CCE);pulses (radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homans sign,; cyanosis, varicosities.

Rectal Exam:

Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; presence or absence of stool in rectal vault, prostate (nodules, tenderness, size).

Neurological:

Mental status & affect; cranial nerves 1-12; gait, strength (graded 0-5); touch sensation, pressure, pain, position & vertigo; deep tendon reflexes (graded 0-4+) (biceps, triceps, patellar, ankle); Romberg’s test (ability of patient to stand erect with arms outstretched and eyes closed).

Cranial Nerve Exam:


I: Smell
II: Visions & Visual fields;
III, IV, VI: Pupil responses to light; positional & pursuit eye movements, ptosis.
V: Facial sensation, ability to open jaw against resistance, corneal reflex.
VII: Close eyes tightly, smile, shows teeth.
VIII: Watch tick, Weber test; Rinne’s Test.
IX, X: Palette moves in midline when patient says ah, speech.
XI: Shoulder shrug & turns head against resistance.
XII: Stick out tongue in midline. Heel to skin test.

Labs:
Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC (hemoglobin, hematocrit, WBC count, platelets, differential); X-rays, ECG, Urine Analysis (UA), liver function tests (LFTs).

 

MINI-MENTAL STATUS EXAM

Orientation:
What is the year, day of the week, date, month? = 5 points

What is barrio, town, city, country, hospital, floor? = 5 points

Registration:
Repeat: 3 objects: apple, book, coat = 3 points

Attention/Calculation:
Spell WORLD backwards = 5 points

Memory:
Recall 3 objects = 3 points

Language
Name a pencil & a watch = 2 points
Repeat, No ifs, ands or buts = 1 point

Three stage command:
Take this paper in your right hand, fold it in half, and put it on the floor= 3 points

Written Command:

Close your eyes. = 1 point
Write a sentence = 1 point

Visual Spatial:

Copy two overlapping pentagons = 1 point

TOTAL SCORE 30 POINTS

Normal: 25-30
Mild Intellectual Impairment: 20-25
Moderate Intellectual Impairment: 10-20
Severe Intellectual Impairment: 0-10

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PROBLEM-ORIENTED PROGRESS NOTE

Problem List:
List each problem separately (heart failure, pneumonia, hypokalemia). Retain number of each problem throughout hospitalization and address each problem daily in progress note. Give post- operative day number, antibiotic day number if applicable.

Subjective:
Write how the patient feels in the patients own words; and give observations about the patient.

Objective:
Vital signs, physical exam for each system, laboratory data.
Assessment:
Evaluate each numbered problem separately, and discuss the progress of each problem.

Plan:
For each numbered problem, discuss any additional orders, changes in drug regimen or plans for discharge or transfer. Discuss conclusions of consultants.

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DISCHARGE SUMMARY

Date of Admission:
Date of Discharge:
Admitting Diagnosis:
Discharge Diagnosis:
Attending or Ward Team Responsible for Patient:
Procedure:
Surgical Procedures, Diagnostic Tests, Invasive Procedures

Brief History & Pertinent Physical Examination & Laboratory Data:
Describe the course of the patients disease up until the patient came to the hospital including physical exam & laboratory data.

Hospital Course:
Describe the course of the patients illness while in the hospital; Include evaluation, treatment, outcome of treatment, and medications given while in the hospital.

Discharged Condition:
Describe improvement or deterioration in patients condition.

Disposition:
Describe the situation to which the patient will be discharged (home, nursing home). Indicate who will take care of the patient.

Discharged Medications:
List medications and list instructions for patient on taking the medications.

Discharged Instructions & Follow -up Care:
Date of return for follow -up care at clinic; diet, exercise.

Problem List:
List all active and past problems.

Copies:
Send copies to attending, clinic, consultants.

GLASGOW COMA SCALE

BEST VERBAL RESPONSE:
1- None
2- Incomprehensible sounds or cries
3- Appropriate words or vocal signs
4- Confused speech or words
5- Oriented speech

BEST EYE OPENING RESPONSE:
1- No eye opening
2- Eyes open to pain
3- Eyes open to speech
4- Eyes open spontaneously

BEST MOTOR RESPONSE:
1- None
2- Abnormal extension to pain
3- Abnormal flexion to pain
4- Withdraws to pain
5- Localizes to pain
6- Obeys commands

TOTAL POSSIBLE SCORE = 3-15

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WHO RECOMMENDATION FOR OVERWEIGHT/ OBESE CUTOFF POINTS FOR ASIANS:

HEIGHT-
BMI of 23- BMI of 25
(inches)- overweight- obese
(pounds)- (pounds)

5'0"- 120- 130
5'1"- 120- 130
5'2"- 125- 135
5'3"- 130- 140
5'4"- 135- 145
5'5"- 140- 150
5'6"- 145- 155
5'7"- 150- 160
5'8"- 150- 165
5'9"- 155- 170
5'10"- 160- 175
5'11"- 165- 180
6'0"- 170- 185
6'1"- 175- 190
6'2"- 180- 195
6'3"- 185- 200
6'4"- 185- 205

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A. FORMULA


1. A-a Gradient = [(PB-PH2O) FiO2-PCO2/R]-PO2 arterial
= (713-pCO2/0.8)- pO2 arterial
PB=760 mmHg; PH/2O= 47 mmHg; R= 0.8; NL<10-15 mmHg (room air)

2. Arterial Oxygen Capacity= (Hgb (gm)/100 ml x 1.36 ml O2/gm Hgb

3. Arterial Oxygen Content= 1.36 (Hgb) (SaO2) + 0.003 (PaO2)= NL 20 vol%

4. O2 delivery= CO x arterial O2 content= NL 640-1000 ml O2/min

5. Cardiac Output= HR x stroke volume

6. CO L/min= 125 ml O2/minM2
---------------------------------------------------------- X 100
8.5{(1.36) (Hgb) (SaO2)- (1.36) (Hgb) (SvO2)

Note: 125 is a crude estimate for normals
Normal CO= 4-6 L/min

7. SVR= MAP- CVP x 80 = NL 800-1200 dyne/sec/cm2
---------------
CO
L/min

8. PVR= PA-PCWP x 80 = NL 45-120 dyne/sec/cm2
--------------
CO
L/min

9. GFR ml/min= (140- age) x wt in Kg
----------------------------
72 (males) x serum Cr (mg/dl)
85 (females) x serum Cr (mg/dl)

10. Creatinine Clearance= U Cr (mg/100 ml) x U vol (ml)
-----------------------------------------------------
P Cr (mg/100 ml) x time (1440 min for 24h)

Normal= 100-125 ml/min (Males)/ 85-105 (Females)



11. Body Water Deficit (L)= 0.6 (weight kg) ([measured serum Na]- 140)
-------------------------------------------------------
140

12. Osmolality mOsm/kg=2[Na+K]+BUN+Glucose= NL 270-290 mOsmH2O
------- --------- ---------
2.8 18 Kg

13. Fractional excreted Na = U Na/ Serum Na x 100 = NL <1%
--------------------
U Cr/ Serum Cr

14. Anion Gap = Na + K- (Cl + HCO3)
*For each 100 mg/dl increase in glucose, Na decreases by 1.6 mEq/L.

15. Corrected Serum Ca (mg/dl)=measured Ca mg/dl + 0.8 x (4- albumin g/dl)

16. Ideal Body Weight Males = 50 kg for first 5 feet + 2.3 kg for each addl inch.

17. Ideal Body weight Females = 45.5 kg for first 5 feet + 2.3 kg for each addl inch.

18. Basal Energy Expenditure (BEE):
Males: 66 + (13.7 x Actual weight Kg) + (5 x height cm)- (6.8 x age)
Females: 655 + (9.6 x Actual weight Kg) + (1.7 x height cm)- (4.7 x age)

19. Nitrogen Balance = Gm protein intake/6.25- urine urea nitrogen- (3-4 gm/d
Insensible loss)

20. Predicted Maximal Heart Rate = 220- age

21. Normal ECG Intervals (sec)
PR 0.12-0.20
QRS 0.06-0.08

22. Heart Rate/ min Q-T
60 0.33- 0.43
70 0.31- 0.41
80 0.29- 0.38
90 0.28- 0.36
100 0.27-0.35

23. Renal Failure Index = Urine Na x 100
-----------
U/PCr
24. Parkland Formula:
Total fluid requirements for 24 hours = 4 ml x kg body weight x % burn surface area
Note: Replace 50% of this total in the first 8 hours after injury, 25% in the second 8 hours, and 25% in the last 8 hours.


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