cohmcstandardreference

PRESENTING COMPLAINT

AS SPOKEN BY THE PATIENT

HISTORY OF PRESENTING COMPLAINTS

HE/SHE WAS IN HIS/HER USUAL STATE OF HEALTH UNTIL ABOUT...AGO WHEN SHE NOTICED THE AFOREMENTIONED COMPLAINTS

ASSOCIATED SYMPTOMS:

DIFFERENTIALS RULE OUT:

REDFLAGS:

FOLLOWING ONSET OF SYMPTOMS/EVENT......

PAIN

SITE:
SEVERITY:
ONSET:
CHARACTER:
RADIATION:
AGGRAVATING FACTOR:
RELEIVING FACTOR:
PROGRESSION:
ASSOCIATED TIMING:
ASSOCIATED SYMPTOMS:

OTHER PRESENTING COMPLAINTS

ONSET:
DURATION:
INTENSITY:
PROGRESSION:
AGGRAVATING FACTOR:
RELEIVING FACTOR:
ASSOCIATED SYMPTOMS:

PREVIOUS OCCURENCE OF SIMILAR SYMPTOMS:

PREVIOUS HOSPITAL STAY ADMISSIONS OR SURGERIES:

PAST MEDICAL HISTORY:

MEDICATION HISTORY :

ALLERGY:

FAMILY HISTORY:

OCCUPATION:

TRAVEL HISTORY:

SOCIALS:

DIET:

EXCERCISE:

SMOKING:

ALCHOHOL:

GENERAL EXAMINATION:
 YOUNG MAN/WOMAN, NIL OVBIOUS DISTRESS, AFEBRILE, ANICTERIC, ACYANOSED, NON DEHYDRATED, NIL PEDAL EDEMA, NIL PERIPHERAL LYMPHADENOPATHY

CENTRAL NERVOUS SYSTEM(CNS) EXAM

GLASGOW COMA SCALE SCORE(GCS):
ORIENTATION:
NECK:

The Glasgow Coma Scale (GCS) assesses consciousness level after a traumatic brain injury by scoring eye opening, verbal response, and motor response, with a total score ranging from 3 (least responsive) to 15 (fully alert). 
Here's a breakdown of the GCS scoring:

1. Components of the GCS:
Eye Opening (E):
4: Spontaneous (eyes open without any stimulation)
3: To voice (eyes open to spoken command)
2: To pain (eyes open to painful stimuli)
1: None (no eye opening)

Verbal Response (V):
5: Alert and oriented (patient is awake and knows who they are, where they are, and what time it is)
4: Confused (patient is awake but disoriented)
3: Inappropriate words (patient makes sounds or words that don't make sense)
2: Incomprehensible sounds (patient makes sounds but no words)
1: None (no verbal response)
Motor Response (M):

6: Obeys commands (patient follows simple commands)
5: Localizes pain (patient moves to try to stop painful stimuli)
4: Withdraws from pain (patient pulls away from painful stimuli)
3: Flexion to pain (decorticate posturing, abnormal flexion to painful stimuli)
2: Extension to pain (decerebrate posturing, abnormal extension to painful stimuli)
1: None (no motor response)

Interpreting the GCS Score:
3-8: Severe brain injury, often indicating a coma.
9-12: Moderate brain injury.
13-15: Mild brain injury.

RESPIRATORY(CHEST) EXAMINATION

RESPIRATORY RATE(RR): 
TRACHEA CENTRALITY:
CHEST DEFORMITY:
CHEST EXPANSION:
CHEST SYMMETRY:
TACTILE VOCAL FREMITUS:
AUSCULTATORY VOCAL FREMITUS:
PERCUSSION NOTE:
ABNORMAL SOUNDS:
BREATH SOUNDS:

ABDOMINAL EXAMINATION

FULL, MOVES WITH RESPIRATION
NIL TENDERNESS ON PALPATION
LIVER: NOT ENLARGED
SPLEEN: NOT ENLARGED
KIDNEYS: NOT BALLOTABLE
LIVER SPAN:
BOWEL SOUND:
AORTIC BRUIT:
RENAL BRUIT:
BLADDER:
FRONT PASSAGE: NOT CONTRIBUTORY
BACK PASSAGE/DRE: NOT CONTRIBUTORY

CARDIOVASCULAR SYSTEM (CVS) EXAMINATION

PULSE RATE(PR):
BLOOD PRESSURE(BP):
CAROTID PULSATION:
JUGULAR VENOUS PRESSURE(JVP):
PRECORDIUM:
APEX BEAT:
HEART SOUND:
MURMURS:

MUSCULOSKELETAL SYSTEM(MSS) EXAMINATION:
KNEE JOINT EXAM:
ON INSPECTION:
DIFFERENTIAL WARMTH:
SWELLING:
TENDERNESS: PATELLA TENDERNESS:
            TIBIO-FEMORAL JOINT LINE TENDERNESS:
SWIPE TEST:
STRESS TEST:
DRAWER"S TEST:
MCMURRAY TEST:
POWER:
TONE:
REFLEX:
NEUROLOGICAL DEFICIT:

BACK EXAM:

TENDERNESS:
SWELLING:
NORMAL CURVATURE:
LORDOSIS:
SCOLIOSIS:

OBSTETRICS EXAMINATION
ON INSPECTION:
DIFFERENTIAL WARMTH:
LEOPOLD'S MANEUVERS PALPATION:
LIE:
PRESENTATION:
STATION:
SYMPHYSIO-FUNDAL HEIGHT(SFH):
FETAL HEART RATE(FHR)
LIVER:
SPLEEN:
KIDNEYS: