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

 


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.

 


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&O´s, 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, EKG´s, 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

 


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.

 


Pre-OP Orders


Operative Note

 

 


Procedure Note

 


Discharge Orders

 

Remember *4DCAF*

 

 


MMSE
(Mini Mental State Exam)


Serial exams will reveal progress, no change, or deterioration.
 

Orientation:  

 

What is the year, season, month, day, date?

1 point each

Where are we (state, county, city, hospital floor)?

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). 1 point each

Repeat "no ifs, ands or buts".

1 point

Have pt read sentence "Close your eyes" and have them do what it says

1 point

Follow a three step command (i.e. take the piece of paper, fold it in half, and toss it on the floor).

1 point each step

Write a sentence.

1 point

Copy a complex polygon.

1 point

 


GCS
(Glasgow Coma Scale)

 

1. Eye opening:

Spontaneous

4

 

To voice

3

 

To pain

2

 

None

1

 

 

 

2. Verbal response:

Oriented

5

 

Confused

4

 

Inappropriated words

3

 

Incomprehensible sounds

2

 

None

1

 

 

 

3. Motor response:

Obeys commands

6

 

Purposeful movement

5

 

Withdrawn

4

 

Flexion

3

 

Extension

2

 

None

1

 


History & Physical


INTRODUCTORY SENTENCE

This sentence should include the number of hospital admissions or clinic visits followed by
the patient´s age, race, parity, sex, occupation, and the patient´s 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


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


PHYSICAL EXAMINATION


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