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Mede E am Writeups Page

Medex Exam Writeups Page

MEDEX Objectives Home: http://faculty.washington.edu/alexbert/MEDEX/

WE RE ALL IN THIS TOGETHER

Writeups System Writeups Admission Note Progress/SOAP Note (Non-ICU) Progress Note (ICU) Pre-OP Orders Operative Note Procedure Note Discharge Summary Mini Mental Status Examination (MMSE) Glasgow Coma Scale (GCS) History & Physical

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Writeups
URI exam: ENT: External ears and nose unremarkable. Tympanic membranes and external auditory canals are clear. Nasopharynx, including septum and turbinates unremarkable. Oropharynx, including anterior and posterior structures clear. NECK: Supple, no adenopathy or masses. Thyroid is normal size, shape and consistency. CHEST: Clear to auscultation, good inspiratory effort.

Well male exam: GENERAL: Well-developed, well-nourished, well-groomed adult male appearing stated age and in no acute distress. EYES: Sclerae, conjunctivae and lids are clear. PERRLA. Fundi benign. ENT: External ears and nose unremarkable. Tympanic membranes and external auditory canals are clear. Nasopharynx, including septum and turbinates unremarkable. Oropharynx, including anterior and posterior structures clear. NECK supple. No adenopathy or masses. Thyroid normal size, shape and consistency. CHEST: Clear to auscultation, good inspiratory effort. CARDIOVASCULAR: COR: Regular rate and rhythm, no gallops, rubs or murmurs. No pedal edema noted. Peripheral pulses intact, equal bilaterally; no bruits or JVD noted.BREASTS: No gynecomastia or masses. ABDOMEN: Soft, symmetrical, active bowel tones, no masses, hepatosplenomegaly or tenderness. No abdominal hernia noted. GU: External genitalia including scrotal contents and penis are unremarkable. RECTAL examination reveals normal rectal sphincter tone, no masses. Prostate is normal size, shape and consistency. EXTREMITIES: Dry, warm with full range of motion for all extremities. SKIN: Clear to palpation and inspection. SCREENING NEUROLOGIC: A&O x3, Cranial nerves II-XII are intact, sensory and cerebellar intact, deep tendon reflexes 2+, toes down. PSYCH: Judgment and insight, memory, mood and affect within normal limits.

Well woman exam: GENERAL: Well-developed, well-nourished, well-groomed adult female appearing stated age and in no acute distress. EYES: Sclerae, conjunctivae and lids clear. PERRLA. Fundi benign. ENT: External ears and nose unremarkable. Tympanic membranes and external auditory canals are clear. Nasopharynx, including septum and turbinates unremarkable. Oropharynx, including anterior and posterior structures clear. NECK: Supple. No adenopathy or masses. Thyroid normal size, shape and consistency. CHEST: Clear to auscultation, good inspiratory effort. CARDIOVASCULAR: COR: Regular rate and rhythm, no gallops, rubs or murmurs. No pedal edema noted. Peripheral pulses intact, equal bilaterally; no bruits or JVD noted. BREASTS: Symmetrical, mildly fibrocystic topography. No specific masses are noted. No nipple discharge. Axillary node examination within normal limits. ABDOMEN: Soft, symmetrical, active bowel tones, no masses, hepatosplenomegaly or tenderness. No abdominal hernia noted. GU: External vulvovaginal region, periurethral area, vaginal canal and cervix are clear. Pap smear is obtained. Bimanual Exam reveals uterus of normal size, shape, consistency and mobility. Adnexal regions without masses or tenderness. RECTOVAGINAL examination reveals normal rectal sphincter tone, no masses. EXTREMITIES: Dry, warm with full range of motion for all extremities. SKIN: Clear to palpation and inspection. SCREENING NEUROLOGIC: A&O x3, cranial nerves II-XII are intact, sensory and cerebellar intact, DTRS 2+, toes down. PSYCH: Judgment and insight, memory, mood and affect are within normal limits.

Eye exam: EYE: Sclerae, conjunctivae and lids are clear. PERRLA. Fundi benign.

ENT exam: ENT: External ears and nose unremarkable. Tympanic membranes and external auditory canals are clear. Nasopharynx, including septum and turbinates unremarkable. Oropharynx, including anterior and posterior structures clear. NECK: Supple. No adenopathy or masses. Thyroid normal size, shape and consistency.

Diabetic foot exam: DIABETIC FOOT EXAM: Examination of the feet reveals normal posterior tibial and dorsalis pedis pulses. Skin to palpation and inspection is intact, without lesions, corns or calluses. No discoloration is present. Ten-gram monofilament nylon test reveals normal sensation bilaterally over plantar surfaces of distal great toe, first, third, and fifth metatarsal heads.

Cardiopulmonary exam: CHEST: Clear to auscultation, good inspiratory effort. HEART: COR: Regular rate and rhythm, no gallops, rubs or murmurs. No pedal edema noted. Peripheral pulses intact, equal bilaterally; no JVD; no bruits in carotids, abdominal, or femoral regions noted.

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System exams:
GENERAL: Well-developed, well-nourished, well-groomed adult male appearing stated age and in no acute distress. EYES: Sclerae, conjunctivae and lids are clear. PERRLA. Fundi benign. ENT: External ears and nose unremarkable. Tympanic membranes and external auditory canals are clear. Nasopharynx, including septum and turbinates unremarkable. Oropharynx, including anterior and posterior structures clear. NECK supple. No adenopathy or masses. Thyroid normal size, shape and consistency. CHEST: Clear to auscultation, good inspiratory effort. CARDIOVASCULAR: COR: Regular rate and rhythm, no gallops, rubs or murmurs. No pedal edema noted. Peripheral pulses intact, equal bilaterally; no bruits or JVD noted. BREASTS (male): No gynecomastia or masses. BREASTS (female): Symmetrical, mildly fibrocystic topography. No specific masses are noted. No nipple discharge. Axillary node examination within normal limits. ABDOMEN: Soft, symmetrical, active bowel tones, no masses, hepatosplenomegaly or tenderness. No abdominal hernia noted. GU (male): External genitalia including scrotal contents and penis are unremarkable. RECTAL examination reveals normal rectal sphincter tone, no masses. Prostate is normal size, shape and consistency. GU (female): External vulvovaginal region, periurethral area, vaginal canal and cervix are clear. Pap smear is obtained. Bimanual Exam reveals uterus of normal size, shape, consistency and mobility. Adnexal regions without masses or tenderness. RECTOVAGINAL examination reveals normal rectal sphincter tone, no masses. EXTREMITIES: Dry, warm with full range of motion for all extremities. SKIN: Clear to palpation and inspection. SCREENING NEUROLOGIC: A&O x3, Cranial nerves II-XII are intact, sensory and cerebellar intact, deep tendon reflexes 2+, toes down. PSYCH: Judgement and insight, memory, mood and affect within normal limits.

Admission Orders
Remember *ADC VANDALISM* or "ADC VAAN DIMLS"

Admit to: (floor, service, MD) Diagnosis: (Because) Condition: (stable, good, fair, poor, critical, guarded) Vital Signs: (q shift, q 4h, per routine, etc.) Allergies: (pen, sulfa, NKDA) Nursing: (l&Os, daily weights, turn patient q 4h, etc.) Call if T >38.5; SBP >180 or <90; DBP >100 or <40; HR >120 or <50; R >20 or <10;
O2 Sat <92% Diet: (regular, clear or full liquid, r g Na, low or hi protein, ADA calories, DM, Cardiac, Renal, etc.) Activity: (ad lib, bed rest with/without bathroom privileges, OOB tid, etc.) Labs: (also x-rays, EKGs, etc.) - CBC qam; Chem 7 qam IV Fluids: (type, added KCI, rate) D5W-1/2NS 100ml/h; saline lock Studies: (CXR, MRI, CT, EKG, EEG, etc.) Meds: None Call if T > 101, BP > 170/110 or < 90/50, HR > 120 or < 50
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Progress Note (Non-ICU)

Remember *SOAP* Hospital day #__ Postop day #__ Antibiotic day #__ Subjective: how the patient feels, new complaints, dizzines, pain, bowel movernent, flatus, nausea, vomiting, etc. Objective: Vital Signs; PE by system including any surgical wounds; Labs: Chem-7 (SMA-7); CBC; Studies (CXR, MRI, EEG, etc.) Assessment: list each problem and ist current status, e.g. #1 IDDM-- still poorly control, patient doesn`t understand disease; #2 HTN-- well controlled on current meds Plan: What are you going to do?, e.g. #1-- increase insulin to 30 units NPH q am, will contact diabetic teaching for education; #2-- continue current meds and doses

Shorthand for laboratory values: CHEM-7 (SMA-7):

CBC:

Attention: Some people switch WBC with platelets Liver Enzymes:

ABGs

Progress Note (ICU)

System oriented. Objective, assessment and plan done for each system in turn. Vitals: (can include weight, growth especially if ped) Meds: list all medications pt is on Systems: Remember you have 11 systems in alphabetical order and you`ll do great. A/B: airway, breathing, vent settings, apneic episodes, ABGs, pO2 (pulse ox), etc. CVS: heart, pulses CNS: ( Da brain) F/E/N: fluids/electrolytes/nutrition (incl I+O`s, TPN and residuals, Chem7/lytes) GI: abdominal exam, pertinent studies, BMs, flatus, guaiac Heme: jaundice, CBC with differential, PT/PTT, etc. ID: infectious disease (include antibiotics, peak/trough levels, fever status, etc.) Joints/Bones/Muscles: Kidney: Lines: List each and # of days it has been in place, local erythema, etc. Skin: rashes, decubitus ulcerus (grade?)

Pre-OP Orders
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Diagnosis: Procedure planned: Labs: (lytes, CBC, PT/PTT, UA, amylase if applicable) CXR EKG (if > 35 yo or h/o heart disease) Type and crossmatch Prep and shave surgical field NPO after midnight Void on call to OR Foley Catheter ( if indicated) Consent form signed and on chart History and Physical on chart

Operative Note
Date of procedure: Procedure performed: Pre-op diagnosis: Post-op diagnosis: Surgeon: Assistant(s): Type of anesthesia: Anesthesiologist: Pump Time (if applicable): Clamp Time (if applicable): Findings: Specimen(s): Tubes/drains: (NG, ETT, Foley, wound drains) EBL: estimated blood loss, ask anesthesiologist Fluids in: type and amount Fluids out: e.g. urine output, NG drainage Complications: (hopefully "none, a resident should be writing this note) Pt`s condition/disposition (e.g. pt transfarred to RR awake, extubated and stable)

Procedure Note
Procedure: type, date, time, indications, who performed Consent form: explained, signed and on chart Description: pt draped and prepped in a sterile manner. Local anesthesia achieved w/__ Findings: Describe fluid withdrawn, specimens sent to lab or pathology, how pt tolerated. Complications: (if there are complications, best to have resident or attending write the procedure note)

Discharge Orders
Remember *4DCAF*

Discharge: when and to where Diagnosis: Discharge Medications: (also need to fill out prescriptions) Diet: Condition: (e.g. good) Activity: (e.g. ad lib with 6 weeks pelvic rest for postpartum patients) Follow up: (e.g. return to clinic in 1 week)

MMSE
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(Mini Mental State Exam)

Serial exams will reveal progress, no change, or deterioration. Orientation:
What is the year, season, month, day, date? Where are we (state, county, city, hospital floor)? 1 point each 1 point each

Registration:
Name 3 objects taking one second to say each. Ask pt to repeat all 3 immediately after you say them. Repeat until he/she learns all three. 1 point each

Attention & Calculation:

Serial 7`s (stop after 5 correct), or spell "world" backwards. 1 point each up to 5

Recall:
Ask pt to name the three objects named above. 1 point each

Language:
Name 2 objects that you show (i.e. pencil, pen, cup). Repeat "no ifs, ands or buts". Have pt read sentence "Close your eyes" and have them do what it says Follow a three step command (i.e. take the piece of paper, fold it in half, and toss it on the floor). Write a sentence. Copy a complex polygon. 1 point each 1 point 1 point 1 point each step 1 point 1 point

GCS (Glasgow Coma Scale)

1. Eye opening: Spontaneous To voice To pain None 2. Verbal response: Oriented Confused Inappropriated words None 3. Motor response: Obeys commands
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Purposeful movement Withdrawn Flexion Extension None

5 4 3 2 1

History & Physical

INTRODUCTORY SENTENCE
This sentence should include the number of hospital admissions or clinic visits followed by the patients age, race, parity, sex, occupation, and the patients chief complaint or complaints (C.C.) in his/her own words.

SOURCE
Source of history, assessment of reliability.

PRRESENT ILLNESS
The present illness should be told in chronological sequence with reference to calendar date or time prior to admission, outlining the course of the illness from its beginning. Expound on each symptom thoroughly and its course. Previous treatment and hospitalizations should be noted; identify all significant medications received. Items of past medical history, family history or social history that might have a bearing on the present illness should be included. Any symptoms suggested by the clinical picture which are not present should be noted and denied, i.e. pertinent negatives.

PAST MEDICAL HISTORY

General Health: Patients general health througout life. Childhood Health: General health a specifically mention acute febrile illnesses of childhood. Medical Illnesses: List and/or describe all illnesses requiring hospitalizations or a physicians care. Give Dates. Note past blood transfusions. Operations and Injuries: Describe briefly and date each operation. Identify the hospital and surgeon, if known. Give dates of severe lacerations, head trauma, sprains, broken bones, or gunshot wounds. Describe sequelae. Medications: List all prescription and OTC medications including dosages and frequency. Allergies and Immunizations: Record all known allergies, specifically allergies to drugs and type of allergic reaction. Remark on the state of immunization of the patient.

FAMILY HISTORY
Ask about diseases in parents, siblings, and children including present age, age at death, and the cause of death where applicable. Specific diseases to be asked about are: cancer, diabetes, gout, TB, bleeding disorders, arthritis, anemia, hypertension, migraine headaches, allergies, mental or nervous disorders, or diseases of the cardiovascular system.

PERSONAL AND SOCIAL HISTORY

Inquire about: alcohol use (quantity and type), smoking (how much, how long), unusual drug habits, occupation, economic status, leisure activities, home, family and marital history.

REVIEW OF SYSTEM
Skin: moisture, temperature, color, texture, changes in hair or nails, itching, rashes, lesions Head: headache, head injury Eyes: vision, glasses, pain, photophobia, proptosis, diplopia, scotomata, lacrimation, inflammation, infection, discharge
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Ears: hearing acuity, pain, tinnitus, vertigo, infection, discharge Nose: head colds, discharge, epistaxis, obstruction, sinus pain, anosmia Mouth & Throat: lesions in mouth, tongue or libs, pain in mouth or tongue, condition of teeth and gums, sore throats, postnasal discharge, speech difficulty, hoarseness Neck: stiffness, pain, limitations of motion, goiter, swelling Breasts (both sexes): pain, swelling, dischrage, masses Respiratory: cough sputum (character, amount) hemoptysis, chills, fever, night sweats, dyspnea, wheezing, asthma, pain, pleurisy, bronchitis, pneumonia CVS: cyanosis, exertional dyspnea, paroxysmal nocturnal dyspnea, edema, palpitations, irregular rhythm, precordial pain (character, radiation, duration, location; relation to exercise, posture, eating, effect of medication), known hypertension, heart disease, or lipid disorder, claudication, varicose veins, phlebitis GI: appetite, food intolerance, dysphagia, belching, water-brash, heart-burn, sour stomach, nausea, vomiting, hematemesis, rectal pain, hemorrhoids, jaundice, hernia, gas (flatus, belching, borborygmis), change in bowel habits (regularity, frequency, laxative use), stools (color, consistency, size, shape, odor, bloody or tarry), eqigastric distress (relation to meals, relief by antacids, belching or food), abdominal pain (localization & radiation; sharp, knife-like, colicky, dull, aching, gnawing; constand or intermittent; severity; relationship to eating, defecation, urination or menstruation; relieved by belching, vomiting, doubling up, defecation, enema or drugs) GU: dysuria, urgency, nocturia, polyuria, incontinence, hesitancy, dribbling, size of stream, retention, oliguria, anuria, smoky urine, hematuria, pyuria, back or CVA pain, history of UTI, stones or gravel, gonorrhea and syphilis by name or symptoms OB-GYN: age of menarche, menses (frequency, regularity, duration, amount, dysmenorrhea, recent changes in cycle, passage of clots, intermenstrual bleeding/metrorrhagia), menopause (spontaneous or surgial, date, complications subsequent vaginal bleeding), vaginal discharge, genital lesions, infertility, past use of birth control pills, pregnancies (number, abortions, complications) Bones, Joints, Muscles: pain, tenderness, swelling, stiffness limitations of movement, previous injuries and deformities. Endocrine: general (weight change, easy fatigability, behavioral changes), diabetes (polyuria, polydipsia, infections), change in size of features, hands, feet, impotence, decrease in libido, change in body hair or distribution, thyroid disease (goiter, heat or cold intolerance, sweating, exophthalmos, tremor, skin and hair changes) Neurological: syncope, convulsions, unconsciousness, dizziness, vertigo, ataxia, tremor, weakness, paralysis, incoordination, pain, numbness, paresthesias, difficulty with speech or swallowing, difficulty with bladder or bowel control, localized or generalized symptoms. Psychiatric: rapid changes in mood, memory loss, phobia, hallucinations, antisocial beahviour, sleep disturbances, previous emotional illness and treatment.

PHYSICAL EXAMINATION
General: a brief sentence to characterize the overall appearance of the patient including body habitus, muscular development, nutrition, and whether the patient appears to be of stated age, acutely ill, in acute distress, pain, dyspneic, coughing, etc. Vital Signs: height, weight, (%`iles and FOC in pediatrics), temperature, blood pressure (which arm and whether supine, sitting, or standing), pulse and respiration. Skin: hands, nails, hair; color, pigmentation, texture, moisture, temperature, and lesions. Lymph nodes posterior auricular, submaxillary, cervical, epitrochlear, axillary, and inguinal. Decubitus ulcers - Grade I = superficial; Grade II = subcutaneous Grade III = muscle exposed; Grade IV = bone exposed Head: symmetry, deformities, skull size, scars, tenderness, tumors, or lesions. Eyes: visual acuity (OD = right eye; OS = left eye) and fields, exophthalmos, EOM, opacity, ulcerations, arcus. Iris (iridectomy or lesions). Pupil size, regularity, equality, and reaction to light and accomodation (PERRLA). Lens (cataract or dislocation). Fundi: disc (color, margins, cupping, and papilledema); vessels (size, tortuosity, AV nicking); hemorrhages, exsudates or lesions. Ears: hearing acuity, symmetry, tenderness, discharge, perforation, tophi; Weber and Rinne test results. Nose: deformity, septal deviation or perforation, obstruction, mucosa (discharge, bleeding, polyps), sinuses. Mouth and Throat: lips and mucous membranes (colors, lesions), tongue (size, color, papillae, lesions). Teeth and gums. Soft palate. Uvula. Tonsils and pharynx (inflammation, exudate and tonsillar size). Neck: symmetry, scars, ROM, stiffness, tenderness; thyroid (size, symmetry, nodules and tenderness); trachea midline; level of jugular venous pressure, carotid pulses, bruits; masses. Spine: curvature, symmetry, mobility, tenderness. Chest: shape, symmetry, respiratory excursions, AP diameter, masses, tenderness, fremitus, percussion, rales, rhonchi, breath sounds, egophony ("e-to-a change), whispered pectoriloquy ("ninety-nine), wheezes, friction rubs. Heart: heart sounds, rythm, precordial heave or thrill, PMI location and character, pulsations, enlargement, murmurs (intensity, timing, location, and radiation), rubs and gallops. Breast: shape, symmetry, retractions, discharge, ulceration, masses, tenderness, scars. Abdomen: contour, scars, striae, venous pattern, abnormal movements; auscultation for bowel sounds (frequency and character) and bruits; percussion for liver and splenic dullness, ascites (shifting dullness); palpation for liver, spleen, kidney, bladder, colon masses, aortic pulsations; CVA tenderness, abdominal tenderness (direct and rebound), guarding, hernias, femoral pulses, lymphadenopathy.
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Genitalia: Male - size and development of penis and testes, hydrocele, varicocele, masses, discharge, lesions. Female - external genitalia, Bartholin`s glands, urethral orifice, clitoris, cystocoele, rectocele, prolapse, vaginal or cervical discharge, lesions, bleeding, cervix, uterus, adnexae, or masses (note size, location, mobility, and tenderness), Pap smear. Rectal: hemorrhoids, fissures, ulcerations, bleeding, sphincter tone, masses, tenderness, prostate, stool, color, stool for occult blood test. Extremities: atrophy, tremor, cyanosis, clubbing, edema, redness, tenderness, limitation of joint motion, deformities, pulses (normal is 2+ and equal bilaterally). Neurological: mental status, behaviour, alertness, orientation, mood, memory (recent and remote), speech; gait, Romberg, cranial nerve function, muscle (coordination, strength, tremor, abnormal movements), sensation (light touch, pin prick, temperature, position, vibration, two point discrimination,) reflexes (abdominals, cremasteric, biceps, triceps, radialis, Hoffman, patellar, achilles, plantar), clonus. Stick figures are helpful for reflexes.

Summary
One or two sentences that contain only those points of the history and physical which contribute directly to the establishment of a diagnosis.

Problem List
Numbered in order of importance, include date of entry.

Impression
List of tentative diagnosis based on the history and physical exam to explain the problems noted under the problem list. This section should express your impressions diagnostically as to possible explanations for the problems found and most importantly why you feel these diagnoses should be considered. Likewise, reasons you feel certain disease processes are operative should also be discussed.

Plan
Record all planned diagnostic and therapeutic procedures and plan for education of the patient based on the problem list generated.

Updated 7 Dec 2003

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