ÿþ40## ##||

1  ##Completed by##- Clear all -|- Clear -|Sr|nurse|Reyneke|Cook|Le Roux|Van Rensburg|Jacobs|Smiles|Langeveld|Engel|Sharon Elliott|Juanita van Eeden||

2  ##Surname##||

3  ##First name##||

4  ##D##- Clear all -|- Clear -|- Back -|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31||

5  ##M##- Clear all -|- Clear -|- Back -|1|2|3|4|5|6|7|8|9|10|11|12||

6  ##y##- Clear all -|- Clear -|- Back -|0|1|2|3|4|5|6|7|8|9||

7  ##Weight [Kg]##- Clear all -|- Clear -|- Back -|10|11|12|13|14|15|0|1|2|3|4|5|6|7|8|9|.||

8  ##Length [cm]##- Clear all -|- Clear -|- Back -|15|16|17|18|19|0|1|2|3|4|5|6|7|8|9|.||

9  ##T°[°C]##- Clear all -|- Clear -|- Back -|36.|37.|38.|39.|40.|0|1|2|3|4|5|6|7|8|9|subN||

10 ##Resp. rate [/min]##- Clear all -|- Clear -|- Back -|10|12|14|16|18|20|22|24|26|28|30|32|34|36|38|40||

11 ##Systolic BP [mmHg]##- Clear all -|- Clear -|- Back -|<50|50|60|70|80|90|100|105|110|115|120|125|130|135|140|145|150|155|160|165|170|175|180||

12 ##Diastolic BP [mmHg]##- Clear all -|- Clear -|- Back -|<20|<50|50|55|60|65|70|75|80|85|90|95|100|105|110|115|120||

13 ##Pulse [/min]##- Clear all -|- Clear -|- Back -|<40|40|45|50|55|60|65|70|75|80|85|90|95|100|105|110|115|120|125|130|135|140|145|150|155|160|165|170|175|180|190|200|>200||

14 ##O2 Sat [%]##- Clear all -|- Clear -|- Back -|100|99|98|97|96|95|94|93|92|91|90|89|88|87|86|85|84|83|82|81|80|<80|<75|<70|<60||

15 ##Age##||

16 ##General##- Clear all -|- Clear -|- Back -|<==|, |none|¢6¢JACCOL|jaundice|anaemia|cyanotic|clubbing|peripheral oedema|splinter bleedings|Du Puytron contractures|present|absent|and|neglected|high mileage|fit and healthy|obese|not|acutely|chronically|sick|stressed|apathetic|weakened|¢14¢lymphadenopathy((1))|lymphadenopathy|general|with|spleenomegaly|without|inguinal|axillary|cervical|supra-clavicular|Virchow-Trossier gland|Present|ant|Post|neck triangle|¢5¢grade|Grade|1+|2+|3+|4+|normal|Weak|cathetic|unexplained weight loss|dehydrated|Pyrexial|sweaty|drowsy|pale|rigors|ischaemic ear lobes||

17 ##Habits##- Clear all -|- Clear -|- Back -|<==|, |and|plerotic|obese|severe|cachectic|unexplained weight loss|anorexic|skinny|athletic|Downs syndrome|Achondroplasia|anasarca||

18 ##Muscular##- Clear all -|- Clear -|- Back -|<==|, |general|muscular atrophy|localised to|arms|legs/lower legs|muscle power|normal|well maintained|diminished|improved|weakened|L |R |flexion|extention|¢21¢gr|gr|5|4|3|2|1|.5|/5|flexion|extention|R |L |fingers|wrist|elbow|shoulder|abd.|add|ankle|knee|hip|and|small hand muscles|suggestive of|congenital myopathy|Charcot-Marie-Tooth disease|wasting|atrophy||

19 ##Skin##- Clear all -|- Clear -|- Back -|<==|, |rash|pressure sores|present|absent|signs of|none|with|without|multiple|spread|single|birth mark on(haemangioma)|(hyperpigmented)|¢34¢type|erythema|papular|papulary|maculopapular|erythematous|nodular|acne|vesicles|bullae|psoriatic|keloid|insect|bite marks on|cellulitis|abscess|Heberden nodules|gout nodules|itchy|offensive|wound sepsis|pussy|lacerations|wounds|scrape marks|scratches|stab wounds|wounds|pale|purple|striae|stretch marks|hunch back|suggestive of Cushings|skin atrophy|¢27¢position|localised|skinny|L |R |lower leg|foot|scattered|lower body|chest|abdomen|back|upper|lower|limb|below breasts|groin|face|palms & soles|lower back|ant.|post|lat.|ant abdominal wall suggestive of|perineal|genital|intergluteal fold|ischio-rectal|¢11¢Infectious|H. Zoster|rash|scars|cellulitis((2))|abscess((2))|wound sepsis((2))|tinea infection|Candidiasis of|Kaposi's sarcoma|Staphillococcal|Anaerob|¢8¢auto-immun|angioneurotic oedema|Stevens Johnson syndrome|cloasma face|vitiligo|Discoid Lupus of face|typical butterfly rash|area of face suggestive of SLE|heliotropic discoloration of upper eyelids|erythema nodosum|¢27¢Scars|scars of|typical scars|umbilical|inguinal|hernia repair|appendisectomy|'Bikini' scar of|caeserian section|surgery|midline|Laporoscopic procedures|upper abdomen|lower abdomen|midline laporotomy|transverse|hip replacement|knee replacement|Lumbar|thoracic|thoraco-lumbar|median sternotomy|thoracotomy|craniotomy|mastectomy|breast prosthesis|breast reduction|procedure|¢9¢Haemorrh|petechiae|echymosis|purpurra|picture suggestive of|general|bleeding tendency|long term steroids|wound haematoma|haematoma|¢1¢Endocrine|Diabetic|¢6¢Burns|Burns|Grade|Gr1|Gr2|Gr3|¢11¢Percentage|1|2|3|4|5|6|7|8|9|0|% of body surface area|neurofibromatosis|generalised neurofibromata|cafè au lait marks|tatoos on|belly button||

20 ##ECG##- Clear all -|- Clear -|- Back -|<==|, |Normal sinus rhythm|irregular heart rate due to|AF|extrasystolies|atrial|ventricular|atrial and ventricular|extrasystolies present|inf.|Anteroseptal|Anterolat.|wide ant|post|MI|Ischaemia|Pacemaker|rhythm|'dying heart'complexes|electro mechanical dissociation|present.|L-|R-|Axis deviation| = °|normal repolarisation|no ST segment changes|non-spesific|ST segment|T-wave|changes.|¢11¢Known|known with|congestive|Post partum|Post viral|Ishaemic|cardiomyopathy|Rheumatic heart disease|cong. heart disease|basal sinus bradycardia|longstanding arythmia|Dextrocardia|¢10¢Block|prolonged PR-time= Gr1 AV-block|2° AV-Block|Gr3 AVB|complete|heartblock|incomplete|RBBB|wide complexes due to|LBBB|LAHB|¢14¢E-ECG|Effort ECG|normal|no symptoms or signs of ischaemia demonstrated|to a heart rate of  /min.|ST-segment depression demonstrated suggestive of |short runs of VT demonstrated|Angina occured during exercise.|claudication of calf R/L elicited|multifocal VES's present during/after exercise|unreliable to assess ischaemia due to LBBB|Suboptimal tests due to|claudication|dyspnoae|weakness|arthritis|¢19¢Numbers|1|2|3|4|5|6|7|8|9|0|10|11|12|13|14|15|16|17|18||

21 ##Thyroid##- Clear all -|- Clear -|- Back -|<==|, |not palpable|size|normal|enlarged|mass lesion|L |R |lobe|isthmus|murmour|multi-nodular|nodule|dominant|tender|with|without|associated signs of clinical hyperthyroidism|a clinical picture suggestive of hypothyroidism.||

22 ##Lymphadenopathy ##- Clear all -|- Clear -|- Back -|<==|, |general|adenopathy|submandibular|L |R |ant|post|neck triangle|¢11¢Numbers|1|2|3|4|5|6|7|8|9|0|10|cm diam|retroauricular|cervical|supraclavicular|submandibular|lymph nodes|inguinal|axillary|fixated|mobile|tender|Virchow Trossier gland|presenting as a Pancoast tumour|present||

23 ##Breasts##- Clear all -|- Back -|<==|,|palpatation|normal|mobile|fixated|mass lesion|upper|lower|L |R |quadrant|bilateral|erythema|tenderness|suggestive of|congestion|fibro-adenosis|cysts|carcinoma|previous|mastectomy|gynecomastia|galactorrhoea|breast prosthesis|breast reduction|abscess|scar|bloody|nipple discharge||   

24 ##Skeletal##- Clear all -|- Clear -|- Back -|<==|, |Du Puytron's contracture|tenderness over|deformities of|suggestive of|¢14¢Back|spine|paraspinal|L |R |kyphosis|lordosis|scoliosis|cervical|thoracic|Lumbar|thoraco-lumbar|lumbo-sacral|vertebrae|kidney triangle|¢16¢Joint|small hand|IP|MP|pulse|elbow|shoulder|acromio-clavicular|sterno-clavicular|hip|knee|ankle|sacro-iliac|calcaneus spur|coccyx|joint|R |L |painful|tenderness and swelling over|ribs|costo-condral junctions|sternal|on movement|at rest|flexion|active|passive|warm|erythema|acute|gout|big toe MP-joint|gout tophi|bursa|rheumatoid nodules on|typical rheumatoid deformities|Heberden nodules|present|absent|Du Puytron contracture|signs of|osteo-arthritis|rheumatoid arthritis||

25 ##Nasopharynx##- Clear all -|- Clear -|- Back -|<==|, |post nasal drip|pharyngitis|present|absent|tonsillitis|peritonsillar abscess|post pharyngeal border|erythematous|tonsils|hypertrophic|purulent|petechiae|poor oral hygiene|severe|minute changes|cavities|Candidiasis|Herpes simplex|aphteous ulcers|lips|dental abcesses||

26 ##EARS##- Clear all -|- Clear -|- Back -|<==|,|normal|fluid|external ear canal|full of wax|normal|erythmatous|retro tympanic collection|not seen|pussy discharge|R |L |deafness|tenderness over mastoid|chronic otitis media|perforation|tympanum||

27 ##Psychiatric##- Clear all -|- Clear -|- Back -|<==|, |normal|calm|agitated|anxious|depressed|aggressive|hysterical|manic|bipolar|catatonic|(auditory)|(visual)|hallucinations|disorientated|re|time|place|known with|manic-depression|psychosis|schizophrenic|personality change|post traumatic stress syndrome|tendency to|psycho-somatic bahavioural episodes|temper tantrums|mainly due to alcohol consumption||

28 ##Cranial nerves##- Clear all -|- Clear -|- Back -|<==|, |and|normal|diminished|outspoken|subtle|¢25¢CrN1-6|smell|hearing|deaf|sight|blind|poor vision|short sighted|far sighted|eye movements|tunnel vision after|visual fields|nasal|temporal|sup.|inf.|CrN V6(Rect ext)|CrN4(sup obl)|bilateral|homoniem|hemianopy|ptosis|Pupil|midriasis|miosis|CrN3 paralysis|R |L |¢18¢CrN7-12|UMN|LMN|CrN V11|CrN V|frontal dev|ophtalmic dev|maxillary dev|sensation|soft palate|normal movement|deviation|glossopharyngeal n.:|choke on swallowing|nasal regurgitation when swallowing|hypoglossal n.:|tongue against cheek|rapid tongue movements|accesory n.|symmetrical|Bell's palsy||

29 ##Tone##- Clear all -|- Clear -|- Back -|<==|, |normal|hypertonic|hypotonic|flaccid|residual to previous|clonus|R |L |ankle|knee|hemi|arm|leg|lead pipe|rigidity|tremors|terminal|outspoken|neck stiffness|present|absent|Babinski response|restricted neck movements|symmetrical|grip|Kernig's sign|Brudzinski's sign||

30 ##Strength##- Clear all -|- Clear -|<==|- Back -|, |muscle power intact|diminished|leg|arm|on the|L |R |paralysis|normal|asymmetrical|flaccid|¢21¢Gr|Gr|5|4|3|2|1|.5|/5|flexion|extention|R |L |fingers|wrist|elbow|shoulder|abd.|add|ankle|knee|hip||

31 ##Reflexes##- Clear all -|- Clear -|- Back -|<==|, |reflexes|normal|and|symmetrically equal|knee|ankle|biceps|triceps|supinator|reflex|reduced|intact|hyper reflexia|absent|unilateral|brisk, but symmetrically equal.|¢6¢Bab.|Plantar reflex(Babinski)|upgoiing|neutral|down|R |L |¢6¢Superficial Refl|Abdominal|reflex|perianal|cremaster|absent|present||

32 ##Co-ordination##- Clear all -|- Clear -|- Back -|<==|, |delicate finger movements|R |L |normal|abnormal|awkward|dysmetric|intention tremor|finger-nose test|heel-knee test|disdiadocokinesis|gait|stable|unstable|generally|impaired balance|rombergism|present|absent|tandem gait|cerebellar|gait|suggestive of|peripheral neuropathy||

33 ##Sensation##- Clear all -|- Clear -|- Back -|<==|, |normal|maintain|absent|reduced|hypo-esthesia|hyperesthesia|glove & stocking distribution|to the level of|distal|mid|proximal|lowerleg|¢15¢Dermatoma|in the distribution of|dermatoma|C|T|L|1|2|3|4|5|6|7|8|9|0|sensory level|absent|present|sphincter function|narrowing|normal|vibration|prolapse|arm|leg|L |R |foot|symmetrical|Vibration sense|Proprioseption|diminished|intact|big toe|¢11¢Amount|=|0|1|2|3|4|5|6|7|8|9|sec.|Lat maleolus||

34 ##Skin colour##- Clear all -|- Clear -|- Back -|<==|, |pale|cyanotic|phletoric|central|peripheral|normal|mucous membranes|jaundice|pre|gangrenous|spider angiomata|present|birth marks|cutaneous hemangioma|solar keratosis|suggestive of|squamous cell|basal cell|carcinoma|suspicious naevus|melanoma||

35 ##Oedema##- Clear all -|- Clear -|- Back -|<==|, |absent|ankle oedema|¢4¢Amount|1+|2+|3+|4+|unilateral|L |R |in sock distribution|at knee level|at thigh level|presacral|pitting oedema|present|symmetrical|bilateral|anasarca|severe|fluid exudation from legs|swollen hands and feet||

36 ##Jugular veins##- Clear all -|- Clear -|- Back -|<==|, |JVP|congested|not visualised|raised|to mid-neck|canon waves|CVP= |JVP raised = __ cmH2O in 45ºposition|¢7¢Number|1|2|3|4|5|6|to angle of jaw|hepato-jugular reflux|present|absent|normal||

37 ##Veins##- Clear all -|- Clear -|- Back -|<==|, |dilated|delicate|varicose veins|present|bilateral|symmetrical|R |L |lower leg|with|without|chronic|stasis|ulcer|varicose veins|important|thrombosis|normal|negative|Homan's sign|positive|suggestive of DVT|phlebitis|tender|girth= cm|thigh|calf|L |R |nil||

38 ##Pulses##- Clear all -|- Clear -|- Back -|<==|, |all pulses present & normal|claudication distance =_ meter|¢10¢Number|1|2|3|4|5|6|7|8|9|0|¢9¢pulses|carotid|radial|cubital|femoral|popliteal|posterior tibialis|pulse|dorsalis pedis|foot pulses|present|absent|slow|strong|abdominal aortic|aneurismal|prominent pulsation,?ectatic,?aneurysmal|carotid|++/++|+/+|++/+|+/++|+/0|0/+|"thready"|cappill filling < 3sec||

39 ##Murmurs##- Clear all -|- Clear -|- Back -|<==|, |carotid|L |R |bilateral|femoral|abdominal aorta|over renal arteries|over fistula|nil|murmur|present|absent||
	
40 ##SBP [mmHg]##- Back -|- Clear all -|- Clear -|0|<50|<60|<70|70|80|90|95|100|105|110|115|120|125|130|135|140|145|150|155|160|165|170|175|180|190|200|210|220|230|240|>250||

41 ##DBP [mmHg]##- Back -|- Clear all -|- Clear -|0|<30|30|40|50|55|60|65|70|75|80|85|90|95|100|105|110|115|120|130|140|150|>150||

42 ##Pulse rate [/min]##- Clear all -|- Clear -|- Back -|<40|40|45|50|55|60|65|70|75|80|85|90|95|100|105|110|115|120|130|140|150|160|170|180|190|200|>200||

43 ##Rhythm##- Clear all -|- Clear -|- Back -|<==|, |normal|regular|3rd|4th|heart sound|gallop rhythm|irregular|extra systoles|tachycardia|bradycardia|AF|present|absent||
	
44 ##Apex beat##- Clear all -|- Clear -|- Back -|<==|, |normal|displaced|to the 6th intercostal space|in|beyond|the L midclavicular line|not palpable|diffuse|vibration|present|absent|apex beat|heaving|parasternal heaving||
	
45 ##Heart Ausculta.##- Clear all -|- Clear -|- Back -|<==|, |systolic|diastolic|functional|murmur|rumble|suggestive of|¢8¢Degree|Gr|1|2|3|4|5|/6|/4|radiating to|carotids|axilla|localised|apex|L parasternal|gallop|no murmur|normal S1+S2|pericardial rub|present|absent|pulmonary|carotid|mitral|tricuspid|area|nil|loudest at|apex|axilla|L-parasternal|over aortic outflow tract|radiates to|carotids|L axilla|accentuated by|inspiration|expiration|¢17¢Cause|suggestive of|rheumatic|congenital|heart disease|MI|and|MS|AI|AS|TI|VSD|mixed valvular disease|aortic sclerosis|mitral valve|prolapse /Barlow's syndrome|papular muscle dysfunction||

46 ##Respiratory rate [/min]##- Clear all -|- Clear -|- Back -|0|10|12|14|16|18|20|22|24|26|28|30|32|34|36|38|40|>40||

47 ##O2 Sat [%] ##- Clear all -|- Clear -|- Back -|100|99|98|97|96|95|94|93|92|91|90|89|88|87|86|85|80|75|70|<70|<60||

48 ##Peak flow [L/min]##- Clear all -|- Clear -|- Back -|.|0|1|2|3|4|5|6|7|8|9||
	
49 ##Sputum##- Clear all -|- Clear -|- Back -|<==|, |no sputum|dry|cough|infected|with|loose cough|haemoptysis|purulent|yellow|green|offensive|sputum|chronic cough|large|small|volumes|present|absent||

50 ##Resp auscultation##- Clear all -|- Clear -|- Back -|<==|, |air entry|normal|diminished|R |L |symmetrical|ronchi|crepitations|scattered|localised|post. basal|bilateral|fine|coarse|prolonged expiration|inspiration|and|expiration|wheezing|diminished air entry|bronchial breathing suggestive of consolidation|stridor|pleural rub|whispering pecteriloque|bronchial breathing|present|absent|typical picture of chronic bronchitis & emphysema|trachea|central|deviated to|L |R ||

51 ##Percussion##- Clear all -|- Clear -|- Back -|<==|, |dullness|symmetrical|unilateral|over the|right|left|base|total lungfield||

52 ##Inspection##- Clear all -|- Clear -|- Back -|<==|, |scar|from previous|laporotomy|gastrectomy|hemicolectomy|bowel surgery|colostomy|splenectomy|nephrectomy|pancreatic surgery|Whipples|abd. aortic|aneurysmectomy|bifemoral bypass|laporoscopic|cholecystectomy|appendisectomy|inguinal|umbilical|epigastric|hiatal|femoral|hernia repair|hernia|present|hernial ports intact|hysterectomy|caesarian sect.|stretch marks|striae|purple|pale|ascites|distended abdomen|distended veins on abdomenal wall||

53 ##Auscultation##- Clear all -|- Clear -|- Back -|<==|, |normal|increased|diminished|bowel sounds|ileus sounds|present|absent|murmur over the|abdominal aorta|renal artery|L |R ||
	
54 ##Palpation##- Clear all -|- Clear -|- Back -|<==|, |normal|no exeptional|tenderness|none|signs of adhesions|palpable mass|tender|firm|mobile|soft|localised|R |L |flank|epigastric|hypochondrium|inguinal|suprapubic|RBK|LBK|retro-umbilical|right sided|left sided|negative|positive|psoas sign|Murphy's sign|pain localised to|colon distribution|¢13¢Pain due to|pain|suggestive of|spastic colon syndrome|pancreatitis|bowel obstruction|obstructive jaundice|cholesystitis|appendicitis|diverticulitis|salpingitis|cystitis|pyelonephritis|renal stones||
		
55 ##Bowel sounds##- Clear all -|- Clear -|- Back -|<==|, |bowel sounds|absent|ileus sounds|murmur|present|over|Abd aorta|L |R |renal art||
	
56 ##Liver##- Clear all -|- Clear -|- Back -|<==|, |not palpable.|at the border of the rib cage|hepatomegaly|with|without|accompanied|splenomegaly|massive|hard|soft|tender|nodular|smooth|border|¢9¢cm|1|2|3|4|5|6|8|>10|cm||
		
57 ##Rectal examination##- Clear all -|- Clear -|- Back -|<==|, |normal, also the prostate|rectal examination|not done|recently done|was|normal|benign|malignancy|suspicious of malignancy|¢8¢Prostate|prostate|normal|moderately|severely|enlarged|feels benign|hard, ?malignant|tender|not tender|severe tenderness|mass palpable|empty|stool colour|normal|stool soft, normal.|brown|normal|bleeding, fresh.|black|melaena|normal rectal tone|painful|haemorrhoids|fistula|ischio-rectal abscess|present|peri-anal skin folds||

58 ##Complete examination##- Clear all -|- Clear -|- Back -|<==|, |pussy|wound|deformity|erythema|heat|echymosis|mobile|not tender|tender|fluctuating weight|palpatation||
	
59 ##Referred by##- Clear all -|- Clear -|¢21¢Loc GP's|Cathy Parsons|Franscois Vorster|Marlie Stols|Teresa de Wet|Johan Immelman|Lise-Marie Steenkamp|Colin Portnoi|Clive Holroyd|James Stander|Neels Booyens|Willem Pretorius|Joe van Vreede|Dr Bavasah|Peter Osman|Deon van Tonder|Hein van Wyk|Hennie Spangenberg|Judie Snyman|Pieter Groenewald|Chris Venter|Manie Kritzinger|¢22¢Regional GP's|Gert Kuhn|Louise van Niekerk|Eben Van Rensburg|JanJob Steenkamp|Louis Conradie|Pieter Fischer|Vossie Vorster|Kobus Haarhof|Andries Grobbelaar|Henk Kruger|Claudette Janse van Vuuren|Christene Botha|Hein Scheepers|Deon Smith|Conrad van Heerden|Waltie Vermeulen|Pieter Slazus|Gert Myburgh|Koos Coetzee|Chris van Zyl|Dawid Calitz|Ian vd Merwe|¢17¢Specialists|Neil Potgieter|Willem Reyneke|Obie Jackson|Gerrie Engelbrecht|Jaco Maartins|Cobus Fourie|Kobus van Niekerk|Lourens de Villiers|Johan Meyer|Dr Maqbool|Haroon Amin|Johan Strauss|Elise Fourie|Zac van Wyk|Chrisbotha Laubscher|Salome Pretorius||

60 ##Treated by## J Mynhardt|&|W Reyneke|C-B Laubscher|A Wonner|L De Villiers|C van Niekerk|C Fourie|N Potgieter|N Weston|J Meyer|H Amin|Dr Maqbool|E Fourie|O Jackson|G Engelbrecht|J Maartens||

61 ##Main complaint##- Clear all -|- Clear -|<-|, |. |history.|typical|suggestive of|direction|of|Known with , now with .|severe|not applicable|weight|loss|gain|recent onset|long standing|tiredness|decreased|general condition|since|¢10¢Pain|chest pain|Headache|Low pressure headache post LP.|Abdominal pain|Backache|Joint pains|pain on swallowing|Toothache|colic pain|Localised pain over|¢9¢Quality|pressing|burning|cramping|stabbing|dull|continous|intermittend|localised|spreading to|¢22¢Duration|x|1|/|52|12|2|3|4|5|6|7|8|9|0|seconds|minutes|hours|days|weeks|months|years|¢13¢Infective|pyrexia|cough|dehydration|rigors|Acute on Chronic bronchitis and empysema|cystitis|pyelonephritis|pneumonia|sinusitus|Meningitis|encephalitis|meningo-encephalitis|H Zoster: |¢13¢Cardiology|dyspnoea|orthopnoea|ankle oedema|angina|atypical|pleuritic|chest pain|palpatations|syncopy|¢8¢AtypCP due to|atypical chest pain|due to|dyspepsia|costo-chondritis/Tietze's syndr|Bornholm's disease|Oesophageal spasm|G-O reflux|congest. Heart failure|¢28¢Respiratory|cough|dyspnoea|orthopnoea|ankle oedema|productive|tachypnoea|pleuritic pain|haemoptysis|sputum|white|yellow|green|dry|infected|offensive|bronchial|aspiration|pneumonia|pleural effusion|PTB|mesothelioma|Bronchus carcinoma|Pulmonary embolism|Pneumoconiosis|Intersticial|post tuberculous|fibrosis|bronchiectasis|¢20¢Abdominal|vomiting|anorexia|abdominal pain|gastritis|peptic ulcer|oesophageal spasm|dyspepsia|heartburn|nocturnal|gastro-oesophageal reflux|Spastic colon syndrome|haematemasis|melaena|fresh|old|rectal bleeding|haemorrhoids|Gastro-enteritis|Crohn's disease|Ulcerative colitis|¢20¢G-U|UTI|haematuria|glomerulonephritis|nephrosis|acute|chronic|kidney failure|acute tubular necrosis|pre renal|due to dehydration|Polycystic kidney disease|HIV|hypertensive|diabetic|interstitial|analgesic|nephropathy|prostatism|renal stone|colic|¢23¢CNS|chronic headache|migraine|analgesic abuse|due to|stress/ depression connotation|syncopy|raised intracranial pressure|Pseudo tumour cerebri|viral|septic|meningitis|encephalitis|meningo encephalitis|MS|Guillain-Barre syndrome|cerebro vascular accident|TIA|L |R |hemi|Bell's palsy|Meniere's syndrome|vertigo|¢10¢Epilepsy|Grand mal|Petit mal|Temporal lobe|hypoglycaemic|'Rum fits'|post|traumatic|infective|epilepsy|hereditary|¢29¢Psyc|manic|depressed|psychosis|anxiety|phobia|hysteria|diverse|psycho-somatic symptoms|analgesics|bensodiazepines|ethanol|drug|abuse|disturbed sleeping pattern|domestic|financial|stress|working conditions|aggression|temper tantrums|abuser|intoxicated|psycotic|post traumatic stress syndrome|hearing|visual|hallusinations|confusion|disorientation|¢12¢Endocr|symptoms suggestive of|Diabetes|Hyperthyroidism|Hypothyroidism|Cushings|Addisons|hot flushes|menopause|pheochromocytoma|carcinoid syndrome|hyperparathyroidism|Mucoviscoidosis|¢33¢Trauma|fracture of|R |L |lacerations of|bruises|scrape marks|fall|wounds of|head|arm|lower arm|hand|hip|leg|knee|ankle|tib-fib fracture|clavicle|base of skull|vertebra|cervical|thoracic|lumbar|lumbosacral|foot|left|right|comatose|Glasgow scale /15|para|quadri|plegic|paretic|¢15¢Musc-skelet|osteo-|rheumatoid|gout|post traumatic|arthritis|post viral|myalgia|proximal|muscle|weakness|spasm|cramps|nocturnal|auto-immune disease|hypokalaemia||
		
62 ##History. of current problem##- Clear all -|- Clear -|- Space -|<-|- Back -|, |. |known with|now has|sudden onset:|history|of|commenced on|pain|since|Problem began|typical of|indicative of|severe|not applicable|weight|weight loss|weight increase|recent onset|longstanding|reduced|general condition|since|suggestive of|¢12¢Sensation|burning|stabbing|pulsating|pressure|dull|cramping|intense|non-|pleuritic|dyspeptic|sensation|shortness of breath|¢9¢Pain|chest pain|headache|abdominal pain|backache|joint pain|dysphagia|Toothache|colic|Local pain over|¢20¢Duration|x|1|/|2|3|4|5|6|7|8|9|0|seconds|minutes|hours|days|weeks|months|years|ago|¢8¢Radiation|radiates to|back|L |R |arm|leg|throat|upper abdomen|¢9¢Nature|pressing|burning|cramplike|stabbing|dull|continous|intermittent|localised|spread to|¢12¢Infective|pyrexial|cough|dehydration|rigors|Acute on Chron bronchitis and emphysema|cystitis|pyelonephritis|pneumonia|sinusitus|Meningitis|encephalitis|meningo-encephalitis|¢9¢Cardiology|angina|dyspnoea|orthopnea|PND|ankleloedema|atypical|pleuritic|chest pain|congest.heart failure|¢6¢Atyp chest pain due to|due to|dyspepsia|costo-chondritis/Tietze syndr|Bornholm's disease|oesophageal spasm|G-O reflux|¢26¢Respiratory|COAD|aspiration|atypical|TB|pneumonia|bronchopneumonia|bronchitis|due to|GE-reflux|cough|dyspnoea|productive|tachypnea|pleuritic pain|haemoptysis|sputum|white|yellow|green|dry|infected|offensive|broncho|aspiration|pneumonia|pleural effusion|PTB|mesothelioma|Bronchus carcinoma|Pulmonary embolism|Pneumoconiosis|Interstitial|post tuberculous|fibrosis|bronchiectasis|¢20¢Abdominal|vomiting|anorexia|abdominal pain|gastritis|peptic ulcer|oesophageal spasm|dyspepsia|heartburn|nocturnal|gastro-oesophageal reflux|Spastic colon syndrome|haematemesis|maelena|fresh|old|rectal bleeding|haemorrhoids|Gastro-enteritis|Crohn's disease|Ulcerative colitis|¢20¢G-U|UTI|hematuria|glomerulo nephritis|nephrosis|acute|chronic|kidney failure|acute tubular necrosis|pre renal|due to dehydration|Polycystic kidney disease|HIV|hypertensive|diabetic|interstitial|analgesic|nephropathy|prostatism|renal stone|colic|¢21¢CNS|chronic headache|migraine|analgesic abuse|stress/ depression connotation|syncopy|raised intra cranial pressure|Pseudo tumour cerebri|low pressure headache|viral|septic|meningitis|encephalitis|meningo encephalitis|MS|Guillain-Barre syndrome|cerebro vascular accident|TIA|L |R |hemi|Bell's palsy|¢10¢Epilepsy|Grand mal|Petit mal|Temporal lobe|hypoglycaemic|'Rum fits'|post|traumatic|infectuous|epilepsy|hereditory|¢30¢Psycho|manic|depressive|psychosis|anxiety|phobia|hysteria|continuous|psycho-somatic symptoms|analgesic|bensodiazepine|ethanol|drug|abuse|disturbed sleeping pattern|late night sleeping disturbance|domestic|financial|stress|at the work place|aggression|uncontrolable rage|abuser of women|when intoxicated|psycopath|post traumatic stress syndrome|hearing|visual|hallucinations|confused|disorientated|¢12¢Endocr|symptoms suggestive of|Diabetes|Hyperthyroidism|Hypothyroidism|Cushings|Addisons|hot flushes|menopause|pheochromocytoma|carcinoid syndrome|hyperparathyroidism|Mucoviscoidosis|¢15¢Musc-skelet|osteo-|rheumatoid|gout|post traumatic|arthritis|post viral|myalgia|proximal|muscle|weakness|spasm|cramps|nocturnal|auto-immune disease|hypokalaemia|¢32¢Trauma|fracture of|R |L |lacerations of|bruises|fall|wounds on|head|arm|lower arm|hand|hip|leg|knee|ankle|tib-fib fracture|clavicle|base of skull|cervical|thoracic|lumbar|lumbosacral|vertebrae|foot|left|right|comatose|Glasgow coma scale /15|para|quadri|plegic|paretic||

63 ##Previous medical history.##- Clear all -|- Clear -|<==|, |& |nil of note|no significant previous|illnesses|or|operations|known with|Porphyria|injury due to|falling|MVA|¢28¢CVS|HT|hypercholesterolaemia|angina|Myocardial infarction|Ischaemic|rheumatic|hypertensive|heart disease|coronary bypass|coronary stent procedure|congest heart failure|AF|arrythmia|postural hypotension|stroke|L |R |hemi|TIA|CVA|paresis|plegia|Arterial insufficiency|with claudication|Aortic-femoral bypass|Abd Aorta aneurysmectomy|DVT|Pulmonary embolism|¢6¢Resp|COAD|Cor pulmonale|lung|fibrosis|restrictive lung disease|Asthma|¢6¢Abd|kidney stone|reduced kidney function|polycystic kidney's|liver cirrhosis|Spastic colon syndrome|diverticulitis|¢7¢Endocr.|type 1|type 2|diabetes|hyperthyroidism|hypothyroidsm|Cushings|pheochromocytoma|¢26¢Skelet.|gout|Rheumatoid|osteo|artritis|osteoporosis|spondylosis|spondylitis|psoriatic|ankylosing|fractured: |R |L |arm|fore arm|Colles|hand|hip|femur|femurneck|knee|ankle|tib-fib|clavicle|base of scull|vertebrae|compression|¢6¢Psycho|depression|para-suicidal attempts|post traumatic stress syndrome|ethanol abuse|hysteria|psycho somatic problems|¢15¢Infect|PTB|H.Zoster|HIV|Hep.B|Hep|Brucellosis|H.pilori gastritis|malaria|Bilharzia|Tick bite fever|sinusitis|Cryptococcal meningitis|cerebral Toxoplasmosis|Candidiasis|atypical pneumonia (Pneumocystus)|¢30¢Tumours|benign|malignant|mass|lipoma|sebacious cysts|basal cell carcinoma|solar keratosis|squamous cell carcinoma|breast|cervix|bronchus|oesophagus|stomach|colon|rectum|prostate|thyroid|pancreas|renal cell|hepatoma|carcinoma|melanoma|Non-|Hodgkins|lymphoma|leucaemia|AML|CML|CLL|Myelo-dysplastic syndrome|¢39¢Surg|Appendisectomy|Tonsillectomy|Cholecystectomy|hysterectomy|with|without|BSO|sterilisation|caesarian sect x1|Gastrectomy|Hemicolectomy|Hiatal hernia repair|laporotomy for|inguinal|umbilical|incisional|hernia repair|prostatectomy|L |R |nephrectomy|hydrocoel repair|orchidectomy|splenectomy|ischio-rectal|abscess drainage|amputation of|hip|knee|replacement|neck|lower back|procedure|fusion|laminectomy|pleurectomy|lobectomy|subtotal|thyroidectomy||
	
64 ##Medications##- Clear all -|- Space -|<==|- Clear -|- Back -|, |¢39¢Doses|1|1.5|2|2.5|5|7.5|10|15|20|25|50|75|100|250|500|750|1000|mcg|mg|g|ml|ivi|imi|sc|mane|nocte|1-0-0|0-0-1|1-0-1|1-1-1|q4h|q6h|q12h|¢10¢Number|1|2|3|4|5|6|7|8|9|0|units|before|with|after|meals|¢12¢cardiology (b)|Aspirin|Furosemide|Spironolactone|Digoxin|Ismo|Isordil|Amiodarone|Mexitil|Streptase|Actylase|Metalase|Dobutrex infusion|¢6¢Blood Dilution|Disprin CV|Ecotrin|Bayer Asperin Cardiac|Plavix|Clexan|Warfarin|¢14¢Diabetes|Metformin|Glucovance|Glycomin|Glyclazide|Diamicron MR|Novorapid|Novomix30|Actraphane|Humalog|Humulin Mix 25|Humulin Mix50|Humulin L|Lantus|Levimir|¢4¢Impot.|Viagra|Cialis|Levitra|Caverject|¢11¢Antibiotics|Augmentin|Amoxil|Klacid|Avelon|Ciprobay ((1))|Tavanic|Flagyl|Fucidin|Chloramphenicol|Urispas|Taravid |¢12¢Antibiotics ivi|Amoxicillin|Maxipim|Rocephin|Ciprobay|Avelon|Tienam|Invance|Merenem|Gentamycin|Amikacin|Ceftriaxone|Flagyl|¢9¢Anti-inflamm|Indomethacin|Celebrex|Coxflam|Mobic|Tilcotil ((1))|Salazopyrin|Methotrexate|Colchisine|Panafcort|¢7¢Analgesia (b)|Sosegon|Tramal|Pethidine|Morphine|Lentogesic caps|Stilpayne|Tylenol|¢9¢Anti-inflamm|Indometasien|Diclofenac|Coxflam|Mobic|Celebrex|Salazopyrin|Methotrexate|Panafcort|colchisine|¢8¢Antacid|Losec|Lansor|Lansoloc|Rosnal|Nexiam|Pantoloc|Controloc|Pariet|¢28¢HT|Tenbloca|Tenoretic|Ziak|Lisinopril|Lisinopril Co|Pharmapress|Pharmapress Co|Coversyl|Coversyl Plus|Prexum|Tritace|Diovan|Co-Diovan|Atacand|Atacand Plus|Co-Micardis|Triplen Forte|Ravamil|Adalat XL60|Zildem|Norvasc|Amloc|Pratsiol|Cardura|Brinerdin|Hypotone|Physiotens|Loniten|¢6¢Lipids|Simvastatin|Lipitor|Prava|Crestor|Bezalip R|Ezetrol|¢10¢Depression|Surmontil|Tydamine|Trepilene|Tofranil|Fluoxetine|Cipralex|Talomil|Efexor|Cymbalta|¢8¢Epilepsy|Epanutin|Tegretol|Epilim|Lamictin|Kepra|Valium|Sod-Gardinal|¢8¢HIV|Aspen Lamzid|3-TC|AZT|Stockrin|Kaletra|Purbac DS|Fluozol|Fungizone|¢1¢Virus|Zelitrex|¢6¢TB|Rifah For 2-1-2|INH|Streptomycin|PZA|Ethambutol|Ethionamide|¢6¢Topical|Lamisil|Travocort|Bactroban|Betadine|Voltaren gel|Scheriproct||

65 ##Family hist.##- Clear all -|- Clear -|- Back -|<==|, |: |brother|sister|father|mother|uncle|aunt|grandpa|grandma|family|suffers from|had|died from|and|¢6¢CVS|angina|infarction|ischaemic heart disease|stroke|hypertension|abdom. aortic aneurysm|diabetes|hereditory|hypercholesterolaemia|obesity|epilepsy|depression|psychosis|Myasthaenia gravis|auto immune disease|congenital problems|Perniscious anaemia|cong.spherocytosis|Porphyria|¢15¢Carcinoma|bronchial|stomach|colon|breast|renal cell|gynaecologic|cervix|endometrial|ovarian|pancreatic|carcinoma|brain tumour|lympho-|myelo-|proliferative disease.||
	
66 ##Risk Factors##- Clear all -|- Clear -|- Back -|<==|, |sedentary lifestyle,|diabetes,|Hypertension,|smoking,|obesity,|hypercholesterolaemia,|bad|family history of|Ischaemic heart disease,|stroke,|stress,||
	
67 ##Smoking hist.##- Clear all -|- Clear -|- Back -|, |never smoked|¢10¢Number|1|2|3|4|5|6|7|8|9|0|cigarettes|/day|/week|stopped|day|weeks|months|years|time period|pipe smoker| pipeloads /day||
	
68 ##Alcohol##- Clear all -|- Clear -|- Back -|, |never|seldom|¢10¢Number|1|2|3|4|5|6|7|8|9|0|beers|wine|dry wine|sweet wine|Magou|mixed alcohol consumption|any alcohol consumption|occasional|weekend drinker|stopped|whiskey|brandy|rum|cane|vodka|single|double|tots|glasses|bottles|/day|/week|/weekend|rehabilitated alcoholic.||
	
69 ##Allergies##- Clear all -|- Clear -|- Back -|<==|, |& |no allergies.|allergic to|Penicillin,|Sulpha's,|unknown|antibiotics|iodine,|contrast media,|opiates,|morphine|pethidine|Tramal|(suspicious)|ATT|asthma|hay fever|Bee sting,|types of food,|types of grains|nuts|seafood|iodine|contrast media|dairy products|known with extra-pyramidal symptoms due to|emetics|Maxolon|Stemetil|Haloperidol|previous drug reactions(not-allergy!) to|Scoline.|Allergic skin tests|RAST tests|positive for||

70 ##Social##- Clear all -|- Clear -|- Back -|<==|, |live alone|married|single|bed ridden|old age home occupant.|wheelchair patient|rehabilitated|alcoholic.|paraplegic.|quadriplegic.||

71 ##General##- Clear all -|- Clear -|- Back -|<==|, |good general health|pyrexial|not|acutely|chronically|toxicly|sick|cachectic|neglected|fit|obese|unsatisfactory progress|shocked|stuporous|comatous||
	
72 ##Cardiovascular##- Clear all -|- Clear -|- Back -|<==|, |dyspnoea|atypical|pleuritic|non-pleuritic|chest pain|suggestive of|¢7¢Atyp chest pain|atypical chest pain|due to|costo-chondritis/Tietze's syndrome|Bornholm's disease|Oesophageal spasm|G-O reflux|dyspepsia.|Palpatations|intermittant claudication|ankle oedema|¢4¢Grade|slight|1+|2+|3+|varicose veins|nocturia|orthopnea|angina|since|worsened|present.||
	
73 ##Respiratory##- Clear all -|- Clear -|- Back -|<==|, |& |cough|with|fever|pleuritic chest pain|¢6¢Connection|connection with|asthma|effort|ACE-inhibitor|post nasal drip|nocturnal G-O reflux|non productive|white|yellow|green|pussy|productive|with|without|accompanying haemoptysis|chronic|since|worsened|dyspnoea|diminished excercise tolerance,|¢6¢Gr|Gr 1|Gr 1-2|Gr 2|Gr 2-3|Gr 3|Gr 4|with minimal effort|with rest|sputum|asthma|bronchial spasm|bronchitis|COAD|pneumonia|broncho pneumonia|TB|bronchial Ca|mesothelioma||
	
74 ##GI##- Clear all -|- Clear -|- Back -|<==|, |problems with|heartburn|associated with certain food|with nocturnal G-O reflux|abdominal|¢9¢sensation|burning|stabbing|throbbing|pressure|dull|cramplike|intense|pain|sensation|epigastric|R |L |hypochondrium|inguinal|para|umbilical area|suprapubic|since|¢21¢Duration|x|1|/|52|12|2|3|4|5|6|7|8|9|0|seconds|minutes|hours|days|weeks|months|year|diarrhoea|nausea|maelena|dyspepsia|dysphagia||
	
75 ##GU##- Clear all -|- Clear -|- Back -|<==|, |dysuria|oliguria|nocturia|enuresis|hematuria|cloudy urine|suprapubic pain|urinary hesitation|since|symptoms of|renal stone|cystitis|pyelonephritis|prostatitis|impotence|erectile dysfunction|low libido|dyspareunia|urethral|vaginal|discharge|present.|menstrual irregularitory|¢11¢Renal Fail/ Nephrop.|acute|chron.|acute on chron.|Glomerulo-nephritis.|Nephrosis.|renal failure|ATN|obstructive|Diabetic|Hypertensive|analgesic|interstitial|Nephropathy.||
	 
76 ##Endocrine system##- Clear all -|- Clear -|- Back -|<==|, |previous RA-I2 for hyperthyroidism|signs|history|suggestive of|of|present|absent|since|hot flushes|purple striae|of breasts|previous|¢21¢Duration|x|1|/|52|12|2|3|4|5|6|7|8|9|0|seconds|minutes|hour|days|weeks|months|year|¢5¢Gluc|polydipsia|&- poly-uria|weight loss|reactive|hypoglycaemia|¢7¢Thyroid|fine tremor|anxiety|hot|cold|intolerance|weight loss|¢6¢Adrenal glands|palpatations|hunch back|acne|hypertension|tired|virilisation|¢10¢Gynaecol|menstrual irregularities|menorrhagia|metrorrhagia|menometrorrhagia|amenorrhoea|dysmenorrhoea|galactorrhoea|gynecomastia|tenderness|engorged||

77 ##Musculo-skeletal##- clear all -|- Clear -|- Back -|<==|,|history|suggestive of|arthralgia|arthritis|OA|lower backache|neck pain|neck muscle spasm|radiates to|occipital|L |R |arm|leg|localised|narrowing|limited|with movement|rotation|flexion|extension|chronic|since|vertebro-basillary syndrome||¢19¢Length|x|1|2|3|4|5|6|7|8|9|0|seconds|minutes|hours|weeks|months|years|since||	

78 ##Neurologies##- Clear all -|- Clear -|- Back -|<==|, |insomnia|weakness|Symptoms|suggestive|of|MS|Alzheimers|demensia|peripheral neuropathy|reduced sensation|sensory symptoms|paresthesea|dysarthria|motor|sensory|dysphasia|aphasia|blind|deaf|disorientation|amnesia|since|chronic|tension|headache|classic|atypical|migraine|dizzyness|vertigo|tinnitus|syncopy|Saturday nights palsy|¢4¢Epilepsy|grand mal|temporal lobe|petit mal|epilepsy.|diplopia|loss of balance|horizontal|nystagmus|dysmetria|dysdiadocokinesis|cerebral symptoms|atypical|psycho-somatic problem|classical|atypical form of|migraine|symptoms of|sens. peripheral neuropathy|carpal tunnel syndrome|¢8¢CSF|CSF-pressure=|cm H2O|normal|CSF colour|clear|cloudy|Xantochromic|bloodstained|¢10¢Number|0|1|2|3|4|5|6|7|8|9||
	
79 ##Labs##- Clear all -|- Clear -|- Back -|<==|. |, |present|absent|raised|increasing|pleural|ascites|exsudat.|transudat.|decreasing|¢11¢Number|0|1|2|3|4|5|6|7|8|9|.|¢9¢Urine|Proteinuria=  &- U nitrite= &-Uleuc= &- Hematuria= |1+, |2+, |3+, |4+, |cylinders|micro albuminuria|present|absent|Proteinuria= g/24h|Creatinine clearance= |Bence Jones prot.= |urine cytology=|¢6¢Cardiac|CK= |Trop T=|positive|negative|pro-BnP=|HS-CRP= |¢11¢Electr|Glucose(fasting)|glucose(random)|HbA1c= |Na= |K= |Urea= |Creat= |Na=  &- K=  &- Urea=  &-Creat=|uric acid=|Ca=|phosphate=|¢7¢Hemat|Hb=|Hct=|GKV=|WCC=|Plt=|CRP=|Hb= &- Plt= &- WST= &- CRP=|¢1¢ Liver enz ltd|ALP= &- GGT= &- AST=|¢2¢Liver enz:full|Bilir(tot)=  &- Bilir(conj)= &- Bilir(unconj)= &- ALP= &- AST= &- ALT= &- LD=|Protein(tot)= &- Alb=|Amilase &-|¢8¢Electroph|Protein-|Immuno-|electrophoresis: |IgM= &- IgG= &- IgA= |normal|poly-|mono|clonal gammopathy|Stool occult blood|¢11¢Endocrine|fasting|random|glucose= |HbA1c= |TSH=|TSH= &- T4= &- T3=|Cortisol 07h00= &- Cortisol 23h00=|Estrogene= &- progesterone=|LH= &- FSH=|Prolactine=|U-Normetanephrine= |¢5¢Lipogr|Triglic.= |Chol.= |LDL-chol.= |HDL-chol.= |Lp(a)= |¢6¢Tumour markers|PSA= |PSA= &- PSA assoc= |CEA= &- Ca19.9= |Stool occult blood= |microglobulin= |±-feto protein= |¢6¢Auto-immune|ANF= &- Anti-DNA= |CmplC3=  &- complC4= |ENA= |ANCA= |Rheumat F= &- RoseWaaler=|Antimitochondriale antibod.= &- Anti smooth muscle @ligg=|ADA pleural/ascites fluid= |¢3¢HIV|HIV|CD4=|CD4= &- VL= |Infective(serol)|¢6¢Coagul.|INR= |PTT= |Platelet count= |Bleeding time=|D-dimers=|Congo fever serol=|¢6¢Hypercoagulation|Protein-C=|Protein-S=|Anti-thrombin3=|Lupus anticoagulant=|FactorV Leyden PCR=|prothrombin20210A PKR=|¢7¢Hemolysis|LD=|Haptoglob=|Coombs(D)=|Retic. count=|cold agglut.=|Hb electroph.:|Osm fragility:|¢4¢Anaemia/Iron|ferritin= |s. iron= &- transferrin= &- % saturation=|Red cell folate=|Vit B12=|¢7¢Toxicology|Digitalis level=|Diphenylhydantoin level=|Valproate level=|Carbamasepine level=|Theophyllin level=|Paracetamol level=|Pseudocholine-esterase= ¢11¢LP|CSF pressure=|CSF|clear|cloudy|xantochromic|bloody|Protein= &- Cl= &- glucose= &- neutrophills=  &- lympho's=  &- RBS'e= |IgG-index= |Cryptococc colouring|posit.|negat.|¢11¢Number|0|1|2|3|4|5|6|7|8|9|.|Histology|cytology||
	
80 ##ABG##- Clear all -|- Clear -|- Back -|<==|¢12¢Amount|- Back -((1))|0|1|2|3|4|5|6|7|8|9|.|pH=|&- PO2=|&- PCO2=|&- HCO3=|&- O2Sat=|&- BE=|pH= &- pO2= &- pCO2=  &- HCO3=  &- BE= ||

81 ##Microbiology##- Clear all -|- Clear -|- Back -|<==|, |Blood culture|positive|negative|outstanding|Urine|sputum|MC&S|sputum ZN|Staphilococcus|Slide|Wound|pus swab|catheter|HIV||

82 ##Radiography##- Clear all -|- Clear -|<==|- Back -|, |infiltrate|basal|left|right|bilateral|pulmonary oedema|diffuse|in the lung fields|pleural effusion|pneumothorax|atelectasis|dilatation|air bronchogram|mediastinal mass|wide mediastinum|cardiomegaly|pericardial effusion|hiatal hernia behind heart shadow|ectatic aortic arch|aortic arch aneursym|consolidation|prominent hilar shadow|R |L |apex|mid lung|basal|cavity formed|present|appearance suggestive of|pneumonia|atypical|TB|carcinoma|mesothelioma|aspiration|contusion|ideopathic lung fibrosis|COAD|hyperinflation|Ecchinococcus cyst|lung abscess|McLeod syndrome||

83 ##CT+MRI##- Clear all -|- Clear -|- Back -|<==|, |CT indicates|MR indicates|¢18¢Organs|sinusses|brain|R |L |cortical|frontal|parietal|occipital|capsula interna|cerebellum|brain stem|chest|abdomen|cervical|thoracic|lumbar|vertebrae|pelvis|obliteration of|mass present in|bleeding/ hematoma in|infarction of|tumour of|metastases of|suggestive of|benign lesion.|malignancy.|Mesothelioma.|Tuberculosis|R |L |¢14¢organ|cerebral cortex|capsula interna|cerebellum|mediastinum|pleura|lung|liver|kidney|pancreas|adrenal gland|ovaries|colon|stomach|sigmoid|¢15¢fractures of|fractures of|skull|base of skull|neck vertebrae C|Thoracic vertebrae T|Lumbar vertebrae L|pelvis|pubic rami|hip|femur|tib-fib|humerus|ribs|clavicle|scapula|#||

84 ##ECHO+Sonar##- Clear all -|- Clear -|- Back -|<==|, |¢25¢Echo|Echocardiography|normal|indicates|LV hypertrophy|hypertrophic|congestive|ischaemic|cardiomyopathy|rheumatic|valve disease: |MS|MI|AS|AI|bicuspid Aortic valve|signs of RV overload|Mitral valve prolapse|segmental|diffuse|dyskinesia|congenital abnormality|ASD|VSD|Fallot's tetrology|pericardial effusion|liver|kidney|pancreas|adrenal gland|thyroid|mass in|cyst|gall stones|gall bladder dilatation|intra-hepatic|to sphincter level|suggestive of|gall stones.|pancreas head carcinoma.|cholecystitis|normal|metastases|hydronephrosis |R |L |Ureter dilated|to level of u-vesical junction.|distended bladder due to  urine retention.|¢18¢present|renal stone|Staghorn stone|simple renal cyst|Polycystic kidney disease|Bile stones|appendicitis|carcinoma|lymphadenopathy|ascites|abscess|haematoma|myomata|metastases|mass lesion of|abdom. aortic aneuryism|residual urine|enlarged prostate|ectopic pregnancy|present||
	
85 ##Other tests##- Clear all -|- Clear -|- Back -|<==|, |arrange for|Radio-isotope scan of|thyroid|skeleton|lungs|kideys|adrenal glands|¢9¢Sonar|Abdominal sonar|kidney sonar|Thyroid sonar|sonar of Abdom. Aorta|Doppler study Carotids|Doppler study for ?DVT|Doppler study of Art.flow in legs|Echocardiogram|Sonar of|¢7¢Scope|Gastroscopy|Bronchoscopy|Sigmoidoscopy|Proctoscopy|Colonoscopy|Laporoscopy|Arthroscopy|¢7¢CT|CT|with contrast|Brain|Thorax|Abd|Neck|Pancreas|¢7¢MRI|MRI|with contrast((1))|Brain((1))|Thorax((1))|Abd((1))|vertebrae|MR angiogram of|¢5¢Ba-studies|Barium enema|Ba-swallow|Ba-meal|small bowel-meal|Ba-enema|IVP|Urinating cystogram|¢5¢Isotope|Isotope scan of|Thyroid|Gallium|Skeletal|isotope scan|Gastrografin meal|Sinogram|Mammogram|Tomogram of||
	
86 ##Differential diagnosis##- Clear all -|- Clear -|- Back -|<==|, |- Space -|: |cardiac|lung|liver|renal|pathology|¢17¢Headache|Headache due to|neck spasm|stress|depression|psycho-somatic factors|migraine|raised IC pressure|pseudotumour cerebri|cervical spondylosis|viral|bacterial|meningitis|encephalitis|meningo-encephalitis|subarachnoid bleeding|temporal arteritis|sinusitus|¢13¢Chest pain|chest pain due to|angina|acute MI|oesophageal spasm|dyspepsia|Tietze's syndrome|Bornholm's disease|musculo-skeletal factors|pleuritis|pericarditis|trauma|rib fracture|cracked ribs|¢25¢Abd. pain|abdominal pain due to|spastic colon syndrome|appendicitis|cholecystitis|peritonitis|renal stone|Bile stones|diverticulitis|ruptured spleen|salpingitis|cystitis|abd. aortic aneurysm|ischaemic bowel|strangulated hernia|bowel obstruction|volvulus|lymph adenitis|ulcerative|colitis|pancreatitis|PU|Gastritis|liver congestion|subphrenic|abscess|¢16¢Nausea|Nausea|& vomiting|haematemesis|due to|gastritis|gastro-enteritis|cholecystitis|PU|Digitalis|Theophyllin|toxicity|SS|raised IC pressure|kidney stones|pyelitis|keto-acidosis|¢8¢Dyspnoea|Dyspnoea due to|asthma|acute on chron bronchitis|pneumonia|cong. HF|lung congestion|large  pleural effusion|pneumothorax|pulm. HT|pulm embolism|¢6¢Syncopy|syncopy due to|vasovagal episode|postural hypotension|arrhythmia|form of epilepsy|TIA|¢6¢Coma|comatose due to|hypoglycaemia|drug overdose|CVA|skull trauma|subarachn bleeding|¢11¢Joint pain|joint pain due to|OA|RA|psoriatic arthritis|ancylosing spondylitis|SLE|auto-immune disease|Brucellosis|iron insufficiency|gout|spondylosis|¢11¢typical|classical|atypical|picture of|multi-organ failure|& |¢12¢CVD|unstable|Angina|MI|congest HF|cor pulmonale|Arterial|central|embolism|L |R |hemi|claudication|¢8¢Resp|pneumonia|acute on chronic|COAD|PTB|pleuritis|mesothelioma|bronchus Ca|pulmonary embolism|¢17¢Abdo|appendicitis|diverticulitis|peritonitis|gastro-enteritis|gastritis|PU|Hiatal|hernia|cholecystitis|Spastic colon syndrome|umbilical|inguinal|epigastric|incisional|hiatal|hernia|Abd. aorta aneurysm|¢9¢G-U|glomerulo|pyelo|nephritis|nephrosis|polycystic kidneys|kidney|ovarian|mass|¢15¢CVS|CVA|TIA|L |R |hemi|MS|Alzheimers|epilepsy|Pseudotumour cerebri|viral|septic|meningitis|subarachnoid|subdural|bleeding|¢9¢Musc-skel|gout|osteo|rheumatoid|septic|arthritis|myositis|spondylosis|myasthenia gravis|osteoporosis|¢9¢Psycho|acute|psychosis|manic|depression|hysteria|psycho-somatic picture|post traumatic stress synd.|delirium|anxiety|¢16¢Infect|HIV|PTB|Gr -|septisaemia|Congo fever|Tick bite fever|Hepatitis|Malaria|Brucellosis|Toxoplasmosis|Cryptococcal meningitis|Infective mononucleosis|H Zoster|staphylococcal|abscess|cellulitis||
	
87 ##Problem##- Clear all -|- Clear -|, |:|??|& |pyrexia|rigors|unexplained|weight loss|increased|non-specific|since|complicated|uncomplicated|severe|recent onset|long standing|tiredness|reduced|¢21¢Pain|,|chest pain|Angina|pleuritic|dyspeptic|musculo-skeletal|costo-chondritis|Headache|Low pressure headache post LP.|Abd.pain|Backache|pain over|colon distribution|kidney areas|Joint pain|pain on swallowing|Toothache|colicky pain|Local pain over|¢9¢Type|pressure|burning|cramplike|stabbing|dull|continuous|intermittant|localised|spread to|¢21¢Duration|since|x|1|2|3|4|5|6|7|8|9|0|seconds|minutes|hours|days|weeks|months|years|how long ago|¢8¢Position|epigastric|R |L |hypochondrium|inguinal|para|umbilical area|suprapubic|¢15¢CVS|oedema|dyspnoea|orthopnoea|uncontrolled|well controlled|HT|unstable|Angina|acute MI|congest HF|cor pulmonale|post viral|ischaemic|postpartum|congestive|cardiomyopathy|rheumatic valve disease|HOCM|arterial|central|embolism|L |R |hemi|claudication|¢8¢Atyp.CP|Atypical chest pain|due to|dyspepsia|costo-chondritis|Tietze's syndrome|Bornholm's disease|oesophageal spasm|G-O reflux|congestive HF|¢34¢Respiratory|&|cough|dyspnoea|orthopnoea|ankle oedema|productive|tachipnoea|pleuritic pain|pleuritis|haemoptysis|sputum|white|yellow|green|dry|infected|offensive|broncho|aspiration|pneumonia|pleural effusion|PTB|mesothelioma|Ca bronchus|pulmonary embolism|pneumoconiosis|interstitial|post TB|bronchiectasis|lung contusion|peripheral oedema|¢35¢Abdominal|diarrhoea|nausea & vomiting|anorexia|abdominal pain|gastritis|pancreatitis|diverticulitis|peritonitis|appendicitis|cholecystitis|peptic ulcer|oesophageal spasm|gastritis|dyspepsia|PU|heartburn|nocturnal|cholecystitis|Spastic colon syndrome|G-O reflux|umbilical|inguinal|epigastric|incisional|hiatal|hernia|Abd. aortic aneurysm|haematemesis|melena|fresh|old blood per rectum|haemorrhoids|gastro-enteritis|Crohn's disease|ulcerative colitis|ileus|ascites|distended abdomen|abd. aortic aneurysm|¢6¢Hernia|umbilical|inguinal|epigastric||incisional|hernia|¢39¢G-U|oliguria|urine retention|weak bladder|urgency|urinary incontinence|haematuria|hemat. & proteinuria|proteinuria|glucosuria|prostatism|UTI|glomerulo|pyelo|nephritis|nephrosis|due to HT|due to reflux|due to DM|due to HIV|obstructive uropathy|analgesic|interstitial|nephropathy|kidney stones|acute|pre-renal|post-renal|chronic|kidney failure|due to acute tubular necrosis/ ATN|due to dehydration|hyperkalaemia|polycystic kidneys|kidney|ovaries|mass|impotence|colic|¢17¢CNS|CVA|TIA|L |R |hemi|MS|Alzheimers|epilepsy|Parkinsons|Pseudotumour cerebri|viral|septic|meningitis|encephalitis|meningo-encephalitis|subarachnoidal|bleeding|subdural|haematoma|Guillian Barre|traumatic|paraplegia|quadriplegia|sensory level|incontinent of|urine|urine & faeces|chronic headache|migraine|with analgesic abuse|stress/depression connotation|syncopy|¢12¢Epilepsy|classical|atypical|Grand mal|Petit mal|Temporal lobe|hypoglycaemic|"Rum fits"|post|traumatic|infective|epilepsy|hereditary|¢36¢Psyc|acute|severe|psychosis|manic|depressive|anxiety|phobia|hysteria|diverse|psyco-somatic problems|& |analgetics|Benzodiazepine|ethanol|drug|abuse|late night|sleeping disturbance|home disturbances|financial|stress|at the work place|aggression|temper tantrums|abuser of women|intoxicated|psychopath|post traumatic stress syndr|auditory|visual|hallucinations|disorientated|delirium|due to sleeping tablet|ADHD|ADD|¢9¢Musc-skel|gout|osteo|rheumatoid|ankylosing spondylitis|psoriatic|septic|sero-negative|arthritis|arthralgia|post|traumatic|virus|auto-immune|myositis|myalgia|spondylosis|myasthenia gravis|osteoporosis|muscle/joint pain secondary to iron def.|nocturnal|muscle cramps|proximal|muscle weakness|¢16¢Infect|HIV|PTB|Gr -|septicaemia|Congo fever|Tick bite fever|Hepatitis|Malaria|Brucellosis|Toxoplasmosis|Cryptococcal meningitis|Infective mononucleosis|H Zoster|staphylococcal|abscess|cellulitis|pyrexia|cough|rigors|acute on chronic bronchitis & emphysema|gastro-enteritis|colitis|cystitis|pyelonephritis|pneumonia|sinusitis|meningitis|encephalitis|meningo-encephalitis|¢11¢Endocr|post pancreatitis|Diabetes|type 1|type 2|hyperthyroidism|hypothyroidism|post RA-12|Cushings|Addisons|Pheochromocytoma|Secondary Hyperparathyroidism|¢34¢Trauma|fracture of|R |L |& |lacerations of|bruises|scrape marks|fall|wounds on|head|arm|fore arm|hand|hip|leg|knee|ankle|tib-fib #|clavicle|base of skull|cervical|thoracic|lumbar|lumbo-saccral|vertebrae|foot|L |R |comatose|Glasgow scale /15|para|quadri|plegic|paretic||

88 ##History##- Clear all -|- Clear -|- Back -|<==|, |increased|decreased|stable|cured|improved|worsened|none|suggestive of|known with|now with|reappearance of|history|of|commenced on|problem commenced|typical of|indicative of|severe|not applicable|weight|loss|increase|recent onset|long standing|reduced|general condition|suggestive of|¢12¢Sensation|burning|stabbing|throbbing|pressing|dull|cramplike|intense|non-|pleuritic|dyspeptic|sensation|dyspnoeic|¢13¢Pain|chest pain|headache|abdominal pain|backache|joint pain|pain on swallowing|dysphagia|Toothache|colic|local pain over|atypical|pain|since|¢20¢Duration|x|1|/|2|3|4|5|6|7|8|9|0|seconds|minutes|hours|days|weeks|months|years|¢8¢Radiates|radiates to|back|L |R |arm|leg|throat|upper abd.|¢9¢Caracter|burning|cramplike|stabbing|dull|continuous|intermittent|localised|spreads to|¢12¢Infective|pyrexia|cough|dehydration|rigors|acute on chronic bronchitis & emphysema|cystitis|pyelonephritis|pneumonia|sinusitis|meningitis|encephalitis|meningo-encephalitis|¢9¢Cardiomyopathy|angina|dyspnoea|orthopnoea|PND|ankle oedema|atypical|pleuritic|chest pain|congenital HF|¢7¢Atyp CP|Atypical chest pain|due to|dyspepsia|costo-chondritis|Tietze's syndrome|Bornholm's disease|oesophageal spasm|G-O reflux|¢26¢Respiratory|cough|dyspnoea|productive|tachypnoea|pleuritic pain|haemoptysis|sputum|white|yellow|green|dry|infected|offensive|broncho|aspiration|pneumonia|pleural effusion|PTB|mesothelioma|Ca bronchus|pulmonary embolism|pneumoconiosis|interstitial|post TB|bronchiectasis|¢35¢Abdominal|diarrhoea|nausea & vomiting|anorexia|abdominal pain|gastritis|pancreatitis|diverticulitis|peritonitis|appendicitis|cholecystitis|peptic ulcer|oesophageal spasm|gastritis|dyspepsia|PU|heartburn|nocturnal|cholecystitis|Spastic colon syndrome|G-O reflux|umbilical|inguinal|epigastric|incisional|hiatal|hernia|Abd. aortic aneurysm|haematemesis|melena|fresh|old blood per rectum|haemorrhoids|gastro-enteritis|Crohn's disease|ulcerative colitis|ileus|ascites|distended abdomen|abd. aortic aneurysm|¢6¢Hernia|umbilical|inguinal|epigastric||incisional|hernia|¢39¢G-U|oliguria|urine retention|weak bladder|urgency|urinary incontinence|haematuria|hemat. & proteinuria|proteinuria|glucosuria|prostatism|UTI|glomerulo|pyelo|nephritis|nephrosis|due to HT|due to reflux|due to DM|due to HIV|obstructive uropathy|analgesic|interstitial|nephropathy|renal stones|acute|pre-renal|post-renal|chronic|kidney failure|due to acute tubular necrosis/ ATN|due to dehydration|hyperkalaemia|polycystic kidneys|kidney|ovaries|mass|impotence|colic|¢16¢CNS|CVA|TIA|L |R |hemi|MS|Alzheimers|epilepsy|Parkinsons|Pseudotumour cerebri|viral|septic|meningitis|encephalitis|meningo-encephalitis|subarachnoidal|subdural|bleeding|Guillian Barre|traumatic|paraplegia|quadriplegia|sensory level|incontinent of|urine|urine & faeces|chronic headache|migraine|with analgesic abuse|stress/depression connotation|syncopy|¢12¢Epilepsy|classical|atypical|Grand mal|Petit mal|Temporal lobe|hypoglycaemic|"Rum fits"|post|traumatic|infective|epilepsy|hereditary|¢9¢Psycho|acute|severe|psychosis|manic|depressive|anxiety|phobia|hysteria|diverse|psycho-somatic problems|analgesic|Benzodiazepine|ethanol|drug|abuse|late night sleeping disturbance|marital problems|financial|stress|at the work place|aggression|temper tantrums|abuser of women|intoxicated|psycopath|post traumatic stress syndr|auditory|visual|hallucinations|disorientated|delirium|due to sleeping tablet|ADHD|ADD|¢9¢Musc-skel|gout|osteo|rheumatoid|ankylosing spondylitis|psoriatic|septic|sero-negative|arthritis|arthralgia|post|traumatic|viral|auto-immune|myositis|myalgia|spondylosis|myasthenia gravis|osteoporosis|muscle/joint pain secondary to iron def.|nocturnal|muscle cramps|proximal|muscle weakness|¢16¢Infect|HIV|PTB|Gr -|septicaemia|Congo fever|Tick bite fever|Hepatitis|Malaria|Brucellosis|Toxoplasmosis|Cryptococcal meningitis|Infective mononucleosis|H Zoster|staphylococcal|abscess|cellulitis|pyrexia|cough|rigors|acute on chronic bronchitis & emphysema|gastro-enteritis|colitis|cystitis|pyelonephritis|pneumonia|sinusitis|meningitis|encephalitis|meningo-encephalitis|¢11¢Endocr|post pancreatitis|Diabetes|type 1|type 2|hyperthyroidism|hypothyroidism|post RA-12|Cushings|Addisons|Pheochromocytoma|Secondary Hyperparathyroidism|¢33¢Trauma|fracture of|R |L |lacerations of|bruises|scrape marks|fall|wounds on|head|arm|lower arm|hand|hip|leg|knee|ankle|tib-fib #|clavicle|base of skull|vertebrae|cervical|thoracic|lumbar|lumbo-saccral|foot|L |R |comatose|Glasgow scale /15|para|quadri|plegic|paretic||

89 ##Findings##- Clear all -|- Clear -|- Back -|<==|, |T= °C|P= /min|BP= / mm Hg|¢25¢Numbers|0|1|2|3|4|5|6|7|8|9|.|36|37|38|39|10|11|12|13|14|15|16|17|18|19|& |shocked|septicaemic|acute|toxic|terminal|chronic|sick|dehydrated|fluid overloaded|dyspnoea|orthopnea|cachectic|anaemic|stupor|comatose|Brain dead||

90 ##Tests##- Clear all -|- Clear -|- Back -|<==|, |¢12¢Numbers|0|1|2|3|4|5|6|7|8|9|.|+|¢12¢Labs|Lab tests|Na &-|K &-|Creat &-|Hb &- GKV &- WCC &- Plt &-|Hb &- Hct &-|Wcc &- CRP &-|Na &- K &- Urea &- Creat &-|¢10¢ArtBGas|pH &-|pO2 &-|pCO2 &-|HCO3 &-|BE &-|pH &- pO2 &- pCO2 &- HCO3 &- BE &-|¢4¢cardiac|CK &-|Trop T &-|pro-Bnp &-|HS-CRP &-|¢12¢Electro|Glucose(fasting) &-|Glucose(random) &-|HbA1c &-|Na &-|K &-|Urea &-|Creat &-|Na &- K &- Urea &- Creat &-|Uric acid &-|Calcium &-|Phosphate &-|¢3¢Haem|FBC &- ESR &-|CRP &-|Hb &- Plt &- WCC &- CRP &-|¢1¢LivFunc(Ltd)|ALP &- gGt &- AST &-|¢2¢LivFunc(full)|Billi(Tot) &- Billi(uncongu) &- Billi(congu) &- ALP &- AST &- ALT &- LD|protein(Tot) &- Alb &- Amilase &-|¢3¢Electroph|protein-|Immuno-|electrophoresis|stool occult blood|¢11¢Endocrine|fasting|random|glucose|HbA1c|TSH|TSH &-T4 &-T3|Cortisol|07h00 &- 23h00|Oestrogen &- Progesterone|LH &- FSH|Prolactin|U-Normetanephrine(24h urine)|¢2¢Lipogr|fasting lipogram|random chol|¢6¢Tumour markers|PSA|PSA &- PSA ratio|CEA &-CA19.9|stool occult blood|microglobulin| Alpha-feto protein|¢6¢Auto-immun|ANF &-Anti-DNA|ComplC3 &-complC4|ENA|ANCA|Rheum Fact &-Rosewaaler|Antimitochondrial AB= &- Anti smooth muscle AB|ADA pleural/ascites fluid|¢3¢HIV|HIV|CD4|CD4= &- VL=|¢11¢Infection(serol)|serologic testing for|Brucella|RPR|Paul Bunnell|Mycoplasma pneum.|Legionaires|Rickettsia|malaria|Congo fever|HIV|Toxoplasmosis|¢6¢Bleeding|INR|PTT|platelets|bleeding time|D-dimers|Congo fever serology|¢6¢|Hypercoagu|Protein-C|Protein-S|Anti-thrombin 3|Lupus anticoagulant|Factor V Leyden PKR|prothrombin20210a PKR|¢7¢Haemolysis|LD|Haptoglob|Coombs(D)|Reticul.count|cold agglut.|Hb electroph.|Osm fragility:|¢4¢Anaemia/Iron|Ferritin|Iron studies|Red cell folate|Vit B12|¢7¢Toxicology|Digitalis level|Diphenylhydantoine level|Valproate level|carbamazepine level|Theophyllin level|Paracetamol level|Pseudocholin-esterase|LP|¢12¢Radiol|Xrays of|abdomen|cervical|lumbar|vertebrae|CXR|Abdomen|CT scan|Abd US|doppler studies|Carotids|veins in legs|¢4¢EEG|EEG|sleep deprivation EEG|Sleep apnoea studies|N conduction studies|Holter ECG|24hr ambulant BP|Bone Density test|Lung functions||

91 ##Medication##- Clear all -|- Clear -|- Back -|<==|, |- Space -|¢45¢Dose|1|1.5|2|2.5|5|7,5|10|15|20|25|50|75|100|250|500|750|1000|mcg|mg|g|ml|me|E|mane|nocte|/os|/d|ivi|imi|sc|1-0-0|0-0-1|1-0-1|1-1-1|q4h|bd|tds|q6h|q12h|¢10¢Number|1|2|3|4|5|6|7|8|9|0|units|before|with|after|meals|¢14¢cardiology (b)|<==|Aspirin|Lasix|Spironolactone|Digoxin|Ismo|Isordil|Amiodarone|Mexitil|Streptase|Actylase|Metalase|Adrenalin|Dobutrex infusion|¢6¢Anticoag.|Disprin CV|Ecotrin|Bayer Asperin Cardiac|Plavix|Clexane|Warfarin|¢14¢Diabetes|<==|Metformin|Glycomin|Glyclazide|Diamicron MR|Novorapid|Novomix30|Actraphane|Humalog|Humulin Mix25|Humulin Mix50|Humulin N|Lantus|Levimer|¢6¢Endocr|<==|Eltroxin|Parlodel|Pancrease|Panafcort|Fluorinef|¢12¢Antibiotics|<==|Augmentin|Amoxil|Klacid|Avelon|Ciprobay ((1))|Tavanic|Flagyl|Fucidin|Chloramphenicol|Urispas|Taravid|¢10¢Antibiotics ivi|<==|Amoxicillin|Maxipime|Rocephin|Ciprobay|Tienam|Invance|Gentamycin|Amiken|Ceftriaxone|Flagyl|¢10¢Anti-inflamm|<==|Indometacin|Celebrex|Coxflam|Mobic|Tilcotil((1))|Salazopyrin|Methotrexate|colchisine|Panafcort|¢10¢Analgesia (b)|Sosegon|Tramal|Pethidine|Morphine|Lentogesic caps|Stillpayne|Tilcotil|Voltaren|Tylenol|Ibuprofen|¢9¢Anti-inflamm|Indometacin|Diclofenac|Coxflam|Mobic|Celebrex|Salazopyrin|Methotrexate|Panafcort|colchisine|¢8¢Antacids|<==|Losec|Rosnal|Nexiam|Pantoloc|Controloc|Pariet|Lansoloc|¢26¢HT|<==|Tenbloka|Tenoretic|Lisinopril|Lisinopril Co|Pharmapress|Pharmapress Co|Coversyl|Coversyl Plus|Prexum|Tritace|Diovan|Co-Diovan|Atacand|Atacand Plus|Triplen Forte|Ravamil|Adalat XL60|Zildem|Norvasc|Amloc|Pratsiol|Cardura|Brinerdin|Hypotone|Loniten|¢6¢Lipids|<==|Simvastatin|Lipitor|Prava|Crestor|Bezalip R|¢11¢Depression|<==|Surmontil|Tydamine|Trepilene|Tofranil|Fluoxetine|Cipralex|Talamil|Efexor|Cymbalta|¢8¢Epilepsy|<==|Epanutin|Tegretol|Epilim|Lamictin|Valium|Sod-Gardinal|¢11¢HIV|<==|Aspen Lamzid|3-TC|AZT|Stockrin|Kaletra|Zerit|Videx|Purbac DS|Fluozol|Fungizone|¢1¢Virus|Zelitrex|¢8¢TB|<==|Rifah For 2-1-2|INH|Streptomycin|PZA|Ethionamide|Ciprobay||
	
92 ##Nursing notes##- clear all -|- clear -|- back -|<==|, |-space -|:|&|0|1|2|3|4|5|6|7|8|9|¢10¢Staff member|Sr|Nurse|Engel: h|Lingham: h|Japhta: h|Langeveldt: h|Smiles: h|Geduld: h|Rossouw: h|Sciocatti: h|¢15¢Amount/time|0|1|2|3|4|5|6|7|8|9|.|/|+|&|¢22¢Patient status|patient is|normal|stable|unstable|Calm|restless|drowsy|confused|neglected|disorientated|aggressive|hypoxic|hypotensive|hypertensive|shocked|Acute respiratory emergency|in pain|anaemic|Fell|out of bed|injured|deceased||

93 ##Plan##- Clear all -|- Clear -|- Back -|<==|, |keep nil per mouth|discharge|tomorrow|¢13¢Arrange|Arrange for|Admission to|ICU|dialysis|bone marrow|pleural|biopsy|E-ECG|Gastroscopy|Bronchoscopy|Colonoscopy|Transfer to|Bloemfontein|¢23¢Referred to|referred to|Surgeon|Orthopaedic surgeon|Gynaecologist|Psychiatrist|Ophthalmologist|Dermatologist|Neuro surgeon|Urologist|Oncologist|and|clin. psychologist|Social worker|physiotherapist|Occupational therapist|Dietician|Bloemfontein for attention|Cardiologist|Cardiothoracic surgeon|Vascular surgeon|Pulmonologist|Nephrologist|Neuro surgeon|¢23¢Referred for|referred for|CT|MR|sonar|brain|chest|abdomen|lower back|EEG|Sleep deprivation EEG|Sleep apnoea studies|Carotid dopplers|Echo cardiography|Bone density estimation|Gastroscopy|Colonoscopy|Bronchoscopy|Lung funtions|E-ECG|24H|Holter ECG|Ambulatory 24hr BP estimation|HIV counselling|¢19¢Diet|Diabetic|Low|High|protein|cholesterol|sodium restrictive|kilojoule restrictive|potassium restrictive|diet|hyperalimentation|enteral|parenteral|Feed|High fibre|Fluid diet|soft diet|diet by|dietician|Mrs Ansie Engelbrecht|¢48¢Do Labs|U&E, Creat|Pot|FBC|Platelets|WCC|WCC & CRP|Bone marrow biopsy|Full LFT's|GGT, AST & ALP|amylase|Blood gasses|fasting|random|glucose|HbA1c|lipogram|chol|INR|PTT|Tumour markers|CEA & CA19.9|PSA|PSA ratio|B2 microglobulin|Bence Jones prot.|Ca|HIV|CD4 & VL|prot & alb|TSH|Thyroid func|ferritin & Iron profile|blood culture|sputum|urine|MC&S|ZNx3|Cytology|Cardiac enzymes|Pro-BNP|Digitalis level|Paracetamol level|Amikacin level|Pseudo-cholinesterase level|ANF, Anti-DNA, ENA|RF|Brucella|malaria|Stool occult blood|¢17¢Monitor|monitor|intake & output|CVP|daily weight|Respiration|blood gasses|Acid base balance|Glucose|BP|for arrhythmia|for bleeding|for abd. distention|for dyspnoea|for BP fluctuations|for bowel sounds|level of consciousness|daily urine output|blood transfusion|mobilisation|rehabilitation|applicable|hydrated|electrolyte correction|antibiotics|continue with|to continue with medication taken at home|stop|Warfarin|Take|FFP|Educate re home monitoring of|glucose profile|Fasting & 2-2.5h after meals(before snacks)||
	
94 ##Room N°##- Clear all -|D1 Int|D2 Int|F Int/ENT/Ortop|Rehab|Icu C|Icu M|Ong C|Ong M|B Chir|C Int/Ortop|E Gynae/Obst|Dialyses|Gastr|Bronchosc||

95 ##BMI##||

96 ##Free 1##||

97 ##Free 2##||
	
98 ##To do##- Clear all -|- Clear -|, |arrange for|phone|lab|X-rays|for results of|blood results done by Dr on //06|¢11¢Number|.|0|1|2|3|4|5|6|7|8|9|phone Dr re|discharge summary|lab tests tomorrow:|appropriate diet|enteral|parenteral|feeding|drugs|increased|decreased|controls|for results of|EEG|Heartsonar|¢15¢LABS|U&E, CR|FBC|LFT|Fasting|lipogram|&- glucose|blood culture|sputum|urine|MC&S|&- ZN|cardiac enzymes|CRP|tumour markers|CD4 & Viral load|¢13¢X-rays|CXR|X-rays|CT|MR|Sonar|of|brain|chest|abdomen|vertebrae|Carotid|dopplers|Echocardiogram|¢16¢Refer to|refer to|Surgeon|Orthopaedic surgeon|Gynaecologist|Psychiatrist|Opthalmologist|Dermatologist|Neuro surgeon|Urologist|Oncologist|and|Clin. psychologist|Social worker|Physiotherapist|Occupational therapist|Dietician|¢22¢Referred for|refered for|CT|MR|sonar|brain|chest|abdomen|lower back|EEG|Sleep deprivation EEG|Sleep apnoea studies|Carotid dopplers|Echocardiography|Bone density estimation|Gastroscopy|Bronchoscopy|Lung functions|E-ECG|24H|Holter ECG|Ambulatory BP estimation|HIV counselling|tomorrow||

99 ##Gastroscopy report##||

100##Date##- clear all -|- clear -|- back -|/ /2006|1|2|3|4|5|6|7|8|9|0||

101##History./Symptoms##- clear all -|- clear -|- Back -|<==|,|- space -|:|&|epigasric|discomfort|pain|heartburn|G-O reflux symptoms|iron deficiency|anaemia|melena|haematemesis|vomiting|dyspepsia|known with previous|oesophageal varices|GU|DU|atrophic gastritis|pernicious anaemia|Ca||

102##Medication##- clear all -|- clear -|- back -|<==|,|- space -|:|&|regular|analgesics|Salicilates|Grandpa|NSAI-drugs|intake|¢8¢Drug|Disprin|Ecotrin|Aspirin|Warfarin|Diclophenic|Voltaren|Coxflam|Indometacine||

103##Social factors##- clear all -|- clear -|- Back -|<==|,|- space|:|&|smoker|regular|excessive|ethanol|beer|spirits|intake|stress++|home|at work||

104##Findings##- clear all -|- clear -|- Back -|<==|,|- space|:|&|Gastroscopy normal|¢13¢Oesopha|Oesophagus:|normal|G-O junction|Barret's|Candida|reflux|Oesophagitis|GrA|GrB|GrC|GrD|varicies|stenosis|Hiatus hernia|oesophageal|stomach|carcinoma|present|absent|¢13¢Stomach|stomach|normal|antrum|fundus|pre-pyloric area|pyloris|erosions|ulcer|acute on chronic|atrophic|gastritis|¢7¢Duodenum|duodenum|normal|duodenitis|bleeding|chronic|deep|DU|present|in|biopsies taken for histology|previous gastrectomy|on|¢13¢Numbers|0|1|2|3|4|5|6|7|8|9|cm|C|M||

105##Edit 5##||

106##Edit 6##||

107##Edit 7##||

108##Edit 8##||

109##Suggested management##- clear all -|- clear -|- Back -|<==|,|- space -|:|&|If biopsy for Helicobacter Pylori positive: please treat e.g. Amoxil 1gr bd and Klacid 500mg bd for 1/52|¢7¢Discontinue|discontinue|analgesics|salisilates|NSAI-drugs|smoking|ethanol/beer|precipitating factors|¢9¢Reflux|for symptomatic relief of symptoms of|reflux|hiatal hernia:|aim for 10% weight loss,|elevate top end of bed,|no eating or drinking for 3hrs before goiing to bed,|avoid gas forming food & drinks,|take chronically a|H2antagonist|antacid|PPI|¢18¢Drug|eg.|Nexiam|Controloc|Pantoloc|Lanzor|Pariet|Roznal|Adco Lanzeloc|or generic equivalant|Gaviscon|Mucaine|Clopamon|before meals|before supper||

110##Edit 10##||

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112##Edit 12##||

113##Edit 13##||

114##Edit 14##||

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116##Edit 16##||

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119##Edit 19##||

120##Surname##||

121##Christian name##||

122##Day##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31||

123##Month##- Clear all -|- Back -|1|2|3|4|5|6|7|8|9|10|11|12||

124##Year##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9||

125##Occupation##- Clear all -|ex-|Teacher|SA Police|Army|House wife|Farmer|Business man|Business woman|Director|Manager|Lawyer|Advocate|Judge|scholar|student|Paramedic|nursing|Politician|Administration|Pensioner|Retired member of|SA Railways|clerk|artisan|Miner|Fitter|Technician in industry|working in|¢12¢Sectors|financial|Banking|Industry|Agriculture|Mining industry|Civil service|Municipality|Teaching|Education|Business|Estate Agent|Manufacturing|sector||

126##Marriage status##- Clear all -|- Back -|Married|Unmarried|Divorced|Widow|Widower|Bachelor|Spinster||

127##Race##- Clear all -|- Back -|White|Black|Mixed|Asian||

128##Religion##- Clear all -|- Back -|Christian|Catholic|Moslem|Hindu||

129##Address##- Clear all -|- Back -|Box|Pb X|str|rd|lane|ave|Blv|1|2|3|4|5|6|7|8|9|0||

130##cITY##- Clear all -|- Back -|Kimberley|Barkley-West|Douglas|Jan Kempdorp|Taung|Hartswater|Kuruman|Hopetown|Boshof|Warrenton|Postmasburg|Prieska|Lime Acres|Danielskuil|Jacobsdal|Modderrivier|Ritchie||

131##	Postal codes##- Clear all -|- Back -|1|2|3|4|5|6|7|8|9|0|*BARKLY-WESTB)* 8375|*BLOEMFONTEIN(B)* 9300|*BLOEMFONTEIN(S)* 9301|*CHRISTIANA(B)* 2680|*DANIELSKUI