Merhabalar arkadaslar.
CS sinavinda en buyuk sikintilardan biri SP'nin(Hasta rolundeki aktor)kontrol listesindeki sorulari sormak ve islemleri yapmak. Heyecen cogu zaman bazi sorulari hatirlamamamiza sebep olabiliyor. Bu sebeple sinavdan once ek'de gonderdigim duzeni iyi ezberler ve hasta ile gorusme sirasinda size verilecek olan kagidi buna gore tasnif edebilirseniz hatirlamaniz ve hasta notu yazmaniz daha kolaylasacatir diye dusunuyorum. umarim yardimci olur.

Patient Name:

Vitals:

Complaints:

HPI (Hx of Present Illness)

1-      Location

2-      Onset

3-      Duration

4-      Quality

5-      Intensity

6-      Frequency

7-      Radiation

8-      Alleviating Factors

9-      Aggravating Factors

10-  Progression

11-  Previous Episodes

12-  Associated Symptoms

1. Pain/ Chest

1)      Headache

2)      Chest pain /Palpitation

3)      Cough/ SOB

4)      Abdominal Pain

5)      Joint Pain

1. Infection

1)      Fever/ Chills

2)      Fatigue

3)      Jaundice

4)      Rash/ Skin changes

1. Gastrointestinal

1)      Appetite/ Weight change

2)      Nausea/ Vomiting

3)      Diarrhea/ Constipation

4)      Traveling Hx/ Sick Contact Hx

1. Systems

1)      Sleep habit changes  

2)      Bowel habit changes

3)      Urinary habit changes

4)      Menstrual habit changes

General Hx

1-      Past Medical Hx

2-      Past Surgical Hx

3-      Medications/ Adverse effects

4-      Allergies

5-      Family Hx

6-      Social Hx

a.       Smoking

b.      Alcohol use

c.       Drug use

d.      Occupation

e.       Sexual Hx

                                                              i.      Sexually active?

                                                            ii.      Partners(#/ M/ F/ MF)

                                                          iii.      Condom

                                                          iv.      STD Hx

Physical Examination

Patient is no acute distress

Vitals are WNL

1-       HEENT

a.        EOMI(Extra Ocular Movement Intact)

b.        PERRLA(Pupils Equal, Round, Reactive to Light & Accommodation)

c.        Oropharynx WNL

d.        No LAP, No JVD

2-       Chest

a.        No rales, ronchi, wheezing or rubs

b.        Tactile fremitus WNL (Say 99)

3-       Heart

a.        RRR(Regular Rate & Rhythm)

b.        No murmurs, rubs or gallops

4-       Abdomen

a.        Soft, Non-tender, Non-distended

b.        BS(+)à Bowel Sounds

c.        No Hepatosplenomegaly, No mass

5-       Extremities

a.        No Clubbing, cyanosis or edema

6-       Neurological Exam

a.        Mental Status

                                                               i.      3/3 registration & recall at 3 times

                                                              ii.      Distant memories are intact

                                                            iii.      Oriented to person/date/place

                                                            iv.      Completed 3 step command

b.        Cranial Nerves : II-XII grossly intact

c.        Motor: Strength 5/5 in all muscle groups

d.        DTRs: Intact, Symmetric, Babinski(-)

e.        Sensation: Intact to sharp & Dull

f.         Cerebellum: (-) Romberg sign, Intact Finger to nose