This document presents a case study report template for recording patient information which includes sections for personal details, chief complaint, history of present illness, past medical history, physical examination, diagnosis, treatment, and nursing diagnosis. The physical examination section outlines methods to inspect, auscultate, percuss, and palpate the body. It also includes a description of the Glasgow Coma Scale for assessing level of consciousness.
This document presents a case study report template for recording patient information which includes sections for personal details, chief complaint, history of present illness, past medical history, physical examination, diagnosis, treatment, and nursing diagnosis. The physical examination section outlines methods to inspect, auscultate, percuss, and palpate the body. It also includes a description of the Glasgow Coma Scale for assessing level of consciousness.
This document presents a case study report template for recording patient information which includes sections for personal details, chief complaint, history of present illness, past medical history, physical examination, diagnosis, treatment, and nursing diagnosis. The physical examination section outlines methods to inspect, auscultate, percuss, and palpate the body. It also includes a description of the Glasgow Coma Scale for assessing level of consciousness.
This document presents a case study report template for recording patient information which includes sections for personal details, chief complaint, history of present illness, past medical history, physical examination, diagnosis, treatment, and nursing diagnosis. The physical examination section outlines methods to inspect, auscultate, percuss, and palpate the body. It also includes a description of the Glasgow Coma Scale for assessing level of consciousness.
Name:- ناو Age:- تەمەن Sex:- رەگەز Occupation:- کار Marital status:-حالە زەوجی Address:- ناونیشان Religion:- ئایین Chief complaint and Duration:- السبب الرئيسي لدخول المستشفى والفترة History of present illness:-)تاريخ المرض الحالي (وصف لحالة المريض Past history:- التاريخ السابق للمريض 1- History of all chronic diseases, such as Diabetes, Hypertension, Heart diseases, Lung diseases, Kidney diseases and other chronic diseases:
2- History of drugs taking:
3- Family history: 4- Record any history of Allergy to (food, drugs, tape, chemicals and others): 5- Surgical history: PHYSICAL EXAMINATION A- Vital Signs: Temp: Blood Pressure: Resp: Pulse:
4=Spontaneous open 5=Normal conversation 6=Normal movement
3=Response to voice 4=Disoriented 5= Purposeful movement E 2= Response to pain conversation but able to to painful stimulus
V 1=No response answer questions
3=Words, but not 4= Withdraws in response to pain
M coherent 2=No words...only sounds 3= Flexion in response to pain 1=None 2= Extension response in response to pain 1=No response
Glasgow Coma Scale
Total = E+V+M= 15
90% less than or equal to 8 are in coma
Greater than or equal to 9 not in coma
8 is the critical score
Less than or equal to 8 at 6 hours - 50% die
9-11 = moderate severity
Greater than or equal to 12 = minor injury
The Glasgow Coma Scale provides a practical method for assessment of
impairment of conscious level in response to defined stimuli. مقياس كالسكو وسيلة عملية لتقييم مستوى الوعي ومدى االستجابة للمؤثرات الخارجية Physical examination or clinical examination
Is the process by which a medical professional investigates the body of a patient
for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan.
Methods of physical examination:
1-Inspection: Is a term when the examiner used eyes to observe body features, skin color, respiration, movement, speaking.
2- Auscultation: Is the technical term for listening to the internal sounds of the body, usually using a stethoscope. Auscultation is normally performed for the purposes of examining the Cardiovascular system and respiratory systems (heart and lung sounds). Gastrointestinal system (bowel sounds) 3- Percussion: Percussion is a method used by a doctor to find out about the changes in the thorax or abdomen. It is done by tapping on a surface to determine the underlying structure. It is done with the middle finger of right hand tapping on the middle finger of the left hand.
4. Palpation: Palpation is a method of examination in which the examiner feels the size or shape or firmness or location of something (of body parts when the examiner is a health professional). Palpation is used by doctors for particularly for Thoracic and abdominal examinations. For examination of edema( swelling of any organ or tissue due to accumulation of excess fluid) And palpation of pulses.
