Clinical Observation Format
  • Prof., Chhin Senya, MD, DTM&H 
  • Prof., Sok Saroeun, DO, Family Physicians (USA) 
  • International University (IU) 
  • Faculty of Health Sciences, Phnom Penh, Cambodia
  • OSCE: Objective Structured Clinical Examination




What does a hospital doctor do?
(1). How to write a Clinical Observation? 
(2). How to do a Physical Examination? 
(3). How to make a Presumptive Diagnosis? 
(4). How to order and interpret of Laboratory and Para Clinical data? 
(5). How to make a Final Diagnosis? 
(6). How to Treat and Use of Medications? 
(7). How to Monitor, Evaluate and Prognosis?

PART-1. Patient’s Identification
  • Date of Entrance: .............. Time: ............... ID: ...........
  • Department: ............................Room: .......
  • Patient’s Name: ......................Sex: .......... Age: ............
  • Nationality: ....................... Occupation: ....................
  • Address: ...........................................................
  • Referral from: ...............................................................
Phnom Penh, Date: .........
Signature
PART-2. Chief Complaint (CC)
  • Main symptoms that the patient come to see the doctor.
  • State, in patient’s words, the current problem.

PART-3. History of Present illness (HPI)
  • Describe the history of illness and also history of chief complaint (history of around the chief complaint). 
  • Onset and characteristic of the illness.

PART-4. Medications
Allergy:
- Medication, food, chemical, and environment, or other, including symptoms, e.g., reaction with penicillin is accompanied with seizure and pruritis.

Current Medications (CM):
- Including OTC (over the counter) and traditional medicine (names, dose, duration of usage and it result, administration ways).

PART-5. Past Medical History (PMH)
Individual past medical history including:
(1). childhood disease and genetic diseases recurrent problem, 
(2). date of hospitalizations and 
(3). treatment given to patient (e.g., cancer of the rectum with resection done on 02/02/05 and chemotherapy was 3 times done on 02/06/05 etc.....)

PART-6. Past Surgical & OBGYN Histories
Past Surgical History:
- Operations: type of operation, date of operation, and pathology if possible (e.g., perforated appendicitis with open laparotomy* on 03/04/06)

OBGYN History (if female patient):
- Include menarche, menstrual cycle, para-gravida and abortion,

Note: Laparotomy is basically a surgical procedure which involves a large incision in the abdomen to facilitate a procedure. 

While laparoscopy is a minimally invasive surgical procedure which sometimes referred as keyhole surgery as it uses a small incision.

Laparoscopy is a surgical procedure in which a fiber-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or permit small-scale surgery.

PART-7. Family History
(1). Age, status (alive, dead) of blood relatives and

(2). medical problems of blood relatives (ask about cancer, especially breast, colon, and prostate; TB (tuberculosis), asthma; MI (myocardial infarction); HTN (hypertension); thyroid disease; kidney disease; PUD (peptic ulcer disease); DM (diabetes mellitus); bleeding disorders; glaucoma, macular degeneration; and depression and alcohol or substance abuse.

PART-8. Personal History

Personal/Psychosocial (Social) History:
(1) Stressors (financial, significant relationships, work or school health) and support: family, friends, significant other, clergy, lifestyle risk factors (alcohol, drugs, tobacco, and caffeine use; diet; exercise; exposure to environmental agent; and sexual practices);

(2) patient profile (may include marital status and children, sexual orientation (sexual attraction: heterosexuality, homosexuality, bisexuality, asexuality); present and past employment; financial support and insurance; education; religion; living conditions)

PART-9. Immunization
  • Childhood and adult vaccinations 
  • Type of vaccination 
(1) completed or 
(2) uncompleted

PART-10. Review of Systems (ROS)
Review each system whether or not the problems exist:

General: Weight loss, weight gain, fatigue, weakness, appetite, fever, chills, night sweats

Skin: Rashes, pruritus, bruising, dryness, skin cancer or other lesions

Head: Trauma, headache, tenderness, dizziness, syncope

Eyes: Vision, changes in visual field, glasses, last prescription change, photo phobia, blurring, diplopia, spots or floaters, inflammation, discharge, vertigo, history of ear infections.

Nose: Sinus problems, epistaxis, obstruction, polyps, changes in or loss of sense of smell.

Necks:
- Tenderness, JVD, lymph nodes, thyroid examination, location of larynx, carotid bruits, HJR (Hepato-jugular Reflux).
- Record JVD in relation to the number of centimeters above or below the sternal angle, such as “1 cm above the sternal angle,” rather than “no JVD”

Note: The jugular venous pressure is usually assessed by observing the right side of the patient's neck. The normal mean jugular venous pressure, determined as the vertical distance above the midpoint of the right atrium, is 6 to 8 cm H2O.

Technique for Examining Hepatojugular Reflux (HJR)
HJR is the distension of the neck veins precipitated by the maneuver of firm pressure over the liver. It is seen in. 
(1) tricuspid regurgitation, 
(2) heart failure due to other non-valvular causes, and 
(3) other conditions including constrictive pericarditis, cardia tamponade, and inferior vena cava obstruction.

The HJR maneuver may be performed as follows: 
(1) The patient is positioned supine with elevation of the head at 45 degrees. 
(2) Look at jugular pulsations during quiet respirations (baseline JVP). 
(3) Apply gentle pressure (30-40 mm Hg) over the right upper quadrant or middle abdomen for at least 10 seconds (some suggest to 1 minute).

Repeat the JVP. 
(1) An increase in JVP of >3 cm is a positive HJR test. 
(2) Note: Normal subjects will have a decrease in JVP with this maneuver since venous return to the heart will be reduced. The JVD may transiently rise and then return to normal or decrease within 10 seconds.

JVD Causes: There are several reasons why JVD may occur, including: 
(1) Right-sided heart failure. 
(2) Pulmonary hypertension. 
(3) Tricuspid valve stenosis 
(4) Superior vena cava obstruction 
(5) Constrictive pericarditis. 
(6) Cardiac tamponade. 

JVD: Jugular vein distention is when a vein on the side of the neck appears to bulge.

Throat: Bleeding gums; dental history (last check up, etc); ulcerations or other lesions on tongue, gums, buccal mucosa. 
Gastrointestinal: Abdominal pain, dysphagia, heartburn, nausea, vomiting, diarrhea, constipation, hematemesis, indigestion, melena (hematochezia), hemorrhoids, change in stool shape and color, jaundice, fatty food intolerance.
Respiratory: Chest pain; dyspnea; cough; amount and color of sputum; hemoptysis; 

Cardiovascular: Chest pain; orthopnea, trepopnea* dyspnea on exertion, murmurs, peripheral edema, palpitations.

Note: * Trepopnea is dyspnea (shortness of breath) that is sensed while lying on one side but not on the other (lateral recumbent position). It results from disease of one lung, one major bronchus, or chronic congestive heart failure.

Gynecologic:
(1) Gravida/para/abortions; age at menarche; last menstrual period (frequency, duration, flow); dysmenorrheal; menopause; contraceptive method.

(2) Sexual history, including history of venereal disease, frequency of intercourse, number of partners, sexual orientation and satisfaction, and dyspareunia.

Note: Sexual orientation is sexual attraction (or a combination of these) to persons of the opposite sex or gender, the same sex or gender, or to both sexes or more than one gender. These attractions are generally subsumed under heterosexuality, homosexuality, and bisexuality, while asexuality (the lack of sexual attraction to others) is sometimes identified as the fourth category.

Genitourinary:
Frequency, urgency, dysuria; hematuria; polyuria; nocturia; incontinence; venereal disease; discharge; sterility; impotence; polydipsia; frequency of intercourse, number of partners, sexual orientation and satisfaction, and history of STD.

Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerance, glycosuria, hormone therapy, changes in hair or skin texture

Musculoskeletal: 
(1) Arthralgia, arthritis, 
(2) trauma, 
(3) joint swelling, 
(4) redness, tenderness, 
(5) limitations in ROM (range of motion), 
(6) back pain, 
(7) musculoskeletal trauma, 
(8) gout

- Flexion/Extension, Abduction/Adduction

Peripheral Vascular: Varicose veins, intermittent claudication, history of thrombophlebitis 
Hematology: Anemia, bleeding tendency, easy bruising, lymphadenopathy

Neuropsychiatric: 
(1) Syncope; seizures; weakness; ataxia or coordination problems; alterations in sensations, memory, mood, or sleep pattern, 
(2) Loss of energy, decreased ability to concentrate, change in weight or appetite, 
(3) Family history of depression or suicide; emotional disturbances; drug and alcohol problems.

PART-11. Physical Examination
General Appearance: 
- Mood, stage of development, race, and sex.
- State if patient is in distress or is assuming an unusual position.

Vital Sings: Weight, BMI, height, BP, temperature, pulse, RR, O2Sat, blood sugar.
Clinical Examination
(1) Inspection 
(2) Palpation 
(3) Auscultation 
(4) Percussion

Physical Examination
  • Skin (integument system)
  • Lymph Nodes
  • HEENT: Head, Eyes, Ears, Nose, Throat.
  • Necks
  • Chest (respiratory system)
  • Heart (cardiovascular system)
  • Breast
  • Abdomen (alimentary system)
  • Male genitalia (genito-urinary system)
  • Pelvic (female patient)
  • Rectal (male and female): Prostate (male), Guaic stools for male and female 
  • Musculoskeletal system
  • Joints
  • Peripheral vascular
  • Neurological system (Mental status evaluation, Cranial Nerves, Motor, Cerebellum, Sensory, Reflexes)

Neurologic Examination
Cranial Nerves: There are 12 cranial nerves, the functions of which are as follows:

I Olfactory-Smell

II Optic-Vision, visual fields, and fundi; afferent limb of papillary response

III, IV, VI, Oculomoto, trochlear, abducens - Efferent limb papillary response, ptosis, volitional eye movements, pursuit eye movements

V Trigeminal-Corneal reflex (afferent), facial sensation; test masseter and temporalis muscle by having patient bite

Note: The pupillary light reflex (PLR) or photo pupillary reflex is a reflex that controls the diameter of the pupil, in response to the intensity (luminance) of light that falls on the retinal ganglion cells of the retina in the back of the eye, thereby assisting in adaptation of vision to various levels of lightness.

VII Facial-Raise eyebrows, close eyes tight, show teeth, smile, or whistle, corneal reflex.

VIII Acoustic-Hearing; test by watch tick, finger rub, Weber-Rinne test if hearing loss noted on history or gross testing. (Air conduction lasts longer than bone conduction in a healthy person.)

IX, X Glossopharyngeal and vagus-Gag reflex; speech. Palate should move upward in midline. 

XI Spinal Accessory-Shoulder shrug, push head against resistance.

XII Hypoglossal-Tongue movement. Test strength by having the patient press tongue against the buccal mucosa on each side while you press a finger against the patient’s cheek. Observe for fascicu-lations.

PART-12. Database
Database (Laboratory and Para Clinical Data):
(1) Laboratory tests (blood, other specimens). 
(2) Imaging (ECG, CT scan, MRI, ultrasound, X-ray), and 
(3) Other available information (culture, specific tests,)

PART-13. Problem List
Problem List: 
(1) Include entry date of problem, date of problem onset, problem number. 
(2) In the initial list, number the problems in order of their severity. 
(3) After the initial list is generated, add problems chronologically. 
(4) List problem by status: active or inactive.

PART-14. Assessment
Assessment (Diagnosis)
- Discussion with a differential diagnosis
(1) diagnosis rule out, and 
(2) diagnosis rule in of each current problem is followed by the plan for each problem.
- The assessment (diagnosis) is more than a listing of problems.

PART-15. Plan
- According to assessment, the patient could be 
(1) hospitalized
(2) send home or admitted to ICU
(3) need medical or surgical treatment or consults. 

- A medical/surgical therapeutic treatment plan 
(1) should be formalized and given to the patient according to his/her conditions and 
(2) should also include education on diet, cessation of tobacco, alcohol, weight loss and exercise etc..... 

- Once the patient is dismissed, the patient should be given an appointment to come back for a follow up treatment.

ENDED!