It is less likely, particularly with more senior clinicians, to have a detailed chest examination unless they are performed by a pulmonologist or a cardiologist. different or atypical) sound when thumped or listened to (ausculated). The most common abbreviation here is CTA (Clear To Auscultation) meaning the quadrants of the chest do not demonstrate any abnormal (i.e. A variety of maneuvers are taught to medical students to describe chest findings. This may or may not include a breast examination. There may also be references to the size of the thyroid as well as the presence or absence of carotid bruits (an abnormal sound made by blood in the carotid arteries when it swirls past a stenotic or ulcerative plaque). Other abbreviations seen here would be JVD, standing for jugular venous distention, which may be increased with right heart failure as with pulmonary hypertension, for example. There may be referral to nuchal (neck) rigidity which may be accompanied by a Brudzinski’s sign (raising of the legs towards the chest when the head is bent forward at the neck) often associated with meningeal irritation or inflammation. This is often described as supple, a rigid neck being a concerning finding regarding the possibility of meningitis in a patient particularly who is febrile. Strabismus refers to the condition of misaligned eyes when looking ahead. Amblyopia refers to when the brain does not process visual signals of a misaligned eye (the eye that is exotropic or esotropic), resulting in vision being based on one eye and a patient losing depth perception. Esotropia refers to an eye being deviated towards the midline (deviated inward), and is a form of strabismus. Exotropia refers to an eye being deviated away from midline (deviated outward), and is a form of strabismus. Strabismus is the lack of muscle co-ordination between the eyes. Gross vision problems may be noted here (or in CN exam section), including strabismus, exotropia, esotropia, or ambylopia. Again, cross-reference with the history as described above is often useful. However, this information is often omitted. Ideally, this section will identify any observed defects and state of the skin, oral mucosa, dentition, use of hearing aides, or glasses. A frequent abbreviation is NC/AT which stands for Normocephalic, Atraumatic. This stands for Head, Eyes, Ears, Nose, and Throat. The following subsections of the Review of Systems are often found: If unavailable basic cognitive testing using nonverbal tasks/tests may provide some useful information, but interpretation and conclusions should be viewed with caution. For practitioners who do not speak the language of the patient, options may include identifying another practitioner who does speak the language or finding an interpreter (caution should be taken if a family member or friend of the patient is used as this may introduce bias). If not a Fluent English speaker, performances and expectations should be altered. For example, the same memory capacity would not be expected of someone with 4 years of education compared to someone with a graduate degree. Of special importance is the patient’s educational history and primary language (if specified), as many neuropsychological skills and test performances vary considerably with education, and consideration should be given to evaluate a patient in his/her primary language. It may also contain information about the number of children, although in an inpatient setting this is often not specified. It will frequently contain information such as marital status or gender, tobacco, alcohol, and drug abuse. This is one of the few sections that actually gives a sense of the person as living on a day-to-day basis. Although this is usually a very truncated section of the history and physical, it is of importance in interpretation of any neuropsychological testing. Transmissible spongiform encephalopathiesįamily and social history. Shaken baby syndrome (Shaken infant syndrome) Postural orthostatic tachycardia syndrome Progressive multifocal leukoencephalopathy Pervasive developmental disorder (Not Otherwise Specified) Neurosciences (Neurological) intensive care unit Mentally retarded/Developmentally disabled Learning disability OR Legionnaires’ disease Inflammatory bowel disease OR Ichthyosis bullosa of siemens Guillain-barre syndrome OR Group B streptococcal (disease) Alzheimer’s disease OR Attachment disorderĪmyotrophic lateral sclerosis (Lou-Gehrig’s disease)Ĭerebral autosomal dominant arteriopathy with sub-cortical infarcts and leukoencephalopathyĬongenital heart disease OR Coronary heart disease OR Congenital hip dysplasiaĬhronic inflammatory demyelinating polyneuropathyĭiabetes mellitus, [Type I (juvenile) Type 2 (acquired)Įmergency department OR emotionally disturbedĮhlers-danlos syndrome OR excessive daytime sleepiness
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