IVMS Physical Diagnosis Approach to the Patient Notes

7/21/2019 IVMS Physical Diagnosis Approach to the Patient Notes

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J\GX-JHG ? /YD/Bost Tpcotdc ey gjh/ ?9/?3 ?

Ymysjhob Cjo`ansjs; Opprnohm tn tmd Yotjdat

(Smd


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J\GX-JHG ? /YD/Bost Tpcotdc ey gjh/ ?9/?3 5

c. Orgs

j. Jaspdht lnrdorgs, dbenws, oac uppdr orgs lnr sjzd, smopd,

syggdtry. Antd oay nevjnus otrnpmy, loshjhubotjna,javnbuatory gnvdgdats, nr oeanrgobjtjds nl pnsjtjna.jj. OS SMD XOGD SJGD, jaspdht sfja lnr tur`nr, gnjsturd,

tdxturd, pj`gdatotjna, hnbnr, oac bdsjnas (smnubc ed oebd tnrdhn`ajzd oac cdshrjed eosjh bdsjnas - suhm os gohubd,popubd, vdsjhbd, pustubd, ancubd, dth.).

jjj. Yobpotd lnrdorgs, dth., lnr enad nr gushbd oeanrgobjtjds.jv. Yobpotd lnr dpjtrnhmbdor ancds. Jl prdsdat, antd sjzd,

hnasjstdahy, gnejbjty, oac prdsdahd nr oesdahd nltdacdradss.

3. Jaspdht Gushbds oac Knjats

o. Gushbds;

j. Hmdhf nppnsdc tmuge oac jacdx lja`dr (purd gdcjoa adrvd).jj. Hmdhf nppnsdc tmuge (gdcjoa adrvd) oac bjttbd lja`dr (ubaor

adrvd).jjj. Hmdhf dxtdasjna nl tmuge (rocjob adrvd).

jv. Hmdhf ejhdps gushbd (gushubnhutoadnus adrvd).v. Hmdhf smnubcdr occuhtjna (prnx. G. `rnup). (5:)vj. Hmdhf dbenw lbdxjna (gushubnhutoadnus a) oac dxtdasjna

(rocjob a.). (89)vjj. Hmdhf wrjst dxtdasjna (rocjob a.) oac lbdxjna (gdcjoa oacubaor a.). (8?)

e. Knjats

j. Hmdhf jatdrpmoboa`dob knjats lnr UNG, cdlnrgjty, oacMdedrcda's/Enuhmorc's ancds.

jj. Hmdhf wrjsts (lbdxjna - :9n, dxtdasjna - 09n, rocjob cdvjotjna

- 59n, ubaor cdvjotjna - 44n) oac dbenws (lbdxjna - ?


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o. Tsd entm pobpotnry oac oushubtotnry gdtmncs (tn ovnjc edja`gjsbdc ey oa oushubtotnry `op).

e. Udhnrc obb tmrdd Fnrntfnll snuacs, usja` opprnprjotdby sjzdc hull.

0. Jaspdht Mdoc;

o. Jaspdht lnr oeanrgobjty nl smopd, sjzd, oac syggdtry nl enads oaclnr bdsjnas nl sfja oac shobp.

e. Yobpotd lnr oay oeanrgobjtjds nr bdsjnas, j.d., eugps, cdprdssjnas,dth.

h. Antd mojr tdxturd oac obnpdhjo, jl prdsdat.

=. Jaspdht Hnakuahtjvod oac Xhbdrod; Antd dspdhjobby tmd troasbuhdahy oacvoshubor pottdra nl entm tmd shbdrob oac pobpderob hnakuahtjvod oac tmdhnbnr nl tmd shbdrod (pj`gdatdc nr jhtdrjh).

:. Sdst \jsuob Ohujty oac \jsuob Ljdbcs;

o. \jsuob Ohujty - wjtm pnhfdt shrddadr (JJ).e. \jsuob Ljdbcs - tdst vjsuob ljdbcs nl dohm dyd, usja` hnalrnatotjna

gdtmnc (JJ).

?9. Sdst Yupjbbory Udohtjna tn Bj`mt oac Ohhnggncotjna;

o. Yupjbbory Udohtjna

j. Jajtjobby antd sjzd oac smopd nl pupjbs.jj. Tsja` pda bj`mt, hmdhf entm cjrdht oac hnasdasuob rdohtjna tn

bj`mt (JJ, JJJ, oac gjc-eroja hnaadhtjnas).

e. Ohhnggncotjna

j. Nesdrvd lnr pupjbbory hnastrjhtjna oac hnavdr`dahd nl dyds -tmd tmjrc hngpnadat nl ohhnggncotjna (tmjhfdaja` nl tmdbdas vjo hnatrohtjna nl tmd hjbjory gushbds) hoaant ed sdda (JJoac JJJ).

??. Hmdhf Dxtronhubor Gushbds; hmdhf obb sjzd horcjaob ljdbcs nl `ozd (JJJ, J\,

\J)6 obsn nesdrvd lnr aysto`gus.

?5. Sdst Bj`mt Snuhm nl Lohd; wjtm bj`mt tnuhm nl lja`dr nr hnttna hbntm, hmdhfoejbjty nl potjdat tn cdtdht bj`mt tnuhm ja obb tmrdd cjvjsjnas nl tmd ljltm hroajob

adrvd (\).?8. Osf Yotjdat tn Prjafbd Lnrdmdoc, Hbnsd Dyds, oac Xmnw Sddtm;

o. Ja uppdr gntnr adurna bdsjna, tmd uppdr mobl nl tmd lohd js spordc.e. Nesdrvd lnr lohjob syggdtry, d.`., bnss nl aosob boejob lnbc (\JJ).


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?3. Sdst Mdorja`; ja o qujdt rnng, potjdat smnubc ed oebd tn mdor pmysjhjoa'slja`drs rueedc bj`mtby tn`dtmdr 5-8 jahmds lrng potjdat's dor (ohnustjh

cjvjsjna \JJJ).?4. Jaspdht Gnutm; (Tsd wnncda tnaùd ebocd hordlubby oac `datby. Osf lnr

cdaturds tn ed rdgnvdc.)

o. Jaspdht;

j. Sddtm; augedr oac hnacjtjna.jj. Snaùd (jahbucja` uacdrsjcd); hnbnr, bdsjnas, popjbbod.jjj. @ugs oac guhnso; swdbbja`, ebddcja`, jaldhtjna,

jalboggotjna, tugnrs, mypdrtrnpmy, cjshnbnrotjna.jv. Snasjbbor lnsso oac pmoryax.

e. Jcdatjly npdaja`s nl Xtdasda's cuht (porntjc boac - ador uppdr

sdhnac gnbor) oac Pmortna's cuht (suegoxjbbory `boac - ot eosd nl

uacdrstruhturd nl tnaùd).h. Osf potjdat tn soy "oom" oac nesdrvd lnr syggdtrjhob gnvdgdat nl

tmd uvubo (J]).c. Osf potjdat tn hnu`m oac kuc`d lnrhd nl snuac gocd ey ojr gnvja`

post opprnxjgotja` vnhob hnrcs (]).d. Osf potjdat tn prntrucd tnaùd, antja` gjcbjad prntrusjna (]JJ).

?


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59. Ydrlnrg Ntnshnpjh Dxogjaotjna; Antd tmot tmd dxtdraob ohnustjh gdotusdxtdacs sngdwmot oatdrjnrby oac supdrjnrby6 tmdrdlnrd, tmd ntnshnpd

dxogjaotjna js edst lohjbjtotdc ey `datby pubbja` tmd ourjhbd upworc oaceohfworc oac ey usja` tmd bor`dst spdhubug tmd hoaob wjbb ohhnggncotd.

o. Nesdrvd lnr ebnnc, jalboggotjna, swdbbja`, hdrugda, lnrdj`a encjds,nr purubdat sdhrdtjna ja tmd oucjtnry hoaob.e. Jcdatjly tmd anrgob oaotngy nl tmd dorcrug, jahbucja` tmd pors

tdaso wjtm jts hnad nl bj`mt, tmd moacbd oac smnrt prnhdss nl tmd

gobbdus, oac tmd oatdrjnr oac pnstdrjnr lnbcs nl tmd pors lbohhjco.h. Jcdatjly oeanrgob hnbnrja`, eub`ja`/rdtrohtjna, pdrlnrotjna, shottdrdc

bj`mt rdlbdx, oac prdsdahd nl lbujc.

5?. Jaspdht Ansd; (usd bor`d ntnshnpd spdhubug)

o. Ansd hnbnr nl aosob guhnso.

e. Jaspdht tmd troasjbbugjaotdc sdptug lnr cdvjotjna, pdrlnrotjna, nrgossds.

h. Jaspdht tmd jaldrjnr oac gjccbd turejaotds.

Gnvd tn pnsjtjna edmjac tmd potjdat

55. Hmdhf Lubb UNG nl Adhf; antd dspdhjobby ohtjvd lbdxjna tn hmja, dxtdasjna,rntotjna, oac tjbtja`.

58. Yobpotd tmd Xobjvory @boacs oac Bygpm Ancds;

o. Jcdatjly tmd suegdatob, suegoacjeubor, oatdrjnr, oac pnstdrjnr

hdrvjhob hmoja.e. Jcdatjly oatdrjnr oac pnstdrjnr ourjhubor, suenhhjpjtob, oacsuprohbovjhubor bygpm ancds. Jl dabor`dc, antd sjzd, hnasjstdahy,gnejbjty, oac prdsdahd nr oesdahd nl tdacdradss.

53. Yobpotd tmd Srohmdo ja tmd Xtdraob Anthm; Antd jts pnsjtjna (smnubc ed

gjcbjad) oac gnejbjty.54. Yobpotd tmd Smyrnjc; wmjbd tmd potjdat swobbnws - o `boss nl wotdr goy

lohjbjtotd tmjs prnhdcurd - pobpotd wjtm jacdx oac gjccbd lja`dr.

o. Antd sjzd oac hnasjstdahy nl rj`mt oac bdlt bneds oac nl jstmgus.

e. Antd oay ancubds os tn sjzd, smopd, hnasjstdahy, gnejbjty, oactdacdradss.

5


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J\GX-JHG ? /YD/Bost Tpcotdc ey gjh/ ?9/?3


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Osf pot jdat tn bjd lb ot oac stoac ot potjdat's rj`mt sjcd

85. Yobpotd Erdosts oac Ordnbod;

o. Yobpotd erdosts ja obb lnur quocroats, antja` dspdhjobby oay

tdacdradss nr gossds. Jl gossds ord prdsdat, antd bnhotjna, sjzdsmopd, hnasjstdahy, gnejbjty, oac tdacdradss.e. Yobpotd oac hngprdss dohm ordnbo, jaspdhtja` lnr cjshmor`d.

Uojsd potjdat tn 34n

88. Jaspdht Adhf \djas;

o. Ja o anrgob dumycrotdc jacjvjcuob, tmd adhf vdjas (jatdraob oacdxtdraob ku`ubor) goy ed cjstdacdc tn tmd oa`bd nl tmd kow wjtm tmdpotjdat byja` lbot. Ottdgpt tn jcdatjly tmd jatdraob oac dxtdraob ku`ubor

vdjas.e. Uojsd tmd mdoc oac truaf nl tmd potjdat tn oa opprnxjgotd oa`bd nl34n. Jl adhf vdja cjstdatjna js prdsdat, ottdgpt tn dstjgotd tmdhdatrob vdanus prdssurd ey antja` tmd cjstoahd ja hdatjgdtdrsedtwdda tmd mj`mdst pnjat nl nshjbbotjna oac tmd stdraob oa`bd. Smjscjstoahd pbus 4-0 hg (tmd cjstoahd edtwdda tmd stdraob oa`bd oacrj`mt otrjug) js o `nnc dstjgotjna nl tmd hdatrob vdanus prdssurd.Obsn ottdgpt tn jcdatjly tmd pnsjtjvd o oac v wovd wjtm tjgja`,

lohjbjtotdc djtmdr ey pobpotjna nl tmd nppnsjtd horntjc ortdry nr eyoushubtotjna nl tmd mdort snuacs. Jl adhf vdja cjstdatjna js antvjsjebd wjtm potjdat ot 34n, jt hoa ed ossugdc tmot hdatrob vdanus

prdssurd js ant oeanrgobby dbdvotdc.

Boy potjdat lbot

83. Yobpotd Horntjc Ortdrjds;

o. Hordlubby jcdatjly oac pobpotd dohm horntjc ortdry, nad ot o tjgd,

antja` tmd rotd, rmytmg, ogpbjtucd, oac hnatnur nl tmd pubsd.e. Hnahdatrotd na tmd ogpbjtucd oac hnatnur nl dvda anrgob pubsds ja

nrcdr tn fanw tmd "lddb" nl anrgob pubsds oac tmus ed oebd tn

jcdatjly oeanrgobs gnrd dosjby.

84. Jaspdht tmd Yrdhnrcjug lnr porostdraob nr opjhob jgpubsds.8


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J\GX-JHG ? /YD/Bost Tpcotdc ey gjh/ ?9/?3 =

e. Sry tn jcdatjly tmd YNJAS NL GO]JGTG JGYTBXD (YGJ). Jl tmdYGJ hoaant ed jcdatjljdc, ottdgpt tn dstjgotd mdort sjzd ey

pdrhussja` lnr horcjoh cubbadss ja tmd bdlt lnurtm oac ljltm jatdrhnstobspohds.

80. Yobpotd tmd Xuprostdraob Anthm lnr oeanrgob pubsotjnas nr tmrjbbs.8=. Oushubtotd Horntjc Ortdrjds.

o. Jcdatjly erujts nr troasgjttdc gurgurs.e. Cn ant ed gjsbdc ey o vdanus mug, wmjhm js usuobby o hnatjaunus

gurgur, bnucdst ja cjostnbd.

8:. Oushubtotd tmd Mdort ja Ljvd Bnhotjnas ja o Xystdgotjh Poy.

o. Xtort ot tmd opdx, gnvd tn tmd bnwdr bdlt stdraob enrcdr (jahbucddpjòstrjug), oac dxtdac tn tmd eosd nl tmd mdort.

e. Gofd surd tn jahbucd tmd YGJ, tmd dpjòstrjug, tmd bdlt stdraobenrcdr, oac tmd sdhnac rj`mt (onrtjh) oac tmd bdlt (pubgnajh)jatdrhnstob spohd.

h. Cn tmjs nahd wjtm tmd cjopmro`g (wmjhm edst lohjbjtotds mdorja`mj`m-pjthmdc snuacs, jahbucja` X? oac X5) oac rdpdot wjtm tmd edbb(wmjhm edst lohjbjtotds mdorja` bnw-pjthmdc snuacs, jahbucja` X8 oacX3).

c. @jvd spdhjob ottdatjna tn tmd jatdasjty nl X? ot tmd opdx oac tn tmdjatdasjty nl Y5 oac spbjttja` nl X5 ja tmd bdlt sdhnac jatdrhnstobspohd.

d. Jcdatjly oay dxtro snuacs ja systnbd nr cjostnbd. Antd oay gurgurs

os tn bnhotjna, tjgja`, quobjty, jatdasjty, oac troasgjssjna.

39. Nesdrvd tmd Oecngda; Yotjdat smnubc ed byja` lbot wjtm orgs ot sjcd oacrdboxdc.

o. Antd hnatnur nl oecngda; shopmnjc, lbot, rnuacdc, prntuedroat.e. Antd oay shors, strjod, cjbotdc vdjas, rosmds, nr bdsjnas.

h. Antd tmd ugejbjhus; hnatnur, bnhotjna, sjàs nl mdrajo.c. Nesdrvd lnr rjsja` pubsotjnas nr pdrjstobsjs.

3?. Oushubtotd tmd Oecngda ja obb lnur quocroats; Antd prdsdahd nr oesdahd

nl anrgob enwdb snuacs oac voshubor erujts.35. Yobpotd Ldgnrob Yubsds; Antd ogpbjtucd oac hnatnur.38. Yobpotd Jaùjaob oac Ldgnrob Ancds; Jl dabor`dc, antd sjzd, hnasjstdahy,

gnejbjty, oac tdacdradss.33. Oushubtotd Ldgnrob Ordos; Antd prdsdahd nr oesdahd nl erujts.34. Yobpotd Oecngda Xupdrljhjobby; Ja systdgotjh goaadr, bj`mtby pobpotd obb

lnur quocroats, antja` prdsdahd nr oesdahd nl tdacdradss, rj`jcjty,ùorcja`, nr gossds.


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J\GX-JHG ? /YD/Bost Tpcotdc ey gjh/ ?9/?3 :

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J\GX-JHG ? /YD/Bost Tpcotdc ey gjh/ ?9/?3 ?9

4?. Jaspdht Bd`s - sfja, gushbds, knjats.

o. Xfja; Sdhmajqud js sogd os ja Xtdp 8. Xpdhjob ottdatjna js `jvda tn

sj`as nl hmrnajh ortdrjob nr vdanus jasulljhjdahy.e. Jaspdht lnr sjzd, smopd, syggdtry, oac otrnpmy. O`oja antd oayotrnpmy, loshjhubotjnas, javnbuatory gnvdgdats, nr oeanrgobjtjds nl

pnsjtjna. Yobpotd lnr enay nr gushbd oeanrgobjtjds. Xhrdda lnrgushbd strda`tm wmjbd potjdat js wobfja` (Xtdp 40).

h. Knjats; Sdst UNG nl dohm knjat.

j. Oafbd; cnrsj (59n) oac pboator (34n) lbdxjna os wdbb osdvdrsjna (59n) oac javdrsjna (89n).

jj. Fadd; lbdxjna (?89n) oac dxtdasjna (9n).jjj. Mjp (wjtm fadd lbdxdc); lbdxjna (?59n) oac jatdraob (59n) oac

dxtdraob (34

n

) rntotjna. Nesdrvd lnr spdhjljh knjat cdlnrgjtjds,tdacdradss, snlt tjssud swdbbja`, dllusjnas, enay dabor`dgdat,oac syanvjob tmjhfdaja`. Hmdhf obsn gushbds tnad (os wjtmuppdr dxtrdgjtjds).

45. Hmdhf lnr Dcdgo; Jcdatjly dcdgo ey antja` pdrsjstdat jacdatotjna oltdrgjbc prdssurd na tmd cnrsug nl lnnt oac smja.

48. Yobpotd Cnrsobjs Ydcjs oac Ynstdrjnr Sjejob Yubsds.

o. Yobpotd dohm pubsd ja tmd rj`mt oac bdlt lnnt sjgubtoadnusby, antja`syggdtry, ogpbjtucd, oac hmorohtdr.

e. Jl pubsds ja tmd lddt ord ant pobpoebd, oa ottdgpt smnubc ed gocd tnpobpotd tmd pnpbjtdob pubsd.

43. Ydrlnrg Xdasnry Dxog; Bj`mt tnuhm oac pnsjtjna sdasd ord tdstdc ey;

o. Oppbyja` o wjsp nl hnttna nr tjssud popdr tn sdvdrob ordos nvdr tmdpotjdat's bd`s oac hngporja` potjdat's oejbjty tn sdasd bj`mt tnuhm nltwn bd`s. (Ed`ja tdstja` ot potjdat's tnd oac prnhddc prnxjgobby tnfadds.)

e. Gnvja` tmd potjdat's `rdot tnd up oac cnwa oac osfja` mjg tnjcdatjly wmjhm woy jt js edja` gnvdc. Smdsd goaduvdrs lohjbjtotd

cnhugdatja` tmd jatd`rjty nl entm tmd hdatrob (jahbucja` tmd spjan-tmobogjh oac cnrsob hnbuga trohts rdspdhtjvdby) oac pdrjpmdrobadrvds nl tmd bnwdr dxtrdgjtjds.

h. Hmdhf mjp lbdxjna oac dxtdasjna (prnx. G. `rnup). (88)

c. Hmdhf fadd dxtdasjna (ldgnrob a.) oac lbdxjna (tjejob a.). (84)


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J\GX-JHG ? /YD/Bost Tpcotdc ey gjh/ ?9/?3 ??

44. Dbjhjt Cddp Sdacna Udlbdxds; Ejhdps (H4-


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h. Antd bnhotjna nl tmd urdtmrob gdotus oac jaspdht lnr cjshmor`d.


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Ldgobd potjdat - osf potjdat tn ossugd bjtmntngy pnsjt jna

4:. @dajtobjo

o. Sn prdpord lnr oa ocdquotd dxogjaotjna, tmd potjdat smnubc ed

`jvda oa nppnrtuajty tn dgpty mdr eboccdr oac smnubc ed cropdcopprnprjotdby. Occjtjnaobby tmd dxogjadr smnubc usd worg `bnvdcmoacs oac worg spdhubug. Dohm stdp nl tmd dxogjaotjna smnubc

ed dxpbojadc ja ocvoahd tn tmd potjdat. Gobd dxogjadrs smnubc edottdacdc ey o ldgobd ossjstoat. Ldgobd dxogjadrs goy wnrf obnadeut smnubc ed ottdacdc jl tmd potjdat js dgntjnaobby cjsturedc.

e. Jajtjobby jaspdht tmd dxtdraob `dajtobjo, antja` tmd gnas puejs, boejogoknro, oac tmd pdrjadug.

h. Adxt hordlubby sdporotd tmd boejo goknro6 oac jaspdht tmd boejogjanro, hbjtnrjs, urdtmrob nrjljhd, oac jatrnjtus. Antd oay jalboggotjna,ubhdrotjna, cjshmor`d, swdbbja`, nr ancubds. Jl pnssjebd, jcdatjly tmd

npdaja` nl tmd pdrjurdtmrob (Xfdad's) oac Eortmnbja's `boac. Hmdhflnr dabor`dgdat nr tdacdradss nl Eortmnbja's `boac ey pobpotja` wjtmtmd jacdx lja`dr ja tmd vo`jao ador tmd pnstdrjnr dac nl tmd jatrnjtusoac tmd tmuge nutsjcd tmd pnstdrjnr port nl tmd boejo goknro. Antd

oay swdbbja`, tdacdradss, nr cjshmor`d (cjshmor`d smnubc edhubturdc). Ljaobby ossdss tmd suppnrt nl tmd vo`jaob nutbdt ey osfja`tmd potjdat tn stroja cnwa oac antja` oeanrgob eub`ja` nl tmd

oatdrjnr (hystnhdbd) nr pnstdrjnr (rdhtnhdbd) vo`jaob wobb.


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boedbdc `boss sbjcd. Oay ebddcja` nl tmd hdrvjx curja` tmjs prnhdcurdsmnubc ed antdc.

h. Ynstdrjnr lnrajx; Unbb o hnttna oppbjhotnr stjhf na tmd lbnnr nl tmdvo`jao pnstdrjnr tn tmd hdrvjx. Xgdor o tmjrc boedbdc `boss sbjcd.Antd; O ljxotjvd gust ed jggdcjotdby oppbjdc tn dohm sbjcd.


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IVMS Physical Diagnosis Approach to the Patient Notes

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