- COUGH X 2/7
- A/W BN/RN AND ST
- YELLOWISH PHLEGM
- NO FEVER
- NO RASH
- NO TRAVEL HX
- NO HAEMOPTYIS/LOW/LOA/SOB/WHEEZE
- NO SX OF MENINGISM
- NO CP/SOB/GIDDINESS
- HOME ART NEGATIVE
ON EX:
ALERT NON-TOXIC AFEB
HS1S2 L CLEAR
PHARYNX MIN INJ TONSILS NAD NO EXUDATES
NO RASH
NECK SUPPLE ROM FULL NEUROLOGICALLY INTACT
IMP: URTI
PLAN: SYMP TX RETURN ADVICE RED FLAGS ADVISED FEVER ADVICE GIVEN TO SEEK MED ATTENTION IN EVENT OF FEVER >5 DAYS/RASH/SX OF MENINGISM/HAEMOPTYSIS/FEELING UNWELL/CP/SOB/GIDDINESS/PERSISTENT SYMPTOMS A&E ADVICE GIVEN MC X 1/7
ANAREX 2 TABS TDS X 20 TELFAST D 1 TAB BD X 10 COUGHEN 10ML TDS X 1 BOTTLE LEFTOSE 30MG BD X 10 MAC LOZ 1 TDS X 12 FLUIMUCIL 600MG OM X 5
- EPIGASTRIC BLOATEDNESS X 2/7
- A/W ON AND OFF BURNING ACHE AT EPIGASTRIUM, NO RADIATION
- NO NAUSEA/VOMITING
- NO FEVER/RASH
- NO DIARRHEA
- NO PR BLEED/MELENA
- NO JAUNDICE/TEA COLOURED URINE/RHC PAIN
- NO URINARY SX
- NO CONST SX/EARLY SATIETY
- NO CP/SOB/GIDDINESS
ON EX:
ALERT NON-TOXIC NO CONJ PALLOR MM MOIST AFEB
A SOFT, NON-TENDER, BS+, NO REBOUND OR GUARDING, NO MASSES
NO RASH
IMP: DYSPEPSIA LIKELY GASTRITIS
PLAN: PPI/ANTACID SYMP TX RETURN ADVICE RED FLAGS ADVISED ABDO PAIN ADVICE KIV UBT/GASTRO REF FOR SCOPES IF SX PERSISTENT PAST 2/52 MC X 1/7
OMEPRAZOLE 20MG BD X 10 MMT 10ML TDS X 1 BOTTTLE BUSCOPAN 10MG TDS X 10 DIMENATE 50MG TDS X 10
- DIARRHEA X 1/7
- WATERY AND BROWN
- 3 EPISODES
- A/W GEN COLICKY ABDO PAIN, NO RADIATION OR LOCALIZATION
- NO N/V
- NO PR BLEED/MELENA
- NO FEVER
- TAKING WELL ORALLY
- NO DIETARY INDESCRETION
- NO TRAVEL HX
- NO URINARY SX
- NO JAUNDICE/TEA COLOURED URINE
ON EX:
ALERT NON-TOXIC AFEB MM MOIST
A SOFT, NON-TENDER. BS+, NO REBOUND OR GUARDING, NO MASSES
IMP: ENTEROCOLITIS
PLAN: SYMP TX RETURN ADVICE ABDO PAIN ADVICE RED FLAGS ADVISED MC X 1/7
LOPERAMIDE 2MG TDS X 10 BUSCOPAN 10MG TDS X 10 LACTEOL FORTE 1 SACHET TDS X 10 ORS 1 SACHET TDS X 10 DIMENATE 50MG TDS X 10
- HEADACHE X 1/7
- NO HI/LOC
- MILD, NOT THUNDERCLAP, BITEMPORAL
- NO FEVER/RASH
- NO CP/SOB/GIDDINESS
- NO FOCAL NEURO SX
- NO BOV/NAUSEA/VOMITING/NECK STIFFNESS
- NO AURAS
- GAIT STEADY
- DOES NOT GET DAILY MORNING HEADACHES
- NO HX OF HTN
ON EX:
ALERT NON-TOXIC AFEB
GCS 15 PEARL 3MM EOMS INTACT NO NYSTAGMUS NO FACIAL ASYMMETRY SPEECH NAD MOVING ALL LIMBS WELL NO CEREBELLAR SIGNS NO PRONATOR DRIFT GAIT STEADY AMB WELL NEUROLOGICALLY INTACT
NECK SUPPLE ROM FULL
BP HR
IMP: NON-SPECIFIC HEADACHE
PLAN: ANALGESIA RETURN ADVICE MC X 1/7 RED FLAGS ADVISED ED ADVICE KIV NEURO REF IF HEADACHES RECURRENT/MORNING HEADACHES
ANAREX 2 TABS TDS X 20 ARCORIA 120MG OM X 5 OMEPRAZOLE 20MG OM X 5
- GIDDINESS X 1/7
- ACUTE ONSET
- LIGHT HEADEDNESS/VERTIGINOUS
- A/W NAUSEA, NO VOMITING
- NO TINNITUS/HEARING LOSS/OTIC PAIN
- NO BOV/NECK STIFFNESS/HEADACHE
- NO CP/SOB
- NO LOC/HI
- NO FOCAL NEURO SX
- NO FACIAL ASYMMETRY/SLURRING OF SPEECH
- NO PR BLEED/MELENA/HAEMATURIA
- NO ABDO PAIN/DIARRHEA
- GAIT STEADY
- NO FEVER/RECENT URTI
- NOT WORSE ON TURNING HEAD OR ON POSTURAL CHANGE
ON EX:
ALERT NON-TOXIC MM MOIST NO CONJ PALLOR
HS1S2 PULSE REGULAR L CLEAR
GCS 15 PEARL 3MM EOMS INTACT NO NYSTAGMUS NO FACIAL ASYNMMETRY SPEECH NAD MOVING ALL LIMBS WELL NO CEREBELLAR SIGNS NO PRONATOR DRIFT GAIT STEADY AMB WELL NEUROLOGICALLY INTACT
BP HR
IMP: NON-SPECIFIC PERIPHERAL GIDDINESS
PLAN: SYMP TX MC X 1/7 RETURN ADVICE RED FLAGS ADVISED A&E ADVICE GIVEN
STEMETIL 10MG TDS X 10 CINNARIZINE 25MG TDS X 10 BETAHISTINE 24MG BD X 10
- LOWER BACK PAIN X 2/7
- MECHANICAL IN NATURE
- CARRIED HEAVY LOADS THAT DAY
- NO TRAUMA
- NO FEVER/CONST SX
- NO SCIATICA/RADICULAR SX
- NO WEAKNESS/NUMBNESS
- NO BOWEL OR BLADDER SX
- NO URINARY SX/LOIN TO GROIN PAIN
- AMBULATING WELL, NO GAIT ISSUES
ON EX:
ALERT NON-TOXIC AFEB
A SOFT, NON-TENDER, BS+, BILAT RENAL PUNCH NEG
L SPINE: NO CENTRAL STEP OR TENDERNESS NO PARAVERTEBRAL SPASM NO LISTING SLR NEG BILAT 70/70 L SPINE FROM POWER AND SENSATION IN LL INTACT IN ALL MYOTOMES/DERMATOMES GAIT STEADY AMBULATING WELL
IMP: LOWER BACK STRAIN
PLAN: ANALGESIA RETURN ADVICE BACK PAIN ADVICE GIVEN, RED FLAGS EXPLAINED KIV XR IN 5/7 IF NOT IMPROVING MC X 1/7
ANAREX 2 TABS TDS X 20 ARCOXIA 120MG OM X 5 OMEPRAZOLE 20MG OM X 5 VOREN GEL 1 APP BD X 1 TUBE
- MENSTRUAL CRAMPS X 2/7
- D2 MENSES
- HAVING SUPRAPUBIC PAIN, SIMILAR TO PREV MENSTRUAL CRAMPS
- NO EXCESSIVELY HEAVY MENSTRUAL BLEEDING, NOT MORE THAN 4 PADS A DAY, NO CLOTS
- PERIODS USUALLY REGULAR 28-30 DAYS
- NO FEVER
- NO ABDO PAIN/DIARRHEA
- NO URINARY SX
- NO SX OF ANAEMIA
ON EX:
ALERT NON-TOXIC NO CONJ PALLOR AFEB
A SOFT, NON-TENDER, BS+, NO REBOUND OR GUARDING, NO PALPABLE UTERUS
IMP: PRIMARY DYSMENORRHOEA
PLAN: ANALGESIA RETURN ADVICE ABDO PAIN ADVICE RED FLAGS ADVISED MC X 1/7 KIV GYNAE REF IF SX WORSENING/EXCESSIVE BLEEDING
PARACETAMOL 1G QDS X 20 MEFANEMIC ACID 500MG TDS X 20 OMEPRAZOLE 20MG BD X 10 BUSCOPAN 10MG TDS X 10
- EMERGENCY CONTRACEPTION
- HAD UNPROTECTED INTERCOURSE WITH BOYFRIEND YESTERDAY NIGHT
- LMP:
- PERIODS USUALLY REGULAR 28-30 DAYS
- CURRENTLY WELL
- NO ABDO OR PELVIC PAIN/PV BLEED
- NO HX OF CLOTS/HX OF THROMBOPHILIAS
ON EX:
ALERT NON-TOXIC
A SNT, BS+, NO REBOUND OR GUARDING, NO MASSES, NO PALPABLE UTERUS
CALVES SUPPLE, NIL EDEMA
IMP: EMERGENCY CONTRACEPTION
PLAN: POSTINOR/ELLA ADVISED ON SIDE EFFECTS OF MEDICATION (CLOT FORMATION, NEXT PERIOD DELAYED) RISK OF FAILURE ADVISED TO RETURN FOR UPT IF PERIOD DOES NOT ARRIVE WITHIN 1/52 OF EXPECTED ADVISED NOT TO TAKE REPEAT COURSE IN THE SAME MONTH CONTRACEPTION ADVISED RETURN ADVICE GIVEN RED FLAGS ADVISED
POSTINOR X 1 BOX
- RASH ON TRUNK AND LIMBS X 2/7
- ACUTE ONSET
- ITCHY AND RED, RAISED LIKE MOSQUITO BITES
- COMING AND GOING WITHIN 24 HRS
- NO PIH
- NO NEW DRUGS
- NO FEVER/RECENT ILLNESS
- NO CONST SX
- NO INSECT BITES
- NO IDENTIFIABLE TRIGGERS
- NO FACIAL SWELLING/SOB/WHEEZE
ON EX:
ALERT NON-TOXIC AFEB
NO ANGIOEDEMA
L CLEAR
URTICARIAL WHEAL AND FLARE NOTED ON TRUNK AND LIMBS EXCORIATIONS + NO PIH MM CLEAR
IMP: ACUTE URTICARIA
PLAN: PRED X 5/7 ANTIHISTAMINES STRICTLY RETURN ADVICE RED FLAGS ADVISED KIV DERM REF IF NOT IMPROVING IN 2/52 DESPITE TX MC X 1/7
PREDNISOLONE 30MG OM X 30 TABS (5MG TABS) TELFAST 180MG OM X 10 ATARAX 10MG ON X 10
- RIGHT EYELID SWELLING X 3/7
- PAINFUL AND RED
- GROWING BIGGER
- NO FEVER/DISCHARGE
- NO TRAUMA
- NO BOV/PHOTOPHOBIA/OCULAR PAIN
- NO CONTACTS USE
ON EX:
ALERT NON-TOXIC AFEB
VA GROSSLY INTACT PEARL 3MM EOMS INTACT CONJ AND CORNEAE GROSSLY NAD BILAT STYE/CHALAZION NOTED AT RIGHT UPPER EYELID, NO DISCHARGE NO PRESEPTAL CELLULITIS
IMP: STYE/CHALAZION
PLAN: XEPANICOL/FUCITHALMIC WARM COMPRESS ADVISED RED FLAGS ADVISED RETURN ADVICE GIVEN ED ADVICE GIVEN, FOR FURTHER OPHTHALMOLOGIC EVALUATION IF RED FLAGS DEVELOP MC X 1/7
- DYSURIA X 2/7
- A/W SUPRAPUBIC DISCOMFORT, NO RADIATION
- NO LOIN OR BACK PAIN
- A/W FREQUENCY AND URGENCY
- NO HAEMATURIA
- NO SMELLY OR CLOUDY URINE
- NO BO SYMPTOMS/CHANGE IN BO HABITS
- NO FEVER
- NO ILICIT SEXUAL INTERCOURSE
- NO HX OF RECURRENT UTI
ON EX:
ALERT NON-TOXIC AFEB
A SOFT, NON-TENDER, BS+, NO REBOUND OR GUARDING, NO PALPABLE BLADDER BILAT RENAL PUNCH NEG
UC9: BLOOD 2+ LEUK 3+ NITRITE NEG PRO NEG GLU NEG
IMP: UTI
PLAN: CIPRO/AUGMENTIN RED FLAGS ADV RETURN ADVICE ED ADVICE SYMP TX TO ED IF LOIN PAIN/NOT IMPROVING BY D3 ABX/PERSISTENT GROSS HAEMATURIA MC X 1/7
- NECK PAIN X 1/7
- SLEPT WITH POOR NECK POSITION
- NO TRAUMA
- NO FOCAL NEURO SX
- NO FEVER
- NO BOWEL OR BLADDER SX
- NO GAIT ISSUES
- NO RADICULAR SX
ON EX:
ALERT NON-TOXIC
C SPINE: NO CENTRAL STEP OR TENDERNESS TENDERNESS NOTED OVER SCM NECK SUPPLE ROM FULL LHERMITTES/HOFFMANS NEG SPURLINGS NEG NEUROLOGICALLY INTACT IN UL AND LL GAIT STEADY
IMP: NECK STRAIN
PLAN: ANALGESIA C SPINE XR IN 5/7 IF NOT IMPROVING RED FLAGS ADV BACK PAIN ADVICE MC X 1/7
- BILATERAL RED EYES X 1/7
- ITCHY AND RED
- TEARY
- NO FEVER/PURULENT DISCHARGE
- NO TRAUMA
- NO BOV/PHOTOPHOBIA/OCULAR PAIN
- NO CONTACTS USE
- NO FLOATERS/FLASHERS
- NO URTI SX
ON EX:
ALERT NON-TOXIC AFEB
VA GROSSLY INTACT PEARL 3MM EOMS INTACT BILAT CONJUNCTIVA INJECTED + CORNEAE GROSSLY NAD BILATERALLY, NO OPACIFICATION/HYPOPYON NO STYE/CHALAZION/OCULAR ADNEXAL ABNORMALITIES
IMP: CONJUNCTIVITIS
PLAN: ISOLATION ADVISED MO FLOREN PATANOL RED FLAGS ADVISED RETURN ADVICE GIVEN ADVISED AGAINST CONTACT LENS USE ED ADVICE GIVEN, FOR FURTHER OPHTHALMOLOGIC EVALUATION IF RED FLAGS DEVELOP MC X 1/7
- RIGHT ANKLE PAIN X 1/7
- TWISTED ANKLE
- INVERSION INJURY
- NOW HAS MECHANICAL PAIN AT LAT ASPECT OF ANKLE
- A/W SWELLING AT LATERAL ASPECT OF ANKLE
- STILL ABLE TO AMBULATE AND WEIGHT BEAR
- NO OTHER INJURIES
- NO WEAKNESS/NUMBNESS
- NO PALLOR/DUSKINESS
- NO KNEE OR FOOT PAIN
ON EX:
ALERT NON-TOXIC
RIGHT ANKLE: NO GROSS DEFORMITIES SOFT TISSUE SWELLING OVER OVER LATERAL ASPECT OF ANKLE TENDERSS + NOTED OVER SOFT TISSUES OF LATERAL ASPECT OF ANKLE NO BONY TENDERNESS NO TIB/FIB/MALLEOLAR/BASE OF 5TH MT/NAVICULAR TENDERNESS ANKLE FROM NV INTACT, DP AND PT ++, CRT<2S ABLE TO WB >4 STEPS ON INJURED LEG GAIT ANTALGIC
IMP: RIGHT ANKLE SPRAIN
PLAN: XR IN 3/7 IF PAIN PERSISTENT/NOT IMPROVING RED FLAGS ADV ANALGESIA RICE RETURN ADVICE MC X 1/7
DERM HISTORY TAKING Shaping Letters Into Words: Further Charaderization of Identified Lesions • Color Pink, red, purple (purpuric lesions do not blanch with pressure with a glass slide [diascopy]), white, tan, brown, black. blue, gray, and yellow. The color can be uniform or variegated. • Margination Well (can be traced with the tip of a pencil) and ill defined. • Shape Round, oval, polygonal. polycyclic, annular (ring-shaped), iris, serpiginous (snakelike), umbilicated • Palpation Consider (1) consistency {soft, firm, hard, fluctuant, boardlike), (2) deviation in temperature (hot, cold), and (3) mobility. Note presence of tenderness, and estimate the depth of the lesion (i.e., dermal or subcutaneous). Forming Sentences and Understanding the Text: Evaluation of Arrangement,Patterns, and Distribution • Number Single or multiple lesions. • Arrangement Multiple lesions may be (1) grouped: herpetifonn, arciform, annular, reticulated (net-shaped), linear, serpiginous (snakelike) or (2) disseminated: scattered discrete lesions. • Confluence Yes or no. • Distribution Consider (1) extent: isolated (single lesions), localized, regional, generalized, universal. and (2) pattern: symmetric, exposed areas, sites of pressure, intertriginous area, follicular localization. random,following dennatomes or Blaschko lines.
HX Demographica Age, race, sex, and occupation
- Constitutional symptoms: Acute illness" syndrome: headaches,chills, feverishness, and weakness. chronic illness" syndrome: fatigue, weakness, anorexia, weight loss, and malaise.
- History of skin lesions. key questions: • When t Onset • Wheret Site of onset • Does it itch or burtt Symptoms • How has it spread (pattern of spread)t Evolution • How have individual lesions changedt Evolution • Provocative factorst Heat, cold, sun, exercise, travel history, drug ingestion, pregnancy, season o Previous treatment(s)t Topical and systemic 3 . General history of present illne111 aa indicated by clinical situation, with particular attention to conatitutional and prodromal symptoms.
- Put medical hiatory: • Operations • Illnesses (hospitalizedt) • Allergies, especially drug allergies • Medications (present and past) • Habits (smoking, alcohol intake, drug abuse) • Atopic history {asthma, hay fever, eczema)
- Family medical history (particularly of psoriasis, atopy, melanoma, xanthomas, tuberous sclerosis).
- Social hiatory, with particular reference to occupation, hobbies, exposure, travel, or injecting drug use.
- Sexual history: histury of risk factors of mv: blood transfusions, IV clrup, sexually active, multiple partners, STDs