Case sheet Proforma

7/21/2019 Case sheet Proforma

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CENTRAL NERVOUS SYSTEM

INTRODUCTION

1.Name2.Age

3.Sex

4. Handedness

5. Resident of

6. Education

7. Occupation8. Informant

9. Reliability

CHIEF COMPLAINTS

1. Xxxxxx Onset and course

2. Yyyyyy onset and course

3. Zzzzzzz onset and course

H/O PRESENT ILLNESS

1. LOC/Seizure

a. Onset

b. Activity at the time of incident

c. Preceded by

i. Chest pain/Palpitationsweating/nausea/ vomiting/

ii. headache/giddiness/presyncope/visual disturbance.

d. Associated with

i. Involuntary movt/Tonic/clonic/focal/generalized

ii. Rolling up of eyes/stare/tongue bite/grunting noise


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iii. Sphincter incontinence/abnormal breathing pattern

e. Lasted for (Duration)

f. Recovered after Spont/treatment

g. Post recovery drowsiness/confusion/weakness

h. Number of episodes

i. Sensorium in between episodes

j. Last episode

k. Any injury sustained.

2. Disorientation

a. To T/P/P

b. Episodic or continuous

c. Orientation between the episodes

d. Any abnormal behavior

e. Recovery

3. Speech disturbance

a. Onset

b. Comprehensionc. Any spontaneous speech/word outflow

d. Slurring

e. Reading/writing/repetition

f. Progression

g. Any stress during speaking

h. Tightness/looseness in tongue

i. Paraphasias

4. Cranial Nerves

I. Smell to commonly used items

soap/shampoo/toothpaste


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II. Decreased visual acuity

Color vision

Color desaturation

Scotoma/Field defectIII. IV and VI

i. Double vision

1. Monoocular/binocular

2. On primary gaze or evoked gaze

3. Horiontal/vertical

4. Disappears by (Closing eye)

ii. Pain in eyes on movements

iii. Ptosis Fatiguability/diurnal variation

iv. Features of Horners syndrome

IV. Same as above

V. Decreased/abnormal sensations over face, difficulty

in mastication.

VI. Same as above

VII. Deviation of angle of mouth

Facial asymmetry

Drooling of salivaDifficulty in closing eyes

Difficulty in speaking

Taste impairment

VIII. Hearing impairement

Giddiness

Vertigo

TinnitusH/O CSOM

IX. And X

Dysphagia solid/liquid/both

Dysphonia


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Dysarthria

Nasal regurgitation

Hoarseness of voice/Nasal twang

X. Same as aboveXI. Neck movements

Shrugging of shoulders

XII. Ability to make the bolus of food

Ability to maneuver the food bolus inside the mouth

Tongue deviation

Dysarthria

5.Motor

a. Weakness (UMN)

i. Reaching overhead objects/taking comb to the head

ii. Lifting a bucket of water/breaking the chapaties

iii. Holding a glass of water/writing task in detail

iv. Holding the pen/grasping the comb

v. Difficulty in getting up from a chair/squatting position

vi. Climbing up/down the stairs/gripping the chappals

vii. Chappals slips away with/without the knowledge

viii. Getting up from lying down position/Turns in the bed

ix. Lifting the head off the bed

x. Breathlessness/ptosis/facial weakness/chewing

b. Dexterity

i. Buttoning/unbuttoning the shirt/ Breaking the chapaties

ii. Tie the nada of payjama/shoe lace

iii. Negotiating the foot into the chappal

iv. Also ask about

1. Proximal/distal

2. Symmetrical/asymmetrical

3. Spasticity/wasting which is more?

4. Onset and progression of the weakness

5. Present status.


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c. Weakness (LMN)

i. Looseness/fasciculations/wasting

ii. Which is earlier weakness or wasting

iii. Proximal/distal

iv. Symmetrical/asymmetrical

v. Periodicity/diurnal variation, fatiguability

vi. Selectivity of muscles

vii. Onset/course/progression

d. Cerebellar

i. Smearing of face/target oriented activities

ii. Tremors/Gait/Speech/Vertigo/Looseness of limbs

iii. Difficulty in reaching the objects

iv. Incoordination during picking up water/during drinking.

e. EPS

i. Tremors at rest/Stiffness/expressionless face

ii. Bradykinesia during bath/dressing etc.

iii. Sleep/Memory/Handwriting/Hypophonia/Gait

iv. Difficulty in walking narrow paths (Pedestrian strip)

f. Gait

i. Broad based/Narrow baseii. Speed/Antalgic gait/Freezing/Parkinsons gait features

iii. Recurrent falls/Buckling/Climbing up/down

iv. Difficulty in walking in dark/Pain while walking

v. Stiffness/crossing of legs

6. Sensory

a. Onset/progression/present status

b. Posterior column

i. Unable to feel clothes over the body

ii. Difficulty in walking in the dark/wash basin (Sink) sign

iii. Slipping of slippers without knowledge

iv. Cotton wool sensations over the feet

v. Band like sensation/Encasement of limbs


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vi. Pins and needles/numbness/tingling/paraesthesias

vii. Lhermittes phenomenon/water flowing underneath the

feet

c. Spinothalamic

i. Hot and cold water during bath

ii. Burning/shooting/pricking pain

iii. Funicular pain/sensory level

iv. Root pain is a sharp shooting pain in a particular n

dermatomal pattern which increases on

coughing/sneezing. It is recurrent and more severe.

d. Cortical sensations

i. Ability to feel the coins in the pocket

ii. Feel wallet in the pocket

7. Autonomic

a. Bladder

i. Urgency/urge incontinence/frequency/hesitancy

ii. Precipitancy/Retention (Painful/less & aware/unaware)

iii. Overflow incontinence/incomplete evacuation

iv. Dribbling of urine/loss of social inhibition

v. Postural giddiness/presyncope/erectile dysfunction

b. Bowel Frequency/consistency/continence

c. Faintness/palpitations

d. Abnormal sweating/Decreased lacrimation

e. Horners syndrome

f. Gastroparesis/nausea/vomiting/diarrhea

ETIOLOGICAL HISTORY

1. Headache (Mnemonic OLD CAARTS)

a. Onset/location/duration/diurnal variation/Ch.

b. Associated with(Nausea/vomiting/photophobia/

phonophobia/ abnormal behavior/LOC/blurring of vision

c. Red flag signs

d. Preceded by aura


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e. Aggravated by/relieved by/timing/severity/

f. Frequency (No of episodes in a day)/abnormal

sweating

g. Pain anywhere in the body2. Injury/RTA/Trauma to the neck

3. Abnormal behavior/nausea/vomiting

4. Fever/chest pain/palpitations/cough/

dyspnea/hemoptysis

5. Bowel symptoms/Jaundice

6. Oliguria/dysuria/hematuria/high colored urine

7. Joint pain/rash/photosensitivity/oral ulcers/hair fall/seizures

8. Dog bite/animal bite/vaccination/injection

9. Alternative drugs/well water drinking/insecticides

exposure

10. Carrying weight in head for long/neck pain for long

11. Skin lesions/Nodules12. Hypo/hyper thyroidism symptoms

13. Blood transfusion

PAST HISTORY

1. DM/TB/HTN/Hansens/CAD/BA

2. Similar illness in the past

3. Animal bite/vaccination/injection in the past

4. Blood transfusion/jaundice

5. Major surgery

PERSONAL HISTORY


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1. Veg/Non veg/Well water drinking/food habits

2. Smoking/Tobacco/Alcohol/Substance abuse

3. Marriage/Children

4. High Risk behavior

MENSTRUAL HISTORY

1. Menarche/Cycles/Menopause

2. LMP/Post menopausal bleed

3. any surgery

OCCUPATIONAL HISTORY

1. Nature/duration/intensity of exposure

2. H/O exposure to dye/paint/glasswares/med

eqpts/jwellery

3. Plumbing/farming/insecticides

4. Vibrating eqpts/repeated trauma

FAMILY HISTORY

1. Pedigree charting of possible genetic disease

2. h/O similar illness in the family

TREATMENT HISTORY

SUMMARY at the end of history and four tier diagnosis

1. Functional

2. Physiological

3. Anatomical


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4. Etioloical 1, 2, 3, 4

GENERAL EXAMINATION

1. Conscious/oriented/cooperative/comfortably lying2. Ht/Wt/BMI/Arm length/upper segment/lower segment/neck:ht ratio.

3. Pulse

Rate/rhythm/volume/character/peripheral pulses/R-R & R-F

Delay/pulse deficit/vessel wall/carotid bruit/shudder

4. BP

mm Hg/Rt Arm supine/No significant postural fall

5. RR rate/rhythm/type

6. P/I/C/C/L/E/JVP

7. Neurocutaneous markers

8. Nerve thickening

9. Vitamin deficiencies

10. Xanthoma/xanthelasma/arcus senilis

11. Congenital anomalies arms/foot/chest/gums/teeth/hair change

12. acanthoma nigricans/scars/sinus

13. Features of hypo/hyper thyroidism

14. acromegaly/marfans features

15. Angioma/cutaneous angiomata/rash/petechiae/purpurae/ecchym.

16. Bed sores/genital ulcers

17. Peripheral stigmata of TB/HIV

SYSTEMIC EXAMINATION

1. CVSa. Apical Impulse/chest wall symmetry/anomalies

b. S1/S2/S3/S4/murmur/pericardial rub/knock

2. RSa. Chest wall symmetry

b. Air entry/Breath sounds/adventitious sounds/pleural rub


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3. P/Aa. Distended/all quadrants moves equally with the respiration

b. Soft/Non tender/organomegaly/free fluid/bowel sounds

c. Hernial sites/peripheral signs of liver failure

CNS EXAMINATION

1. HMF

a. consciousness

b. oriented to T/P/P

c. Registration

d. attention/calculation

e. Recall

f. Language-Speech (Mnemonic CNS R3)

i. Comprehension

ii. Naming

iii. Spontaneous speed

iv. Reading

v. Writing

vi. Repetition

g. Language Dysarthria

i. UMN/Pseudobulbar British constitution

ii. Bulbar Pa Ta Ka

iii. Cerebellar Rashtrapaty Amritsar se Hyderabad gaye

Ask to repeat Yellow Lorry.

iv. Tongue muscles fasciculations/flaccidity.

v. NMJ Fatiguability/Nasal voice.

2. Cranial NervesI - Coffe powder/soap/shampoo/tooth paste

II - Acuity/Color/field/pupils/RAPD/Fundus.

III/IV & VI

- Position of the eye at primary gaze


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- Conjugate eye movements

a. convergence/divergence/saccades/pursuits

- Individual eye movements

- Nystagmus

V- Facial sensations touch/pain/temp/vibration

- Muscles of mastication- clench the teeth

- Movements of mandible

- Corneal reflex

- Jaw reflex

VII

- Wrinkling of forehead

- Frowning of eyebrows/eyelid closure- Bells phenomenon/facial expression/nasolabial fold

- Angle of mouth deviation/buccinators

- Taste sensation ant 2/3rd sugar/vinegar/salt

- Parotid swelling/tenderness

- Herpes zoster in EAM

VIII

- Rinnes/webers/ABC/Ear examination

IX & X

- Uvular position

- On saying AH uvula/palatal/post phar. wall movement

- Gag reflex

- Taste on post 1/3rd of tongue

- Dysphonia/dysphagia testing (?????)

XI

- Shrugging of shoulders

- Left/right turn of neck (SCM)

XII

- Tongue position in resting state/on protrusion

- Flaccidity/fasciculations/tremors/spasticity

- Myotonia/movements/Deviation of tongue


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3. Motor system examination

a. Position/attitude of limbs

b. Bulk (wasting/hypertrophy)

c. Tonei. Spasticity clasp knife

ii. Rigidity cog wheel/lead pipe

iii. Flaccidity

iv. Fasciculations

d. Power

i. Shoulder Abduction/adduction/flexion/extension (5/5)

ii. Elbow Flexion/extension (5/5)

iii. Wrist Dorsiflexion/Palmar flexion (5/5)iv. Hand grip Percentage (25/50/75), Myotonia (+/-)

v. Individual muscles of hand Normal or weak.

vi. -------

vii. Hip - Abduction/adduction/flexion/extension (5/5)

viii. Knee - Flexion/extension (5/5)

ix. Ankle Dorsiflexion/Plantar flexion (5/5)

x. EDP muscle wasting Present/not

xi. Truncal weakness Percentage (25/50/75)

xii. Neck muscle weakness - Percentage (25/50/75)

(Flexion/extension/lateral flexion)

e. DTR

i. Biceps/triceps/supinator/knee/ankle

ii. Clonus (+/-)

iii. Myotonia (+/-)

iv. Pseudomyotonic reflex

f. Superficial Reflexes

i. Plantar

ii. Abdominal

iii. Cremastric


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iv. Perianal reflex

g. Whartenburg sign

h. Koffman sign

j. Release reflexes

i. palmo mental

ii. Glabellar tap

iii. Rooting reflex

iv. Suckling reflex

v. Grasping reflex

k. Coordination UL/LL

4. Sensory System Examination

a. Superficial sensations

i. First test pin prick sensation

ii. Touch

b. Deep sensations

i. Pain

ii. Temperature Cold (Tuning fork) and warm

c. Combinedi. Vibration- Forehead/Mastoid/Sternum/Vertebral spine

- Clavicle/Elbow/wrist

- ASIS/PSIS/Tibial tuberosity/ankle

ii Joint position

- Great toe/index finger

d. Cortical sensations

I all the peripheral sensations are intact, then, check forcortical sensations.

e. Lhermittes phenomenon

f. Rhombergs sign

g. determine pattern of sensory loss


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i. Symmetrical/asymmetrical

ii. Glove stocking/Patchy

iii. Root level

5. Cerebelluma. Nystagmus

i. Primary gaze

ii. evoked gaze

iii. Horizontal/vertical/torsional

iv. Fatiguable/not

b. Intention tremor

c. Rebound phenomenon (Holmes)

d. Dysmetria

(these tests to be done with eyes open and then eyes

Closed and initially slow & then rapid)

i. Finger nose test

ii. Finger nose finger

iii. Knee shin dragging test

- First tap the knee with heel to r/o sensory loss

- Then excursion along skin of the tibia

(Cerebellar broken movements)

(Sensory waving of heel here & there)

iv. Finger toe test

e. Past pointing

f. Alternating movements

i. Draw a circle in air with finger/toe

ii. Alternatively pat the foot steadily on the ground

iii. Pronation supination (Disdiadochokinesia)

iv. Alternating opening and fisting of both hands

v. Screwing like movements

vi. Door knob opening like movements

vii. Opposition of thumb and fingers

viii. Tap out simple rhythm with finger.


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g. Speech

h. Hypotonia

j. Pendular knee jerk

k. Titubation

l. Gait and how the patient stands

m. Drift

i. Cerebellar Upward

ii. Pyramidal Down and pronated

iii. Parietal lesion Upward and wavy

6. Gait

7. EPS

a. Rigidity

b. Tremor

c. Mask like face

d. Gait

e. Micrographiaf. Hypophonia

g. Hypomimia

8. ANS

a. Postural hypotension

b. Sweating

SUMMARYAt the end of examination

FOUR TIER DIAGNOSIS


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CARDIOVASCULAR SYSTEM

INTRODUCTION

1.Name2.Age

3.Sex

4. Handedness

5. Resident of

6. Education

7. Occupation8. Informant

9. Reliability

CHIEF COMPLAINTS

1. Xxxxxx Onset and course

2. Yyyyyy onset and course

3. Zzzzzzz onset and course

H/O PRESENT ILLNESS

1. Chest Pain (Mnemonic OLD CAARTS)

a. Onset/location/duration/diurnal variation/Ch.

b. Associated with(Nausea/vomiting/photophobia/

phonophobia/ abnormal behavior/LOC

/blurring of vision

c. Red flag signs

d. Preceded by aura

e. Aggravated by/relieved by/timing/severity/

f. Frequency (No of epis. in a day)/abn sweating


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g. Pain anywhere in the body/

h. Diurnal variation/progress/present status

j. NYHA Class

2. Palpitations

a. Onset Rest/exertional, Duration

b. Regular/irregular

c. Aggravated/relieved by

d. Associated with

i. Presyncope/syncope/sweating/anxiety

ii. Post palpitations dieresis

e. Progress/Present status

f. NYHA Class

3. Dyspnoea

a. Onset

b. Progression

c. Duration

d. Rest same as for Palpitationse. Any Orthopnea/PND/Platypnea/Trepopnea

f. Present status/NYHA Class

4. Easy Fatiguability

a. Quantity and quality of the fatigue in terms of patient

activity which he used to do before and now.

b. Progress/Present statusc. NYHA Class

5. Syncope and pre-syncopea. As Described in CNS


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6. Cough and expectoration/Hemoptysis

a. As described in Respiratory system

7.Fevera. Onset/duration

b. Continuous/intermittent/remittent

c. Any evening rise

d. Subsides on medication/not

e. Chills/rigors

f. Associated headache/bodyache/sweating

8. Anorexia and weight loss

9. Recurrent respiratory tract infections

10. Failure to thrive

11. Cyanosis

a. Location Sclera/lips/tongue/tip of nose/ear lobule/

finger/toes

b. Onsetc. Lasted for

d. Relieved by

e. Any associated pain/paraesthesias

12. Clubbing

13. Hoarseness of voice

14. Edemaa. Onset

b. Progress

c. Extent

d. Any involvement of UL/Abdomen/Face/Sacral


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e. Diurnal variation

f. Aggravated by/relieved by Posture/activity/meals

g. Painful/painless

h. Any associated redness/discharge

15. Hematuria/oliguria/anuria/dysuria/recurrent UTI

16. H/O Rheumatic Fever

a. Any joint pain/redness

b. Subcutaneous nodules

c. Involuntary movements

17. H/S/O Infective Endocarditis

a. Joint pain/Petechiae/Puprpurae/ecchymoses

b. Painful nodules over finger tips/Rash

c. Hges under nail beds/discoloration of digits

d. Prolonged fever/Pain abdo/Visual disturbance

e. Hematuria

18. Bowel disturbance

19. TIA/FND/Seizures

20. History s/o hpo/hyperthyroidism

a. Hypothyroidism

i. Tiredness/weakness/dry skin

ii. Cold intolerance/hair loss/memory loss

iii. Hoarseness of voice/Constipationiv. Weight gain/Poor appetite

b. Hyperthyroidism

i. Heat intolerance/palpitations/fatigue

ii. Increased appetite/weight loss

iii. Tremor/restlessness/Hyperdefecation


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iv. Loss of libido

21. CTD history

PAST HISTORY1. DM/TB/HTN/Hansens/CAD/BA

2. Similar illness in the past

3. RHD History

a. Joint pain/nodules/abnormal movt/rash

b. Recurrent sore throat/penicillin prophylaxis

c. Digoxin therapy

4. Blood transfusion/jaundice/Allergy

5. Childhood infections

PERSONAL HISTORY

1. Veg/Non veg/Well water drinking/food habits

2. Smoking/Tobacco/Alcohol/Substance abuse

3. Marriage/Children4. High Risk behavior

MENSTRUAL HISTORY

1. Menarche/Cycles/Menopause

2. LMP/Post menopausal bleed

3. any surgery

FAMILY HISTORY

1. H/O similar illness in the family

2. Socioeconomic status/Poverty/overcrowded place


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TREATMENT HISTORY

1. Penicillin prophylaxis/digoxin/diuretics

2. Surgery/intervention

SUMMARY at the end of history.

1. D/D 1, 2, 3, 4

GENERAL EXAMINATION1. Conscious/oriented/cooperative/comfortably lying

2. Ht/Wt/BMI/Arm length/upper segment/lower segment/neck:ht ratio.

3. PulseRate/rhythm/volume/character/peripheral pulses/R-R & R-F

Delay/pulse deficit/vessel wall/carotid bruit/shudder

4. BP

mm Hg/Rt Arm supine/No significant postural fall

Hills sign UL and LL BP difference, Take all four limbs

5. RR rate/rhythm/type

6. P/I/C/C/L/E

7. JVP Height/waveform/prominent wave/H-J reflex8. Peripheral signs of AR/IE/RF

9. Marfanoid features/WHR

10. Xanthoma/xanthelasma/Pseudoxanthoma elasticum/arcus senilis

11. Hypertelorism/low set ears/micrognathia/orange f

12. Telengiectasias/bronze discoloration/acanthoma nigricans

13. Features of hypo/hyper thyroidism

14. acromegaly/marfans features

15. Angioma/cutaneous angiomata/rash/petechiae/purpurae/ecchym.

16. Bed sores/genital ulcers

17. Peripheral stigmata of TB/HIV

18. Scars/sinuses/lupus perenio/erythema nodosum/lipemia retinalis

19. Spine K/S/KS


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SYSTEMIC EXAMINATION

1. CVSa. Inspection

i. Chest wall symmetry/deformity/Precordial bulgeii. Apical Impulse site/no. of spaces visible

iii. Pulsation in precordium/epigastric/supraster./supracla.

iv. Scars/sinus/dilated veins

b. Palpation

i. Apical Impulse site/no. of spaces visible/character

ii. Palpable sounds/thrill in apical area

iii. Palpable sounds/thrill in other areas

iv. Parasternal heave

v. Origin of epigastric pulsations (Ru.)

c. Auscultation

i. S1

ii. S2 A2/P2/loudness/split

iii. S3/S4

iv. OS/Ejection click/tumor plop/valve click

v. Pericardial rub/knock

vi. Murmur (Described belowlater)

2. RSa. Chest wall symmetry

b. Trachea/resp movts/

c. Percussion

b. Air entry/Breath sounds/adventitious sounds/pleural rub

3. P/Aa. Distended/all quadrants moves equally with the respiration

b. Soft/Non tender/organomegaly/free fluid/bowel sounds

c. Hernial sites/peripheral signs of liver failure

4. CNS


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a. HMF/CN/Motor/Sensorycerebellar

b. EPS/ANS

Murmurs Description

1. Middiastolic Murmura. Low pitched/Rumbling/MDM

b. In Apex/with bell of stethoscope

c. With pt in left lateral position

d. Breath held in expiration

e. Assoc. with OS and presystolic accentuation

f. Duration of murmur

g. A2-OS gap

h. Increased by mild exercise (few rapid sit ups)

2. PSM IN MRa. Grade 3/6

b. PSM/Apex/diaphragm of stethoscope

c. radiating to axilla

d. Increased by hand grip

e. reduced during strain phase of valsalva.

3. Seagull Murmura. In case of rupture of tendinae or primary involvement of

posterior mitral leaflet, a murmur mistaken as AS murmur,

radiating to base of heart.

b. Has a musical quality.

4. PSM in TRa. Left parasternal region

b. Increased by leg raising

c. well heard during inspiration

d. Grade 3/6


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5. AS Murmura. Grade 3/6

b. Rough, rasping

c. ESM (MSM)

d. with diaphragm of stethoscope

e. In aortic area/with pt sitting up/leaning forward

f. Breath held in expiration

g. Radiating to carotids

h. Peaking of murmur/duration of murmur

j. Dynamic auscultation

6. Graham Steel Murmura. PAH leading to PR and murmur thereof.

b. High pitched

c. EDM with decrescendo blowing murmur

d. Along left sterna border

e. Increases on inspiration

f. Associated with loud P2

7. MVP Murmura. High pitched/systolic murmur

b. Crescendo-decrescendo murmur

c. Heard best in apex

d. Associated with mid or late non ejection click.

e. Click and murmur occurs earlier and is louder with

i. Standing

ii. Strain phase of valsalva

iii. Any intervention that decreases LV volume

f. Click and murmur is delayed and is decreased in intensityi. Squatting

ii. Isometric exercise

iii. Any intervention which increases LV volume

8. AR Murmur


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a. High pitched

b. EDM with blowing and decrescendo character

c. Best at 3rd Lt ICS along sterna border

d. With diaphragm of stethoscope

e. Pt sitting up and leaning forwardf. Breath held in expiration

g. Loudness of murmur/duration of murmur

NOTEa. Right sternal border heave aneurysmal dilatation of aortic

r

SUMMARYAt the end of examination

DIAGNOSIS


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RESPIRATORY SYSTEM

I. Introduction

Name: Age: Sex: Handedness: Resident of:

Education: Occupation: Religion: Informant: Reliability:

II. Chief Complaints (in chronological order)

III. HOPI

1) Cough- Onset, Dry/Wet, Day/Night/ Postural/seasonal variation, associated

with, aggravated by / relieved by, present status

2) Expectoration- Color, Consistency, Quantity, Smell, Diurnal/ Postural variation,

More in the early morning, Aggravated by / Relieved by, Present status

3) Hemoptysis- Color, Quantity, Frequency, Postural variation, Associated with,

Last episode, Postural symptoms, Aggravated by / Relieved by, Present status

4) Dyspnoea- Onset, Progression (describe wrt activities), Associated with,

Aggravated by / Relieved by, Present status, MMRC grading (0-4), PND,

Orthopnoea

5) Wheeze- Duration , Periodicity, Seasonal/ Diurnal variation, Associated allergic

features like allergic rhinitis, urticaria, recurrent sneezing, Aggravated by /

Relieved by, Present status

6) Chest pain-( OLD CAARTS) Onset, Location, Duration, Character,

Associated features, Aggravating and Relieving factors, Radiation, Time, Severity

7) Fever- Grade, Max Temp, Type, Associated with chills& rigors, Diurnal

variation, Evening rise of temp., night sweats, relieved by, present status

8) Anorexia

9) Weight loss- Quantified/Unquantified, lntentional /Unintentional,

Significant/insignificant


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10) Hoarseness of voice

11) Ptosis

12) Recurrent respiratory infection

13) History suggestive of Collagen Vascular Disease-Joint pain/rash/oral

ulcers/seizures/excessive hairfall

14) Palpitation /Easy fatiguability

15) Bladder / Bowel symptoms

16) Swelling of face/ edema

17) CNS symptoms-LOC/Head ache/weakness/vomiting

IV. Past History

DM/ HTN / TB/ Bronchial asthma/IHD

Childhood infection

Jaundice/ Blood Txn

Allergies/ FB inhalation

Trauma/ Surgeries/ similar illness in the past

V. Personal History

Smoking - pack years/smoking index/ Chula smoking

Alcohol / Tobacco

Veg / Non veg

Marital status/ Children/Menstrual history in detail

High risk behavior/Bladder/Bowel/Sleep

Immunization history

Socio-economic status/ over crowding

VI. Family history

TB/ Similar illness in the family

VII. Treatment history

VIII. Summary at the end of the history

IX. Impression/ DD


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General physical examination

Conscious/oriented/comfortable

Ht- Weight- BMI- Temp-

Pulse- (Rate, Rhythm, Volume, Character, Peripheral pulses. R-R/ R-F delay, Pulse

deficit, Vessel wall, Carotid bruit)

BP- mmHg, Respiration - Rate, Rhythm, Type (Abdomino-Thoracic / Thoraco-

Abdominal)

SpO2- BCG scar

P/J/Cy/Cl/LNE/PE/JVP/rash/facial plethora/neck veins/puffiness of face/ Pemberten

sign /Lt supra clavicular LN /Voice/asterixis

Signs of Malnutrition- Temporal / Buccal fat wasting, Hollowness of supraclavicular

infraclavicular fossae, Emaciated look

Nicotine stain- lips, Nail, teeth, gums, Vitamin deficiencies

Spine Kyphosis / Scoliosis /Gibbus, Skull

Peripheral signs of TB / Sarcoid / HIV

Marfanoid features, Thyroid, Testes, Low hair line, Horners Features, Congenital

anomalies

Systemic Examination

Respiratory System:

Upper Respiratory Tract

Ear, Nose ( polyps, postnasal drip, DNS )

Throat ( tonsils, oral hygiene, nicotine stain )


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Inspection

Chest symmetry, Pectus excavatum/ Carinatum

Shape of chest

Respiratory movements - equal / decreased

Tracheal position / Trail sign

Signs of volume loss shoulder droop/wasting ( supra/infra clavicular)/Nipple position/

Spino scapular distance/ Rib crowding/ Intercostal spaces

Intercostal space indrawing / Hoovers sign/Respiratory paradox/ Respiratory alternans

Accessary muscles of respiration

Apical impulse

Dilated veins/Scars/Sinuses/Visible pulsations/Skin

Palpation

Inspiratory findings confirmed

Tracheal position

Apical impulse

Rib crowding

Chest wall tenderness/ Crepitus / SC emphysema/ Nodules / LNE

Harrisons sulcus / Hoovers sign

Measurements

Chest

CircumferanceExpansion Hemithorax

Hemithorax

expansion

Spino

Scapular

Distance

Antero-

Posterior

Diameter

Transverse

Diameter

Right

Left


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Supra

Clavicular

Infra

clavicularMammary Axillary

Infra

Axillary

Supra

Scapular

Inter

Scapular

Infra

Scapular

Respiratory

Movement

Rt

Lt

Percussi

on

Rt

Lt

Kronigs

Isthmus

Rt

Lt

Percussion

over

clavicle

Rt

Lt

Percussion over Traube Space

Liver Dullness, Tidal Percussion

AuscultationSupra

Clavicular

Infra

clavicularMammary Axillary

Infra

Axillary

Supra

Scapular

Inter

Scapular

Infra

Scapular

Air EntryRt

Lt

VF, VRRt

Lt

VBSRt

Lt

Bronchial

Breathing

Rt

Lt

Wheeze/

Rhonchi

Rt

Lt

CracklesRt

Lt

Whispering

Pectroloquy

Aegophony

Pleural Rub


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Cardio-Vascular System

Apical Impulse

Precardial buldge, Parasternal heave

Palpable sounds, Thrill

S1,S2,S3,S4

Murmurs

Abdomen

Symmetry/Distension

All quadrants moves with respiration

Soft, Tenderness, Liver, Spleen, Any mass, Bowel sounds, Hernial orifices

Central Nervous System

Consciousness,Orientation

FND, Horners Syndrome, Planters

Summary after Examination

Diagnosis/DD

Investigation

Treatment


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Abdomen

I. Introduction

Name: Age: Sex: Handedness: Resident of:

Education: Occupation: Religion: Informant: Reliability:

II. Chief Complaints (in chronological order)

III. HOPI

1. Dysphagia- Onset, Solids/Liquids/Both, Odynophagia, progression

2. Heart burn,Reflux,Indigestion,Flatulence

3. Vomiting-Onset,Duration,Projectile/Non

projectile,Bilious/Nonbilious,Content,Preceded by nausea,Asso. with

hematemesis, Frequency,Aggravated by,Releived by, Last episode

4. Hematemesis-Onset, Color,Quandity, Preceded by nausea, Frequency,

Aggravated by, Releived by, Last episode

5. Melena- Frequency, Color, Consistency, Odour, Lasted for, Last episode

6. Abd.Pain-(OLDCAARTS)Onset, Location, Duration, Character,Colicky/Noncolicky,

Associated features, Aggravating and Relieving factors,Relation with food

Radiation, Time, Severity

7. Abd. Distension- Onset, Diffuse/Localised, Progress, Asso.with-

Pain/Fever/Constipation/Diarrhoea/Altered bowel habits/Nausea &

Vomiting/Hematemesis/Melena/BleedingPR/Jaundice/Menstrual

Irregularities/Oliguria/Anuria/Hematuria/Anorexia/Wt loss/Periorbital


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puffiness[To r/o Fat,Fluid,Faeces,Flatus,Foetus,Fatal growth,Liver & Kidney

diseases], Releived by [diuretics/fluid tapping etc], Intermittent/persistent

8. Fever- Grade, Max Temp, Type, Associated with chills& rigors, Diurnal

variation, Evening rise of temp., night sweats, relieved by, present status

9. Anorexia & Weight loss- Quantified/Unquantified, lntentional /Unintentional,

Significant/insignificant

10. Constipation- Frequency, Fluid intake

11. Diarrhoea-

Onset,Duration,Frequency,Consistency,Quantity,Color,Odour,Painful/Painless,Te

nesmus,Stickyness,Steatorrhoea, Feeling of incomplete evacuation,Mixed with

blood/mucus/undigested food,Abd. Pain, Abd. Distension

12. Bleeding Per Rectum

13. Oliguria/Anuria/Dysuria/Hematuria/Urine color/Periorbital puffiness/loin pain

14. Jaundice- Onset, Sites [skin, eyes, urine], Urine color, stool color, Preceded by

any Prodrome/Pain abd / Abd. Distension, Progress,

Persistent/Intermittent/Fluctuating Pruritus, Bone pains, night blindness, Easy

bruisiability ,Bitot spots,Bleeding manifestations, Altered sensorium, Lasted for,

Releived by

15. Symptoms of Liver cell failure-Alopecia/Jaundice/parotid swelling/loss of hair in

axilla,Pubis/Loss of libido/Gynaecomastia/palmar erythema/

Contratures/Testicular atrophy/Ascitis/Spider nevi/Hematemesis/Melena


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16. Altered Bowel habits

17. Joint pain/Rash/Photosensitivity/oral ulcers/Excessive hair

loss/Seizure/Abnormal behavior

18. Cough/Hemoptysis/Chest pain/Palpitation/dyspnoea

19. Well water drinking/Alternative medicine intake/Chronic drug intake

20. Blood transfusion

21. Pedal edema-Onset, Progression, Extension, Preceded/along with/after Abd.

Distension, relieved by

IV. Past History

DM/ HTN / TB/ Bronchial asthma/IHD

Childhood Jaundice

Jaundice/ Blood Txn

Allergies/ FB inhalation

Trauma/ Surgeries/ similar illness in the past

V. Personal History

Smoking - pack years/smoking index/ Chula smoking

Alcohol Quandity in gm/day X yrs, Type of liquor,last consumed, Binge drinking

Tobacco/Substance abuse

Veg / Non veg

Marital status/ Children

High risk behavior

Bladder/Bowel/Sleep

Menstrual History in detail

Occupation /Residence/Heavy metal exposure

Immunization history

Socio-economic status/ over crowding


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VI. Family history

Similar illness in the family

VII. Treatment history

VIII. Summary at the end of the history

IX. Impression/ DD

Examination

General physical examination

Conscious/oriented/comfortable

Ht- Weight- BMI- Temp-

Pulse- (Rate, Rhythm, Volume, Character, Peripheral pulses. R-R/ R-F delay, Pulse

deficit, Vessel wall, Carotid bruit)

BP- mmHg, Respiration - Rate, Rhythm, Type (Abdomino-Thoracic / Thoraco-

Abdominal)

P/J/Cy/Cl/LNE/PE/JVP/rash/Lt supra clavicular LN /asterixis

Signs of Liver Cell Failure-Alopecia, Jaundice, Bitots spots, Parotid swelling, Foetor

hepaticus, Spider nevi, Gynaecomastia, Loss of axillary/ pubic hair, Palmar erythema,

Deputuryn contracture, Asterixis , Ascitis, Testicular atrophy

Nicotine stain- lips, Nail, teeth, gums, Vitamin deficiencies

Spine Kyphosis / Scoliosis /Gibbus, Skull

Peripheral signs of TB / HIV


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Systemic Examination

Abdomen

Inspection

Symmetry

Distension- Generalised/Localised

Flanks

All quadrants moves with respiration

Umblicus

Skin over the Abdomen- Striae/pigmentation/Injection marks/Ascitic

tapping/Petechiae/Ecchymosis

Scars/Sinuses/Dilated/Prominent veins

Visible peristalsis/Pulsations

Hernial orifices

Palpation

Inspectory findings confirmed

Soft/ Guarding/ Rigidity

Tenderness-Localised/Diffuse/Dull/Severe/Specific area tenderness/Signs

Liver-Size/Extend/Border/Surface/Consistency/Tenderness/Moves with

respiration/intercostal tenderness

Spleen- Size/Extend/Border/Surface/Consistency/Tenderness/Notch/Moves with

respiration

Kidney- Above + Bimanually palpable, ballotability

Any other mass

Direction of venous flow


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Hernial Orifices

Testicular examination

Sister Joseph Nodules

Pulsations

Percussion

Fluid thrill/Shifting dullness/Puddle sign

Liver span

Traubes Space

Colonic band of resonance on the lt side

Various methods of percussion of Spleen- Nixon/Castell/Traube space

Auscultation

Bowel sounds/Hepatic bruit/Renal bruit/Venous hum

Perinium, Genitals

Per Rectal Examination

Per Vaginal Examination

Naked eye Urine & Stool Examination

Respiratory System

Chest wall symmetry

Respiratory movements

Percussion- any e/o PE

Air entry/NVBS/BB/Crackles/Rhonchi/Pl.Rub


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Cardio-Vascular System

Apical Impulse

Precardial buldge, Parasternal heave

Palpable sounds, Thrill

S1,S2,S3,S4

Murmurs

Central Nervous System

Consciousness,Orientation

FND, Horners Syndrome, Planters

Summary after Examination

Diagnosis/DD

Investigation

Treatment

Documents

Case sheet Proforma