Student`s no.
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Libyan International Medical University Faculty of Medicine Fourth year/ Second term Assignments form 2011-2012 Student's name: Student's no.: Department: Hospital: Date: Supervisor name: Supervisor's signature: Students are required to allocate two different clinical cases in both psychiatry and medical emergencies branches during their clinical training with the consultation of the medical coordinator. Students are required to complete two assigned forms completely in each Psychiatry and Medical emergencies (total are four). Students are required to have them signed by medical coordinator of each specialty. Students are required to hand over those assigned forms to fourth year coordinator before the end of each course of the course late formats will not be accepted. Students are required to use the faculty of medicine assignments form, it is the students' responsibility to photo copy the assignment form which is available with faculty of medicine administration secretary. Faculty of Medicine Clinical assignments format: Patient's personal information: Name:………………………………………………………….. Age:………............................................................. Sex:……………………………………………….. Marital status:……………………………………. Nationality:……………………………………….. Occupation:………………………………………. Special habits:……………………………………. Presenting complains and duration: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… History of presenting complains: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Systemic review: System Cardiovascular system Respiratory system Symptoms * Chest pain on exertion (angina) * Breathlessness: - Lying flat (orthopnoea) - At night (paroxysemal nocturnal dyspnea) - On minimal exertion * Palpitation * Pain in legs on walking * Shortness of breath Ankle swelling * Cough * Wheeze * Sputum production (color & amount) * Blood in sputum (haemoptysis) * Chest pain (due to inspiration or coughing) 2 Faculty dean: Dr. Jamal Eltalhi Present or not Faculty of Medicine Gastrointestinal system Genitourinary system men * Mouth (oral ulcers, dental problems) * Difficulty in swallowing (dysphagia) * Nausea & vomiting * Vomiting blood (haematemesis) * Indigestion * Heartburn * Abdominal pain * Change in bowel habit * Change in color of stool (pale, dark, black, fresh blood) * Pain during micturation (dysuria) * Frequent micturation * Blood in urine (hematuria) * If appropriate: Prostatic symptoms: - Difficulty starting & hesitancy - Poor stream or flow - Terminal dribbling - Urine incontinence - Urethral discharge - Libido - Erectile difficulties Women * Last menstrual period (consider pregnancy) * Timing & regularity of periods * length of periods * Abnormal bleeding * Vaginal discharge * Contraception * If appropriate: - Libido - Pain during intercourse (dyspareunia) - Urine incontinence (stress & urge) Nervous system * Headache * Dizziness (vertigo or light-headed) * Faints * Fits 3 Faculty dean: Dr. Jamal Eltalhi Faculty of Medicine Musculoskeletal system Endocrine Skin * Altered sensation (numbness or paraethesia) * Weakness * Visual disturbance * Hearing problems (deafness, tinnitus) * Memory and concentration changes * Joint pain, stiffness or swelling * Mobility * Falls * Heat or cold intolerance * Change in sweating * Excessive thirst (polydipsia) * Bleeding or bruising * Skin rash Past medical and surgical histories …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… ………………………………………………………………………………………………… Drug history: Drug Dose Duration …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Family history …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… 4 Faculty dean: Dr. Jamal Eltalhi Faculty of Medicine Social history: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… General examination: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Vital signs: BP:…………………… RR…………………..T…………………. PR……………… Systemic examination: System Positive and negative findings Cardiovascular system Respiratory system Gastrointestinal system 5 Faculty dean: Dr. Jamal Eltalhi Faculty of Medicine Genitourinary system men Women Nervous system Musculoskeletal system Endocrine 6 Faculty dean: Dr. Jamal Eltalhi Faculty of Medicine Skin Investigation ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………. Diagnosis: …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… ……………………………………………………………………………………………………. Managements: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Follow up: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ………………………………………………………………………………………. 7 Faculty dean: Dr. Jamal Eltalhi Faculty of Medicine Overview the condition: Epidemiology: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ………………………………………………………………………………………. Clinical features: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ……………………………………………………………………………………….………………….. Presenting of condition: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ………………………………………………………………………………………. …………………... Diagnosis: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Managements: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… 8 Faculty dean: Dr. Jamal Eltalhi Faculty of Medicine …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… New guidelines in managements: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ……………………………………………………………………………………………………………. Prevention: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ………………………………………………………………………………………. Other comments: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ………………………………………………………………………………………. 9 Faculty dean: Dr. Jamal Eltalhi
