Gastrointestinal system

1. Inspection of oral cavity - teeth, gingival, tongue, a pharynx and tonsils

2. Inspection of abdomen: Contour of the abdomen; symmetry of abdomen, Movements of the abdomen; Bulging because of enlargement of organs; Pulsation in the abdomen; Pigmentation of the abdominal wall; Prominent veins; Peristaltic waves; Pubic hair; Umbilicus; Hernias Orifices; Scars striae.

3. Palpation of the abdomen:

- Superficial palpation - characteristics;

- Deep palpation:

1. Left iliac region – sigmoid colon;

2. Right iliac region – cecum;

3. right lumbar region - ascending colon;

4. left lumbar region - descending colon;

5. umbilical region – transverse colon; before of it find low border of stomach

6. epigastrium - palpation of stomach and duodenum;

7. epigastrium – pancreas;

- Percussion of abdomen – presence or absence of ascites

Hepatolienal system

1. Liver: percussion (by MCL, Midsternal line (MSL), and by left costal margin), palpation (sizes, edge tenderness, consistence, surface)

2. Gallbladder: Murphy’s sign, Orthner’s sign, frenicus sign.

3.Spleen: percussion (above the 10^th rib, and by mid-axillary line), its palpation (sizes, edge tenderness, consistence, surface)

Urinary system

- right lumbar area – right kidney;

- left lumbar area – left kidney;

- hypogastrium – urinary bladder (with Percussion);

- ureter’s points – superior and inferior;

- Murphy’s renal punch;

Auscultation: stomach and intestine (peristalsis), auscultation of renal arteries.

Endocrine system

1. Thyroid gland, its size and consistence, presence of eye signs at hyperthyroidism

2. Secondary sexual attributes

III. Provisional diagnosis (according to complaints on …, history of present illness…, past history…, results of physical and system’s examination…, DS:…)

C. LABORATORY AND INSTRUMENTAL EXAMINATION

1) Plan of investigations (laboratory, instrumental)

1.

2.

3.

2) Laboratory and instrumental investigations (results and their interpretation) – in tables, for example:

D. Clinical diagnosis (based on provisional diagnosis and laboratory and instrumental results)

E. Plan of treatment (only principles) -

F. Diary – on next day of examination, describe the dynamics of patient’s condition, shortly the results and changes of physical examination.

G. Temperature curve

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Date: 2015-01-12; view: 877