Survival in Long Case

Survival In Long Case Chinadol MD. Preparation before exam Hair / Nail / Dressing Stethoscope / Watch / Pen / A4 X2 Flashlight / Snellen chart / Opthalmoscope / Jerk / Tooth prick / Tuning fork Vital signs tool General information 75 min / case History taking + Physical examination 30 min Presentation 10 min Discussion-Question and answer 35 min Problem list Diagnosis / Differential diagnosis Investigation for diagnosis / treatment Final diagnosis Plan of treatment Advice Consequence Step approach Introduce myself History taking General information Sex / Age / Native Habitat Occupation Occupational disease Contact vector Right of treatment Chief complaint : Defined symptom Choose to approach 1st except non sp.

Present illness : Characteristic Causes à Effect (time sequence) Co-morbid disease Complication Contraindication for INV / TX Pain syndrome Onset Duration Interval Characteristic Variation of symptom Aggravating factors Alleviating factors Severity Associated symptom Constitutional symptom Performance status FC / NYHC / ECOG / PS Staging Past history Underlying disease Previous treatment and outcome Side effect of treatment Growth and development Mental status and vaccine Previous drug allergy Classified type of hypersensitivity

Previous operation Brain : Seizure Heart : Palliative shunt / Dz. Intra-abd : Adhesion Appendices : R/O appendicitis Pituitary : Panhypopituitarism Thyroid : HypoTH-PTH Traveling and Tropical disease History drug and substance use Steroid Duration for suppress axis Effect and withdrawal effect NSAIDs Antibiotics Alcohol : degree / addict-withdrawal Smoking : pack-year Substance : Amphetamine / Cocaine Oral contraceptive pills History unsafe sex / multiple partner Intravenous drug use (IVDU) Blood transfusion Family history Transmitted disease Genetic disease : AD / AR / X-linked

ROS Fatigue / Dyspnea / Chest pain PND-Orthopnea / Claudication / Cyanosis Palpitation / Syncope Cough / Hemoptysis / Pleurisy Dysphagia / Odynophagia Abdominal pain / Dyspepsia / Diarrhea Heartburn / Bowel habit change Malena / Hematochezia / Hematemes Jaundice / Pale stool / Pruritus Hematuria / Dysuria / Oliguria / Polyuria Flank pain / Air bubble / Pass stone Headache / Seizure / Weakness Numbness / Conscious change Ataxia / Dementia / Movement Autonomic dysfunction Dizziness / Vertigo Blurred vision / Double vision Anemia / Bleeding / Mass-LN+ / Hburia Edema Nutritional status Polyuria / Polydipsia / Polyphagia Libido / Erectile dysfn : morning erection Galactorrhea / Lactation Hisutism : frequency for shave Menstruation : menarche / menopause Pregnancy / Abortion Back pain / Athralgia / Arthritis Skin lesion Oral ulcer / Alopecia / Photosense

Physical Examination General appearance Dysmorphic features Cyanosis Cachexia Vital signs BP 4 extremities PR rate / rhythm / volume RR pattern BT HEENT Pale / Jaundice / Injected Subconjunctival hemorrhage Salivary gland Oral mucosa / Tongue Thyroid and bruit Neck mass / CLN / SCLN Carotid bruit Heart (CVS) Peripheral pulse Jugular venous wave form Precordium Heaving / Thrill S1 / S2 Extra sound / Gallop Murmur / Maneuver Pericardial friction rub Subclavian bruit Lungs (Chest) Thoracic cage Pectus E/C Scoliosis Gynecomastia Superficial vein dilatation

Spider nevi Trachea Lung expansion / VF-VR Percussion Breath sound Rhonchi / Wheezing Generalized / Localized Crackle / Crepitation Fine / Medium / Coarse Abdomen Distended / Scaphoid abdomen Superficial vein dilatation Direction by Harvey test Sister-Joseph node Bowel sound Abdominal and hepatic bruit Superficial and deep palpation Liver / Spleen / GB Mass Size / Site / Shape / Surface Surrounding tissue Consistency / Movable Intra-abd or Extra-abd Intra / Retroperitoneum Bowel mass / Mesentery Bimanual palpation Kidney Per rectal Examination Musculoskeleton Back Spine : C / T / LS Joint : Peripheral / Axial

Extremities Skin and skin appendage Edema Clubbing finger Palmar erythema Gangrene / Raynauld / Digital pitting scar Sclerodactyly / Dilated capillary nailfold Neurosigns