case report on physical exam patient was

A case report is a descriptive study that documents an unusual clinical phenomenon in a single patient. It describes in details the patient’s history, signs, symptoms, test results, diagnosis, prognosis and treatment.

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What is a medical examination report?

Medical examination reports are the type of reports that mainly focus on a person’s information and more. They are as important as the next information that should be kept. These reports can also be used by patients as a way to understand the problems they may be facing and can use it to gain knowledge about it.

What is a case report in medical terms?

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine.

How to write a patient case study?

Writing Your Patient Case Study 1 Work on Your Introduction Select a case. You have to identify your focus and scope for the study. ... 2 Get to Know the Participants You can have one or multiple case participants. ... 3 Perform Data Analyses Method Your results will depend on your interpretation of the raw data. ... 4 Report the Case Study Results

How do you write a case analysis report?

Report the Case Study Results Your patient case analysis is an investigation of a medical plight or case. When you present your findings, you have to balance the description of the situation and the detailing of the analyses. You have to illustrate how and why you came to a conclusion by providing the necessary background information.

How do you write a case history of a patient?

III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•

What is physical examination in a case study?

Physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history and pathophysiology.

How do you present a case of general physical examination?

0:194:24How to present examination findings | askCamDoc | Lessons - YouTubeYouTubeStart of suggested clipEnd of suggested clipYou might comment on any nail findings and he find it in the palm. Any findings on the arm his pulseMoreYou might comment on any nail findings and he find it in the palm. Any findings on the arm his pulse rate blood pressure any findings in the neck the face and the chest or the precordial.

How do you write a physical assessment?

WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you're performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you'd inspect, auscultate, percuss, then palpate an abdomen.

How do you write a case study?

5 key steps for writing your case studyIntroduce the customer. Set the stage for your case study with an introduction. ... State the problem. Every product or service is a solution to a problem. ... Introduce your product. This is where you begin solving the problem. ... Show results. The big reveal. ... Prove it.

How do you write a case presentation?

SUMMARYSET THE STAGE.PROVIDE ONLY INITIAL CUES AT FIRST.ASK FOR HYPOTHESES AND WRITE THEM UP ON THE BLACKBOARD.ALLOW THE AUDIENCE TO ASK FOR INFORMATION.HAVE THE AUDIENCE RE-FORMULATE THEIR LIST OF HYPOTHESES.FACILITATE A DISCUSSION ABOUT REASONING.ALLOW ANOTHER ROUND OF INFORMATION SEEKING.More items...

How do you introduce a patient in a case study?

First, we describe the complaint that brought the patient to us. It is often useful to use the patient's own words. Next, we introduce the important information that we obtained from our history-taking. We don't need to include every detail – just the information that helped us to settle on our diagnosis.

What does a case report describe?

Listen to pronunciation. (kays reh-PORT) A detailed report of the diagnosis, treatment, and follow-up of an individual patient. Case reports also contain some demographic information about the patient (for example, age, gender, ethnic origin).

What are the five steps of patient assessment?

emergency call; determining scene safety, taking BSI precautions, noting the mechanism of injury or patient's nature of illness, determining the number of patients, and deciding what, if any additional resources are needed including Advanced Life Support.

What is assessment of patient?

Patient assessment commences with assessing the general appearance of the patient. Use observation to identify the general appearance of the patient which includes level of interaction, looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.

What is the purpose of physical examination?

A physical examination helps your PCP to determine the general status of your health. The exam also gives you a chance to talk to them about any ongoing pain or symptoms that you're experiencing or any other health concerns that you might have.

What is the purpose of a thorough assessment of a patient's head, eyes, ears, neck, and

A thorough assessment of a patients head, eyes, ears, neck, and throat can reveal a wealth of objective information that is useful in developing nursing diagnoses. Careful attention to the patient’s subjective information and objective information obtained during the assessment will contribute to positive outcomes.

How is the right ear examined?

The right ear is examined using an otoscope. The otoscope exam is performed on a child by gently pulling the auricle of the ear downward and backward (Jarvis, 2012). This process will move the acoustic meatus in line with the canal. The otoscope is held like a pen/pencil and the little finger is used as a fulcrum.

How old is Patient 2?

Patient two is a 51 year old female that reports fatigue, difficulty swallowing, increased sensitivity to cold, weight gain of twelve pounds in two months, and weakness over the past four months.

How old is the first patient in a syringe?

The first patient is a 2 year old female that presents with her mother. The mother reports the patient is fussy, unwilling to eat, has nasal drainage, and is tugging at her right ear.

What Is a Medical Examination Report?

First of all, what is a medical examination report? What does this do and why is this needed? To begin, a medical examination report also called as MER is a kind of document that is given to an individual or a patient. The patient or the individual then fills out a form that would give the physician ideas about the person.

How to Write a Medical Examination Report

Have you ever wondered how they would be writing a medical examination report? Where are they going to base their data from? If you are, here are some things to check out if you are curious as to how they write your medical report.

How is a medical examination report important?

A medical examination report helps by giving an idea of what the patient may be suffering. It is also a tool used by individuals to get a check up before getting hired for a job.

What is a medical examination report in simple terms?

A type of document that gives out the information of a patient. From their medical history to their current issue.

Who is in charge of doing the medical report?

The form has to be filled out by the patient. However the one doing the report would be the physician present during the medical examination.

Why is it necessary to have a medical examination report?

For those who seek jobs, this is one of the requirements. To be able to see if you are fit enough and have no illnesses whatsoever.

Can a medical examination report be used as an excuse?

For anyone who has been admitted for ailments, they often ask for a doctor’s note as evidence they have been here.

Simple Medical History

Once you have collected these medical data, you can record them as a pdf by using this medical history PDF template. In addition, you don't need to be worried about the safety of data, because our forms are HIPAA compliant.

Doctors Note

Validate the medical condition of the patient by giving them a Doctor's Note Template. This PDF template shows the medical diagnosis of the patient and medical treatment.

Patient Medical Record

Medical History Record PDF template lets you collect the patient's data such as personal information, contact information in an emergency case, general medical history. By using this sample, the doctor ensures the patient's better care and treatment.

Short Medical History

Medical History Record PDF template is mostly used in order to provide significant information about the health history, care requirements, and risk factors of the patient to doctors. It is for collecting data from the patients.

Veterinary Hospital Treatment Sheet

Veterinary Hospital Treatment Sheet helps both the hospital and pet owners in understanding and tracking a pet's treatment process. Just like any other hospitals, keeping patient's treatment records is necessary to monitor progress and make sure proper treatment is given.

COVID-19 Vaccine Administration Record

Keep track of patient vaccination records online. Secure with GDPR, CCPA, and optional HIPAA compliance. Download or print as PDFs. Free, easy-to-customize template.

Dental Health Record

The Dental Health Record Template is easy for patients to fill out and designed to get the doctor the most important information. Patients can fill out their information on a computer or tablet using our Dental Health Record Template.

What is a patient case study?

Writing Your Patient Case Study. Since patient case studies are generally descriptive, they are under the a phenomenological principle. This means that subjectivity is entertained and allowed in research design. The medical scenarios are open to the researcher’s interpretation and input of insights.

How do case studies make a difference in the medical arena?

Patient case studies make a difference in the medical arena by reporting clinical interactions that can improve medical practices, suggest new health projects, as well as provide a new research direction. By looking at an event as it exists in the natural setting, case studies shed understanding on a complex medical phenomenon.

What is a case study?

Case studies are a qualitative research method that offers a complete and in-depth look into some of the situations that baffled medical science. They document the cases that escape the ordinary in a hospital that has seen a manifold of plights. They serve as cautionary tales of the intricacy in dealing with human health.

Why do medical practitioners use case studies?

Medical practitioners use case studies to examine a medical condition in the context of a research question. They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. The following are case study samples and guides on case presentation.

Can you generalize a population using one case study?

You cannot generalize a population using one case study. However, multiple case study contains two or more cases under the point of interest can give you a replicated result. When the findings remain true for several cases under this research method, your case study’s results become more reliable.

Should you look into all possible explanations for a medical condition?

You should look into all of the possible explanations for the medical condition at hand. If a plight can be explained by more than one reason , then you have to look into the less obvious but similarly compelling explanations. Make your case study as informative as possible.

Is a clinical interaction report valid for generalization?

Since it documents stand-out clinical interactions where a single person or a few number of people are a party of, the findings may not be valid for generalization for a wider population.