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Scenario: Severe headache for the last 2 days

Patient conversation

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General Examination

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General Appearance

  • DressAdd notes here
  • GroomingAdd notes here
  • Personal hygieneAdd notes here
  • Level of consciousnessAdd notes here

Vital Signs

  • TemperatureAdd notes here
  • Heart Rate (Pulse)Add notes here
  • Blood PressureAdd notes here
  • Respiratory RateAdd notes here

Skin color

  • PallorAdd notes here
  • CyanosisAdd notes here
  • JaundiceAdd notes here

Obvious lesions

  • RashesAdd notes here
  • BruisesAdd notes here
  • ScarsAdd notes here
  • DiscolorationAdd notes here

Odors of breath

  • AlcoholAdd notes here
  • AcetoneAdd notes here
  • Fetor hepaticusAdd notes here
  • UremicAdd notes here
  • PutridAdd notes here

Behavior and Motor Activity

  • Preferred postureAdd notes here
  • ParalysisAdd notes here
  • RestlessnessAdd notes here
  • TremorsAdd notes here
  • AtaxiaAdd notes here
  • Ease of WalkingAdd notes here

Indications of distress

  • Cardiorespiratory insufficiencyAdd notes here
  • PainAdd notes here
  • AnxietyAdd notes here
  • Physical discomfortAdd notes here
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Physical Examination

ABCs of First Aid

Clear airway, no signs of obstruction. Even and unlabored breathing, clear breath sounds, regular pulse, adequate perfusion, normal blood pressure.

Cardiovascular

No visible pulsations, normal heart sounds without murmurs or extra sounds,Strong and equal pulses in all extremities,Good capillary refill less than 2 seconds

Respiratory

Chest moves symmetrically with respiration, clear breath sounds throughout lung fields,12-20 breaths per minute

Abdominal

Abdominal contour normal, no tenderness, masses or scars, normal bowel sounds.

Musculoskeletal

No swelling, deformities, or tenderness, normal range of motion.

Neurological

Alert and oriented to time, place, and person, intact cranial nerves, normal strength and sensation, brisk reflexes.

Ophthalmic

Visual acuity appropriate for age, normal extraocular movements, clear fundus, Clear optic disc margins, no hemorrhages or exudates

Ent

Clear external ear canals, intact tympanic membranes, normal nasal patency,Nasal passages clear, septum midline,Oropharynx clear, no erythema or exudate, tonsils not enlarged.

Skin and Extremities

Skin intact without lesions, normal skin temperature and moisture,No clubbing or cyanosis, peripheral pulses present and equal bilaterally.

Genitourinary

No lesions or discharge,No tenderness or masses in the suprapubic area,

psychiatry

No hallucinations, delusions, or suicidal ideation,Mood congruent with situation, affect appropriatem Logical and coherent thought process
Alarm

Patient is not breathing. Please take action!

Alarm

Patient is dehydrated. Please take action!

Alarm

Patient has peritonitis. Please take action!

Differential diagnosis

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Cardiovascular

Respiratory

Gastrointestinal

Neurological

Musculoskeletal

Endocrine

Hematologic

Genitourinary

Psychiatric

Selected Diagnoses (0/4)

    Consultation

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    Cardiologist

    Pulmonologist

    Gastroenterologist

    Neurologist

    Endocrinologist

    Nephrologist

    Rheumatologist

    Orthopedic Surgeon

    General Surgeon

    Final Diagnosis

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    Cardiac Diseases

    Respiratory Diseases

    GIT Diseases

    Neurological Diseases

    Musculoskeletal Diseases

    Endocrine Diseases

    Hematologic Diseases

    Genitourinary Diseases

    psychiatric Diseases

    Selected Final Diagnosis

      Management

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      Cardiac Medication

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      Cardiac Procedures

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      Respiratory Medication

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      Respiratory Procedures

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      GIT Medication

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      GIT Procedures

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      CNS Medication

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      CNS Procedures

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      Endocrine Medication

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      Endocrine Procedures

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      Renal Medication

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      Renal Procedures

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      Musculoskeletal Medication

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      Musculoskeletal Procedures

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      Infection Medication

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      Infection Procedures

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      Allergy Medication

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      Analgesia

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