Writing a medical clerking sheet

medical history sample cases pdf

She denies tobacco or illicit drug use and rarely drinks a glass of wine. Cellulitis, group A streptococcal bactermia, no recurrences 5.

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Associated symptoms '' She develops horizontal diplopia in all directions of gaze especially when looking to the left. Fundoscopic exam is normal with sharp discs and no vascular changes. Your residents can assist you.

Examples of medical clerking

Convergence is impaired. MVA with left leg fracture 4. There was no fever, cough, sputum, chest pressure, nausea, vomiting, bloating, or hematemesis. Smith also notes that for the past two to three weeks, she has been having intermittent pounding bifrontal headaches that worsen with straining, such as when coughing or having a bowel movement. Her maternal grandfather had a stroke at age He has no prior history of trauma to the chest, prior coronary artery disease or anxiety. Fundoscopic exam is normal with sharp discs and no vascular changes. Other causes of chest pain to consider in this case are pneumonia fever, cough, sputum , coronary artery disease radiating chest pressure, nausea , peptic ulcer disease nausea, vomiting, hematemesis , anxiety or musculoskelatal disease. Only negative statements belong in the pertinent negatives section.

Pupils are 4 mm and briskly reactive to light. She denies associated nausea, vomiting, photophobia, loss of vision, seeing flashing lights or zigzag lines, numbness, weakness, language difficulties, and gait abnormalities.

medical clerking template pdf

She denies head trauma, recent illness, fever, tinnitus or other neurologic symptoms.

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Clinical Case Write Up Sample