1 1 GRAY MATTER 2012 a collection of clinical facts for students at The University of Texas Medical School at Houston Originally produced and graciously shared by Baylor College of Medicine Office of Student Affairs Edited by: UTMSH Office of Student Affairs
2 2 Welcome to the 8th edition of Gray Matter, a clinical handbook for The University of Texas Medical School at Houston students first conceived by Mark Edelman and David Savage at Baylor College of Medicine. It is hoped that this collection of practical information will be useful during your clinical assignments. Please address any corrections or suggestions to: Revised 6/12
3 TABLE OF CONTENTS 3 PHONE DIRECTORIES... 4 UT-H... 4 Texas Medical Center & other important numbers HCPC... 5 Hermann... 5 LBJ MD Anderson Ben Taub/Texas Children s/va... 8 St. Joseph... 8 HOLIDAY POLICY... 9 CLINICAL ROTATION SCHEDULE NEEDLESTICK POLICIES & PROCEDURES CCCE EXAM POLICY ON APPROPRIATE STUDENT TREATMENT DUTY HOURS POLICY ORDERS HISTORY & PHYSICAL Heart sounds SURGERY NOTES Progress Notes Surgical Notes Operative Note Procedure Note Discharge Summary LABOR & DELIVERY H&P Delivery Notes PEDI NOTES APGAR Score Neonatal/Birth H&P Primitive Reflexes of Infancy Pediatric H&P Estimating Body Surface Area in Children Abridged Denver Chart PSYCHIATRIC HISTORY ABBREVIATED NEUROLOGIC EXAM Mini Mental Status Exam Glasgow Coma Scale Cranial Nerves, Motor, Cerebellar, Sensory, Gait Dermatomes PROCEDURES EKG INTERPRETATION NORMAL LAB VALUES DIAGNOSTIC PARAMETERS Body Mass Index (BMI) NORMAL PHYSIOLOGIC VALUES FLUIDS & ELECTROLYTES MEDICAL SPANISH HEALTH CARE RESOURCES FOR THE HOMELESS METABOLIC ROUNDS CAREER CONSIDERATIONS EMR Log-in Information... 60
4 4 UNIVERSITY OF TEXAS MEDICAL SCHOOL AT HOUSTON (713) EMERGENCY 911 or 4357 (HELP) SECURITY 911 or 4357 (HELP) POLICE (non-emergency) (713) NEEDLESTICK HOTLINE (713) Student Affairs: Margaret C. McNeese, M.D Sheela Lahoti, M.D Yolanda Clay Bell (parking) Pat Caver Steve Jones (schedules) Jamie Munsinger Kara Ramirez Kendall McKee (match) Yvette Pinales Fax Student Health UTPB 1010 Student Counseling Registrar: Brenda Powers Fax Financial Aid: Fax Admissions Alumni Relations Auxiliary Enterprises Bookstore (8:30 AM-5 PM M-F) Cashier s Window UCT (8 AM-5 PM M-F) Educational Programs Office Graduate Medical Education I.D. Badge Replacement (Cashier s Window) I.D. Badge Activation (Student Affairs) Learning Resource Center (LRC) Library - TMC Mon-Th 7 AM-10 PM Friday 7 AM-9 PM Saturday 9 AM-5 PM Sunday 1 PM-8 PM Online Catalog (computer) TexSearch (computer) Quick Copy (Med School) Rec Center (Knight Road) Risk Management Office Security Escorts PHONE DIRECTORIES Clerkship contacts Family Medicine Internal Medicine Obstetrics/Gynecology (MHH) (LBJ) (St. Joseph) Pediatrics Psychiatry Surgery Neurology APC/RCC/ACLS/RTR CCCE UT-H Clinics Cardiology Dermatology Endocrinology Family Practice General Medicine General Surgery Infectious Diseases Nephrology Neurology Neurosurgery Ob/Gyn Orthopaedics Otolrhinoaryngology Pediatrics Plastic Surgery Pulmonary Rheumatology Women s Health Center TEXAS MEDICAL CENTER AND OTHER IMPORTANT NUMBERS Child Abuse Hotline (rpt within 24 hrs) (800) City Health Dept Favrot Hall
5 Houston Area Women s Center Information (Houston) Information (TMC) Metro Bus Route Info Southeast Poison Control Ctr TMC Brown Lot Office (Car Trouble) TMC Credit and Collections TMC Cust. Svc. (Garage #2) TMC Police (Garage #2) HCPC, HERMANN-TMC, ST. JOSEPH, LBJ, and MDA HCPC (713) Main 5000 Admissions 3883 Lab/EKG 8621, 7854 Medical Records 7888 Pharmacy 8610 Security 8686 Unit 1B C 4710/4810 1D 4816/5016 1E 4815/4715 2B C D E B C D E 4835 MEMORIAL HERMANN - TMC (713)70 Main Hospital Admissions CT Scan Cardiac Care Unit (CCU) Cardiovascular ICU (CVICU) Care 4 EMR Help Desk Central Supply Consults call and request to be transferred Day Surgery EEG Emergency Center (Triage) Eye Center General Medicine (Cullen 5W), (Cullen 5E) Interventional Radiology Labor and Delivery Laboratory Services (4-LABS) PHONE DIRECTORIES (continued) 5 Medical Intensive Care (MICU) Medical Intermediate Care (MIMU) Medical Records Fax MRI-Radiology Neonatal Intensive Care (NICU) Neonatal Level II Nursery Neuroscience Unit Nuclear Medicine Nursery (Well Baby) Pharmacy Central (Cullen), (Jones) Surgery Satellite (OR Pharmacy) Pharmacy - Pedi Ortho Trauma Pedi Intensive Care (PICU) Radiology Radiology-Pedi Recovery (PACU) Resident Paging alternate in Hermann Surgical Intermediate Care (SIMU) Social Work Surgical Trauma ICU (STICU) A&B Surgery (Control Desk) Translator / Pager (inside) LBJ (713)56... Main Hospital (713) Page operator HCHD Administration HCHD Computer Help (713)-566-HELP UT Chief of Staff Nursing Administration Legal Affairs-UT (713) Security EMERGENCY NUMBERS FIRE CONDITION A Code & Conditions Admitting Office Business Office , Alcohol/Drug Abuse Counselor Audiologist , Bed Control Biomedical Technician , Chemotherapy Clinic
6 6 Discharge Planning Coordinator Women and Children Services Med, Surg, Ortho and Renal Obstetrics & Gynecology , Oncology Pediatrics Primary Medicine Clinic (4C) Surgery, General Surgery, Jail Surgery, Ophthalmology Surgery, Oral and Maxillofacial (only MWF) Surgery, Orthopedics (only MTh) Surgery, Otolaryngology/ENT (only TTh) Surgery, Plastics , Callroom Repairs/Maintenance Cardiology Department , Cashier Central (employee) Discharge Emergency Center OB/Gyn Chaplain Clinics Internal Medicine Midwifery Surgery, Urology Dietician EMERGENCY CENTER (Adult) Discharge Front Desk , Holding , Registration Suture Room Chemotherapy Triage EMERGENCY CENTER (Pediatrics) ECHO Cardiograms , EEG EKG GI Engineering (reporting maintenance) Housekeeping Infection Control IR IT Help Desk LABORATORY/PATHOLOGY Anatomical Pathology Bood Bank Bone Marrow Chemistry , , Cytology PHONE DIRECTORIES (continued) Fine Needle Aspirates Hematology , Histology , Micro , Lab Administration , Reports , Residents Room Serology (Ben Taub) Specimen Collection , STAT Lab TB Urinalysis LBJ Information Medical Records Charts pulled for completion Patient charts Fax Nuclear Medicine NURSING STATIONS 2A (Pediatrics) B (Surgical Post OB/GYN) C (OB/GYN Clinic) A (Med/Surg) B (Surg/Ortho) C (IMU) A (Medicine) B (Chemotherapy) B (Dialysis) C (Primary Medicine Clinic) Obstetrics and Gynecology Birthing Center Labor and Delivery Midwives B Perinatal Testing/Genetic Counselor Residents Lounge Triage Occupational Therapy Operating Room OR Director OR Front Desk , OR # OR # OR # OR # OR # OR # OR Nurse Manager OR Holding/SDSU , OR Materials Manager OR Post Scheduling MICU
7 PACU , PACU/SDSU Nurse Manager Sterile Processing Manager Ophthalmology Clinic Oral and Maxillofacial Surgery Oral Surgery Clinic Oral Surgery Front Desk Ortho clinic Pediatrics Chief Resident Chief, Community & Gen Pediatrics Clinic Emergency Center In-Patient (Nursing Unit 4A) Director, Newborn Service , Newborn Nursery NICU Pharmacy Director Drug Information Center (Ben Taub) In-Patient 3 rd floor satellite , IV Room , Out-Patient , Physical Therapy Operations Manager PT & OT Physician Services Psychiatry Consults Pulmonary Function Test Radiology (reading rooms in back) Reading Room CT Dictation Line Instructions: select #1, Doctor,2,000 MRN File Room Mammogram MRI Nuclear Medicine , Special Procedures Ultrasound X-ray Rehabilitation Services Operations Manager Occupational Therapy Physical Therapy Respiratory Therapy Risk Manag/Legal Affairs-UT (713) Social Services Speech/Language Pathologist Stress Testing (Cardiology) Translator/Interpreter , PHONE DIRECTORIES (continued) MD ANDERSON (713)79 General Information Cardiology Cytology/FNA Cytopathology Division of Medicine Division of Surgery Emergency Center General Oncology GI Center Head and Neck Imaging: CT/nuclear / Inpt. Routine Lab Stat Lab Leukemia/Bioimmunity Center Lymphoma/Myeloma Medical Records Fax Nursing Stations 3 Purple E Purple W Purple E Purple W Purple E Purple W PACU Purple E Purple E Purple E Purple E Purple E Purple E Purple E Purple E Green SW(Pedi Tx Rm) Green NW Green NE Green SE Green SW Green NW Green NE Green SE Green SW Green NW Green NE Green SE Green SW Green NW Green NE Green SE
8 8 ICU Pod A/B/C ICU Pod D/E Operator Page Operator Pathology , Pedi Pharmacy Surgery Check-In OR Social Work Translator After Hours TEXAS CHILDREN S (832) VA HOSPITAL (713) PHONE DIRECTORIES (continued) Labor and Delivery (713) nd floor, MGJ Bldg NICU (713) st floor, MGJ Bldg Family Birth Center (713) rd floor, MGJ Bldg Women s Surgery Unit (713) th floor, SKS Bldg Antepartum Unit (713) th floor, MGJ Bldg *From in house, for numbers beginning with 756, 757, 657, or 356, only the last four digits of the telephone number need to be dialed. For local calls dial 9 + local number. Dial 0 for the Hospital Operator and 1111 for the Page Operator. ST. JOSEPH *(713) Administration (713) Help Desk (713) Main Laboratory (713) ext 1557 Radiology (713) Dictation line 7499 Instructions: #111111, MRN Physical Therapy (713) Surgery (713) Medical Records (713) Pharmacy 6 GWS (713) ext 1070 Security Dispatch (713) ext 1313 Social Work/Case Management (713) Graduate Medical Education: Director (713) Resident Study Room (713) Coordinator FP Prog (713) Coordinator Ob/Gyn Prog (713) Coordin. Plastic Surg Prog (713) Coordinator Trans Prog (713) Patient Care Units: ICU (713) th floor Pavillion Rehab (713) rd floor, GWS Bldg SNF (713) th floor, GWS Bldg 5 Main Med/Surg Floor (713) th floor, GWS Bldg 6 Main Telemetry Floor (713) th floor, GWS bldg 8 Main Medical Floor (713) th floor, GWS Bldg BEN TAUB (713) Medical Records Fax
9 HOLIDAY POLICY Holiday Policy for Third-Year Students Students are excused from their clinical duties for the following holidays: July 4 Labor Day Thanksgiving Day Friday after Thanksgiving Memorial Day 9 Students will be excused at the end of their assigned duties the day before the holiday and are expected to report for duty the morning after the holiday. These days will be considered your day off for the week when you are on an in-patient ward service. Holiday Policy for Fourth-Year Students Students are excused from their clinical duties for the following holidays: July 4 Labor Day Thanksgiving Day Friday after Thanksgiving Christmas Eve Christmas Day New Year s Day Match Day Memorial Day Students will be excused at the end of their assigned duties the day before the holiday and are expected to report for duty the morning after the holiday. USEFUL WEB SITES Am I On (Call schedule for Internal Medicine at LBJ and Hermann) Harrison s Online HCHD Medical Records (for first-time Hermann patients that have been to LBJ or Ben Taub) https://epicweb.hchd.tmc.edu/epicweb/common/epic_login.asp HAM-TMC Library MD Consult Memorial Hermann Online Check-out Sheet National Guideline Clearinghouse Office of Student Affairs One45 Tracking System https://one45.uth.tmc.edu Guide to clinical clerkships used to complete evaluations and log patient encounters, clinical skills, clinical procedures, and duty hours. Use your UTHSC-H user ID and password to log in. Contact the Help Desk at if you have difficulty accessing the system. PubMed Resident Pager Service (passwords: uthpeds, uthim) Student Pages DynaMed
10 CLINICAL ROTATION SCHEDULE
11 NEEDLESTICK POLICIES & PROCEDURES 11 UT Student Health Services operates a Needlestick Hotline 24 hours a day, 7 days a week to expedite your treatment in case of needlestick or body fluid exposure. Regardless of the hospital or clinic where you are working, the procedure is the same. You should have a Needlestick sticker on the back of your student identification badge. If you sustain a needlestick or have an accidental exposure to bloodborne pathogens... page (713) 500-OUCH 24 hours a day Do NOT go to the nearest emergency room. Your page will be answered promptly, and you will receive specific instructions and information. After you page the hotline, remain by the phone but do not use it or your call cannot be returned. Most calls will be answered within 5-10 minutes. You will be asked to give a detailed description of the incident. Your baseline labs will be checked, as well as the labs on your source patient. Then you will be counseled on your overall risk, and if treatment is necessary. You will be given follow-up labs at defined intervals over the next 6 months to a year. The costs associated with the Needlestick Hotline (your laboratory work and medications) are covered by the medical school. However, if you choose not to follow the Needlestick Hotline procedure and see your own physician (private or through an emergency department, for example), you will be personally responsible for all costs, and these will not be reimbursed by UT Student Health Services. If you have any questions, please call the clinic at (713) , or stop by UT Student Health Services, which is located in the UT Professional Building, Suite 1010.
12 12 CCCE EXAM/POLICY ON APPROPRIATE STUDENT TREATMENT CCCE EXAM The CCCE is a standardized patient examination composed of seven patient encounters and one simulation station with different scenarios. The exam assesses a student s clinical skills. History taking, physical examination, communication/ interpersonal skills and problem solving management skills are all included. The purpose of the exam is: - To provide students with a comprehensive and valid assessment of their clinical skills, following the completion of all required third-year clerkships, and to target areas of deficiency. - To provide students with practice for the USMLE Step II clinical performance exam required by the National Board of Medical Examiners. - To gather overall class data on student clinical skills. This information is used to address student needs by implementing curriculum and training changes. Exam Format The exam format is similar to that of the USMLE exam. It is comprised of seven student/ pa tient encounters with one simulation station with different scenarios and post encounter exercises. Seven of the patient encounters including the simulation station are 15 minutes in length. One case is 40 minutes in length. Students have ten minutes between cases, during which time they are required to answer multiple choice questions or write a SOAP Note related to the case and complete a case evaluation. POLICY ON APPROPRIATE STUDENT TREATMENT I. Standards for Conduct in the Teacher-Learner Relationship The academic environment, particularly in medical education, requires civility from all participants, regardless of role or level, and a particular respect for the values of professionalism, ethics, and humanism in the practice of medicine. The relationship between teacher and learner is based on mutual respect and trust. Faculty must respect students level of knowledge and skills, which students have the responsibility to represent honestly to faculty. Faculty are obligated to evaluate students work fairly and honestly, without discrimination based on gender, ethnicity, national origin, sexual orientation, or religious beliefs. Faculty have a duty not only to promote growth of the intellect but at the same time to model the qualities of candor, compassion, perseverance, diligence, humility, and respect for all human beings. Because this policy pertains to students as learners, references to teachers or faculty shall also include Residents and fellows in their teaching and supervisory role with regard to students. Examples of unacceptable behavior include, but are not limited to: Physical or sexual harassment or abuse Discrimination or harassment based on race, gender, age, ethnicity, national origin, religion, sexual orientation, veteran status or disability Speaking in disparaging ways about an individual including humor that demeans an individual or a group
13 POLICY ON APPROPRIATE STUDENT TREATMENT (continued) 13 Sending students on inappropriate errands Loss of personal civility: shouting, displays of temper, publicly or privately abusing, belittling, or humiliating a student Use of grading or other forms of evaluation in a punitive or retaliatory manner Students are also expected to maintain the same high standards of conduct in their relationships with faculty, residents, support staff, and fellow students. II. Procedures for Reporting and Investigating Violations Students enrolled in the Medical School (or Medical School portion of the M.D./Ph.D. program) should report abuse or mistreatment to the Associate Dean for Student Affairs. The Associate Dean for Admissions and Student Affairs will meet with the student to discuss the incident or behavior and the options for action. UTHSC-H policies concerning misconduct by faculty and staff, including allegations of discrimination (including harassment) and retaliation, are outlined in the Handbook of Operating Procedures (HOOP). The Associate Dean for Admissions and Student Affairs will advise and assist the student in following applicable procedures of the institution. In the rare instance when there is no existing procedure applicable to the specific situation, the Associate Dean for Admissions and Student Affairs, in consultation with the student, will determine the most appropriate plan of action. This may involve an investigation by the Associate Dean for Admissions and Student Affairs to establish the facts while respecting the rights and confidentiality of the involved parties. Depending on the nature or scope of the reported mistreatment, the Associate Dean for Admissions and Student Affairs has the authority to appoint an ad hoc Committee on Student Treatment consisting of three faculty members, one of whom will be appointed to chair the committee. An attorney from the UTHSC-H Office of Legal Affairs will serve as an ex officio member of the Committee. The purpose of the ad hoc Committee will be to investigate the complaint, establish facts respecting the rights of the involved parties, and recommend a course of action to the Associate Dean for Admissions and Student Affairs. It will be made clear from the fact-finding or investigation stage forward and through final disposition of the report that retaliatory behavior of any kind will not be tolerated. The Committee on Student Treatment will be required to report its findings in writing to the Associate Dean for Admissions and Student Affairs within 30 days of its appointment. If, following determination of the facts (and consideration of the recommendation of the ad hoc Committee on Student Treatment, if one was appointed), the Associate Dean for Admissions and Student Affairs may take one or more of the following actions in consultation with the Office of Legal Affairs: Arrange mediation between the parties Report findings and recommendations to the Dean Report findings and recommendations to the appropriate department chair
14 14 POLICY ON APPROPRIATE STUDENT TREATMENT (continued) Report findings and recommendations to the faculty member in charge of the course, clerkship, or elective in which the alleged mistreatment took place In the event the perpetrator is a resident, report findings and recommendations to the residency program director and Senior Associate Dean for Educational Programs These actions may be in addition to or superseded by actions taken in accordance with specific UTHSC-H policy(ies). III. Dissemination and Education In order to make sure that faculty, residents, fellows, and students are aware of the Policy on Appropriate Student Treatment, several mechanisms for dissemination will be used. The Policy will be added to the Medical School website on the main student, faculty, and house staff web pages. A paper copy of the Policy will be provided to current house staff and fellows and given to new house staff during orientation. A paper copy of the Policy will be provided to current students, and thereafter to entering students at orientation. The policy will be reviewed and discussed at orientation and in the fall semester meetings of the Master Advisory groups. A paper copy of the Policy will be provided to faculty and distributed at faculty orientations. Department Chairs and Directors will be responsible for ensuring that the Policy is discussed at departmental/division meetings. Each course director, clerkship director and/or Program Director will be responsible for providing a paper or electronic copy of the Policy to their respective teaching faculty and to all students at the start of each course, clerkship or rotation.
15 DUTY HOURS POLICY 15 U.T. Medical School at Houston Duty Hours Policy for Medical Students on Clinical Clerkships Approved by the Curriculum Committee on March 16, 2011 for implementation effective June 27, Clerkships must provide students with adequate time for individual study, sleep and relaxation. The following policies set forth the acceptable amount of time that clerkships may require of students. Duty hours include inpatient and outpatient clinical activities and scheduled academic exercises such as conferences and lectures that are related to the clerkship. I. Total duty hours must not exceed 80 hours per week, averaged over a fourweek period. II. Call will be scheduled to coincide with the attending and resident team. III. Duty hour periods in the hospital will not exceed 28 consecutive hours. IV. In each month the clerkship will provide each student with four individual 24-hour periods free from any required clinical or educational activities. Clerkship directors are responsible for overseeing this policy.
16 16 ORDERS ADMISSION ORDERS (Remember ABC VANDALISM ) Admit to: (floor, service, MD) Diagnosis: (Because) Condition: (good, fair, poor, critical, guarded) Vital Signs: (q shift, q 4h, per routine, etc.) Allergies: Nursing: (I&O s, daily weights, turn patient q 4h, etc.) Diet: (regular, clear or full liquid, 4 g Na, low or hi protein, ADA calories, etc.) Activity: (ad lib, bedrest with/without bathroom privileges, OOB tid, etc.) Labs: (also x-rays, EKG s, etc.) IV Fluids: (type, added KCl, rate) Studies: (CXR, MRI, CT, EKG, EEG, etc.) Meds: Call house officer if T>101, BP>170/110 or <90/50, HR>120 or <50 PRE-OP ORDERS Diagnosis: Procedure planned: Labs: (lytes, CBC, PT/PTT, UA, amylase if applicable) CXR EKG (if > 35 yo or h/o heart disease) Type and crossmatch Prep and shave surgical field NPO after midnight Void on call to OR Foley catheter (if indicated) Consent form signed and on chart History and Physical on chart DISCHARGE ORDERS (Remember 4DCAF ) Discharge: when and to where Diagnosis: Discharge Medications: (also need to fill out prescriptions) Diet: Condition: (eg. good) Activity: (eg. ad lib with 6 weeks pelvic rest for postpartum patients) Follow up: (eg. return to clinic in 1 week) Call MD for (where and when) PRESCRIPTION WRITING Patient s name, address, age Date Rx: (drug name, strength, type) Sig: (quantity, route, frequency, any other instructions) Disp #: (amount to be dispensed) Refills? Substitutions? M.D. Signature
17 HISTORY & PHYSICAL 17 INTRODUCTORY SENTENCE This sentence should include the number of hospital admissions or clinic visits followed by the patient s age, race, parity, sex, occupation, and the patient s chief complaint or complaints (C.C.) in his/her own words. SOURCE Source of history, assessment of reliability. PRESENT ILLNESS The present illness should be told in chronological sequence with reference to calendar date or time prior to admission, outlining the course of the illness from its beginning. Expound on each symptom thoroughly and its course. Previous treatment and hospitalizations should be noted; identify all significant medications received. Items of past medical history, family history, occupational history or social history that might have a bearing on the present illness should be included. Any symptoms suggested by the clinical picture which are not present should be noted and denied, i.e. pertinent negatives. PAST MEDICAL HISTORY General Health: Patient s general health throughout life. Childhood Health: General health and development. Note important deviations. Also, specifically mention acute febrile illnesses of childhood. Medical Illnesses: List and/or describe all illnesses requiring hospitalizations or a physician s care. Give dates. Note past blood transfusions. Operations and Injuries: Describe briefly and date each operation. Identify the hospital and surgeon, if known. Give dates of severe lacerations, head trauma, sprains, broken bones, or gunshot wounds. Describe sequelae. Medications: List all prescription and OTC medications including dosages and frequency. Allergies and Immunizations: Record all known allergies, specifically allergies to drugs and type of allergic reaction. Remark on the state of immunization of the patient. FAMILY HISTORY Ask about diseases in parents, siblings, and children including present age, age at death, and the cause of death where applicable. Specific diseases to be asked about are: cancer, diabetes, gout, TB, bleeding disorders, arthritis, anemia, hypertension, migraine headaches, allergies, mental or nervous disorders, diseases of the cardiovascular system, congenital defects in children, SIDS, or consanguinity. PERSONAL AND SOCIAL HISTORY Inquire about: alcohol use (quantity and type), smoking (how much, how long), unusual drug habits, occupation, economic status, leisure activities, home, family and marital history. REVIEW OF SYSTEMS Skin: moisture, temperature, color, texture, changes in hair or nails, itching, rashes, lesions Head: headache, head injury Eyes: vision, glasses, pain, photophobia, proptosis, diplopia, scotomata, lacrimation, inflammation, infection, discharge
18 18 HISTORY & PHYSICAL (continued) Ears: hearing acuity, pain, tinnitus,vertigo, infection, discharge Nose: head colds, discharge, epistaxis, obstruction, sinus pain, anosmia Mouth & Throat: lesions in mouth, tongue or lips, pain in mouth or tongue, condition of teeth and gums, sore throats, postnasal discharge, speech difficulty, hoarseness Neck: stiffness, pain, limitations of motion, goiter, swelling Breasts (both sexes): pain, swelling, discharge, masses Respiratory: cough sputum (character, amount), hemoptysis, chills, fever, night sweats, dyspnea, wheezing, asthma, pain, pleurisy, bronchitis, pneumonia CVS: cyanosis, exertional dyspnea, paroxysmal nocturnal dyspnea, edema, palpitations, irregular rhythm, precordial pain (character, radiation, duration, location; relation to exercise, posture, eating, effect of medication), known hypertension, heart disease, or lipid disorder, claudication, varicose veins, phlebitis GI: appetite, food intolerance, dysphagia, belching, water-brash, heart-burn, sour stomach, nausea, vomiting, hematemesis, rectal pain, hemorrhoids, jaundice, hernia, gas (flatus, belching, borborygmis), change in bowel habits (regularity, frequency, laxative use), stools (color, consistency, size, shape, odor, bloody or tarry), epigastric distress (rel. to meals, relief by antacids, belching or food), abdominal pain (loc. & radiation; sharp, knife-like, colicky, dull, aching, gnawing; constant or intermittent; severity; relationship to eating, defecation, urination or menstruation; relieved by belching, vomiting, doubling up, defecation, urination, enema or drugs) GU: dysuria, urgency, frequency, nocturia, polyuria, incontinence, hesitancy, dribbling, size of stream, retention, oliguria, anuria, smoky urine, hematuria, pyuria, back or CVA pain, history of UTI, stones or gravel, gonorrhea and syphilis by name or symptoms OB-GYN: age of menarche, menses (freq., regularity, duration, amount, dysmenorrhea, recent changes in cycle, passage of clots, intermenstrual bleeding/metrorrhagia), menopause (spontaneous or surgical, date, complications subsequent vaginal bleeding), vaginal discharge, genital lesions, infertility, past use of birth control pills, pregnancies (number, abortions, complications, vaginal or cesarian, weight of babies) Bones, Joints, Muscles: pain, tenderness, swelling, stiffness limitations of movement, previous injuries and deformities Endocrine: general (weight change, easy fatigability, behavioral changes), diabetes (polyuria, polydipsia, infections), change in size of features, hands, feet, impotence, decrease in libido, change in body hair or distribution, thyroid disease (goiter, heat or cold intolerance, sweating, exophthalmos, tremor, skin and hair changes) Neurological: syncope, convulsions, unconsciousness, dizziness, vertigo, ataxia, tremor, weakness, paralysis, incoordination, pain, numbness, paresthesias, difficulty with speech or swallowing, difficulty with bladder or bowel control, localized or generalized symptoms Psychiatric: rapid changes in mood, memory loss, phobias, hallucinations, antisocial behavior, sleep disturbances, previous emotional illness and treatment PHYSICAL EXAMINATION General: A brief sentence to characterize the overall appearance of the patient including body habitus, muscular development, nutrition, and whether the patient appears to be of stated age, acutely ill, in acute distress, pain, dyspneic, coughing, etc. Vital Signs: ht, wt, (% iles and FOC in pediatrics), temp, blood pressure (which arm and whether supine, sitting, or standing), pulse, and respiration.
19 HISTORY & PHYSICAL (continued) 19 Skin: hands, nails, hair; color, pigmentation, texture, moisture, temperature, and lesions. Lymph nodes posterior auricular, submaxillary, cervical, epitrochlear, axillary, and inguinal. Decubitus ulcers Grade I = superficial Grade III = muscle exposed Grade II = subcutaneous Grade IV = bone exposed Head: symmetry, deformities, skull size, scars, tenderness, tumors, or lesions. Eyes: visual acuity (OD=right eye; OS=left eye) and fields, exophthalmos, EOM, nystagmus, strabismus, inflammation, discharge, conjunctivae, sclera, corneal scars, opacity, ulcerations, arcus. Iris (iridectomy or lesions). Pupil size, regularity, equality, and reaction to light and accomodation (PERRLA). Lens (cataract, or dislocation). Fundi: disc (color, margins, cupping, and papilledema); vessels (size, tortuosity, AV nicking); hemorrhages, exudates, or lesions. Ears: hearing acuity, symmetry, tenderness, discharge, perforation, tophi; Weber and Rinne test results. Nose: deformity, septal deviation or perforation, obstruction, mucosa (discharge, bleeding, polyps), sinuses. Mouth and Throat: lips and mucous membranes (colors, lesions), tongue (size, color, papillae, lesions). Teeth and gums. Soft Palate. Uvula. Tonsils and pharynx (inflammation, exudate, and tonsillar size). Neck: symmetry, scars, ROM, stiffness, tenderness; thyroid (size, symmetry, nodules, and tenderness); trachea midline; level of jugular venous pressure, carotid pulses, bruits; masses. Spine: curvature, symmetry, mobility, tenderness. Chest: shape, symmetry, respiratory excursions, AP diameter, masses, tenderness, fremitus, percussion, rales, rhonchi, breath sounds, egophony ( e-to-a change), whispered pectoriloquy ( ninety-nine ), wheezes, friction rubs. Heart: heart sounds** (see page 19), rhythm, precordial heave or thrill, PMI location and character, pulsations, enlargement, murmurs (intensity, timing, location, and radiation), rubs and gallops. Breast: shape, symmetry, retractions, discharge, ulceration, masses, tenderness, scars. Abdomen: contour, scars, striae, venous pattern, abnormal movements; auscultation for bowel sounds (frequency and character) and bruits; percussion for liver and splenic dullness, ascites (shifting dullness); palpation for liver, spleen, kidneys, bladder, colon, masses, aortic pulsations; CVA tenderness, abdominal tenderness (direct and rebound), guarding, hernias, femoral pulses, lymphadenopathy. Genitalia: Male size and development of penis and testes, hydrocoele, varicocoele, masses, discharge, lesions. Female External genitalia, Bartholin s glands, uretheral orifice, clitoris, cystocoele, rectocoele, prolapse, vaginal or cervical discharge, lesions, bleeding, cervix, uterus, adnexae, or masses (note size, location, mobility, and tenderness), Pap smear. Rectal: hemorrhoids, fissures, ulcerations, bleeding, sphincter tone, masses, tenderness, prostate, stool color, stool for occult blood test. Extremities: atrophy, tremor, cyanosis, clubbing, edema, redness, tenderness, limitation of joint motion, deformities, pulses (normal is 2+ and equal bilaterally). Neurological: (see pages 32-34) mental status, behavior, alertness, orientation, mood, memory (recent and remote), speech; gait, Rhomberg, cranial nerve function, muscle (coordination, strength, tremor, abnormal movements), sensation (light touch, pin prick, temperature, position, vibration, two point discrimination), reflexes (abdominalis, cremasteric, biceps, triceps, radials, Hoffman, patellar, Achilles, plantar), clonus. Stick figures are helpful for reflexes.
20 20 HISTORY & PHYSICAL (continued) SUMMARY One or two sentences that contain only those points of the history and physical which contribute directly to the establishment of a diagnosis. PROBLEM LIST Numbered in order of importance, include date of entry. IMPRESSION List of tentative diagnosis based on the history and physical exam to explain the problems noted under the problem list. This section should express your impressions diagnostically as to possible explanations for the problems found and most importantly why you feel these diagnoses should be considered. Likewise, reasons you feel certain disease processes are operative should also be discussed. PLAN Record all planned diagnostic and therapeutic procedures and plan for education of the patient based on the problem list generated. This format for history and physical exams is modeled after the Baylor College of Medicine Publication Guidelines: Medical, History and Physical Examination Writeup (1/83) **Heart Sounds S1: Loud: MS, short PR, hyperkinetic heart, thin chest wall Soft: Long PR, heart failure, MR, thick chest wall, emphysema S2: Nl: A2 before P2 with h splitting on inspiration Loud A2: Systemic HTN Widened spitting: RBBB, PS, MR Soft A2: AS Fixed splitting: ASD Loud P2: Pulmonary HTN Narrow splitting: Pulmonary HTN Soft P3: PS Paradoxical splitting: (narrows w/ respiration) AS, LBBB,CHF S3: Best heard w/ bell at apex and follows S2; LV failure, vol overload, nl in children S4: Best heard w/ bell at apex and precedes S1; AS, HTN, IHSS, CAD Ejection click: High pitch following S1; dilation of aortic root or pulmonary artery, AS, PS Opening Snap: High-pitched, follows S2, at L sternal border and apex in MS Midsystolic Clicks: Lower L sternal border in MVP Murmur grading: I=Faintest audible; heard only w/ special effort II=Faint, but easily audible III=Moderately loud IV=Loud; assoc w/ a thrill V=Very loud; + thrill; may be heard w/ stethoscope off chest VI=Max loudness; heard without a stethoscope Systolic murmurs: Lesion Type Valsalva HandGrip Squat Stand AS Crecendo MR Holosystolic VSD Holosystolic MVP Late systolic IHSS Harsh, diamond shaped Diastolic Murmurs: Early: Aortic or Pulmonary Regurgitation Mid-to-Late: MS, TS, mitral myxoma Continuous: PDA, AV fistula, Aortopulmonary septal defect