Page 1 : 1, Format of medical case-sheet, Chief complaints and their interrogation:, , 1.general:, a)fever – duration, -- onset – sudden/insidious, -- chills/rigors, -- severity of fever, -- diurnal variation, -- sweating, -- type of fever, -- any other assosciated symptom, b)oedema/swelling – duration, --- onset, --- unilateral/bilateral, --- where did it appear first, --- progress, --- painful/painless, --- diurnal variation, --- any other(urine output), (note – bedridden patients may not complain of pedal oedema), c)pain --- duration, --- onset, --- site, --- type, --- radiation, --- aggravating factors, --- relieving factors, --- assosciated symptoms, --- any other, 2. symptoms suggestive of cardio-respiratory disease:, a)cough --- duration, --- onset – sudden/insidious, --- diurnal variation, --- postural variation, --- seasonal variation, --- any special character(eg. Whooping, bovine, brassy etc.), --- prolonged/short/paroxysmal, --- assosciated symptoms – syncope, vomiting, --- with/without expectoration, sputum --- quantity/24 hrs, --- quality, --- colour, --- odour, --- any h/o haemoptysis – duration, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 2 : 2, -- frequency, -- character(rusty/streaky/, frothy/frank blood), -- assosciated symptoms, --- any other (for eg. Salty taste – s/o alveolar cell Ca), b)breathlesness, , --- duration, --- onset – sudden/insidious, --- severity at its height, --- progress, --- aggravating and relieving factors, --- type – exertional/not exertional, --- if exertional, then grade the breathlessness, --- h/o wheeze, --- h/o orthopnea, --- h/o PND, --- h/o bluish discoloration of fingers/toes/nails, --- other unusual types eg. Platypnea/trepopnea, --- assosciated symptoms, , c)palpitations --- duration, --- onset, --- intermittent/sustained, --- regular/irregular, --- progress, --- how does it subside, --- assosciated symptoms, --- any other, d)chest pain – as in 1-c, (note – pleuritic chest pain is superficial, well localized and worsens on deep, breathing/coughing/sneezing. Anginal chest pain is deep seated and poorly localized, and worsens on exertion), e)fainting attacks(syncope) --- duration, --- frequency, --- position at onset, --- premonitory symptoms, 3.symptoms suggestive of G.I.T. disease, a)vomiting --- duration, --- frequency/24 hrs, --- assosciated nausea, --- abdominal pain(proceed with h/o pain as in1-c), --- contents of vomitus, --- colour of vomitus, --- projectile/non-projectile, --- blood in vomitus – fresh/altered, --- assosciated symptoms, --- any other, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 3 : 3, , b)loose motions --- duration, --- frequency/24hrs, --- type of stool – watery/rice water/semi solid, --- contents – worms/undigested food particles, --- colour, --- presence of blood or mucous, --- assosciated symptoms, --- any other, c)abdominal pain --- as in 1-c, d)loss of appetite --- duration, --- is it for any particular type of food, --- assosciated symptoms, --- any other, --- loss of weight, e)bleeding per rectum – duration, -----, , amount, colour-altered/frank blood/streaky, relation to defecation, malaena/haematochezia, , f)jaundice --- duration, --- how was it noticed, --- h/o high coloured urine, --- h/o clay coloured stools, --- h/o pruritus, --- h/o drug intake, --- assosciated symptoms, 4.symptoms suggestive of urinary tract disease:, a)frequency of micturition, b)pyuria, c)haematuria, d)burning micturition, e)flank or renal angle pain, ( for all the above symptoms enquire about the duration, onset, assosciated, symptoms, any other), 5.symptoms suggestive of C.N.S. disease:, a)loss of power – duration, -- onset, -- which are the limbs affected, -- which muscle groups affected(proximal/distal), -- details of events, -- progress, -- h/o stiffness, -- h/o thinning of the affected limbs(wasting), DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 4 : 4, -- h/o fasciculations/flexor spasms, -- any other, b)sensory complaints – tingling/numbness/pins and needles, sensation/burning sensation of palms, and soles etc., -- duration, -- onset, -- progress – where it began and how it, progressed to other parts, -- appreciation of hot/cold(eg. Bathing), -- appreciation of touch(clothes on body etc.), -- assosciated symptoms, -- any other, c)involuntary, movements(tremor/chorea/athetosis/hemiballism-us etc.) –, duration, -- onset, -- parts of body involved, -- aggravating factors, -- relieving factors, -- assosciated symptoms, -- any other, d)bladder – retention of urine, -- precipitancy, -- hesitancy, -- incontinence, -- automatic micturition, -- autonomous micturition, (enquire about the duration, onset, assosciated symptoms), f)bowel continence, g) h/o cranial nerve dysfunction – visual, disturbances/diplopia/dysphagia/dysphoria/deviation of the angle of the mouth etc.), , h)h/o loss of consciousness – details, g) h/o seizures or fits – duration, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955.., , ------------, , frequency, what was the pt. doing at the time of onset, focal/general, tonic/clonic, h/o tongue bite, h/o uprolling of eyes, h/o frothing, h/o incontinence, h/o any other injury, h/o sensory disturbances(tingling etc), h/o premonitory symptoms

Page 5 : 5, -- h/o precipitating factors(alcohol/tv/, menses etc.), -- h/o post ictal palsy/neurological deficits, h)h/o difficulty in speaking/reading, i)h/o raised ICP – headache(as in 1-c)/blurring of vision/vomiting, j)tinnitus/vertigo/giddiness/blackouts/syncope/drop attacks, -- duration, -- frequency, -- assosciated symptoms, -- any other, k)h/o trauma, l)h/o fever, m)h/o ear discharge, n)h/o bleeding tendencies, o)h/o exposure to environmental toxins, p)h/o recent vaccination, 6.consumption of poison, -- time and date, -- name/nature/quantity of poison consumed, -- symptoms developed after consumption of poison, -- time elapsed between consumption of poison and reaching, -- was stomach wash given, -- purpose of consumption, -- any other, 7.joint pains, -- duration, -- onset, -- joints involved in chronological order, -- h/o morning stiffness, -- h/o swelling of joints, -- h/o restricted movements, -- h/o joint deformity, -- assosciated symptoms(fever etc.), , Past history, -- any h/o similar complaints in the past, -- any other major illness like diabetes/TB/hypertension/jaundice, etc., -- h/o previous hospitalization - details, -- h/o major operations/accidents, -- h/o blood transfusion, -- any other, if answer is yes to any of the above, give details, Personal history, DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 6 : Diet –, Appetite –, Sleep –, Micturition –, Bowels –, Habits – smoking – duration/frequency/quantity/brand, -- alcohol – duration /frequency/quantity/brand, Family history, -- married/single, -- if married – duration, -- no. of issues/no. alive/abortions/pedigree chart, -- if unmarried – no. of brothers/sisters/their health and health of, parents, -- h/o hereditary/familial disease, -- h/o similar complaints/tb/hypertension/diabetes/infections, Sexual history, -- pre/extramarital sexual contact, -- h/o multiple partners, -- h/o visiting commercial sex workers, -- whether homosexual/heterosexual/bisexual, -- h/o penile ulcer, -- h/o inguinal swelling/urethral discharge etc., Socioeconomic history, -- social background and annual income, Examination, , General physical examination, 1.Build/nourishment/consciousness/co-operation/orientation, to time, place and person, 2.vital signs:, pulse – rate/rhythm/volume/force/tension/character of, vessel wall/any special character of pulse/radio-radial, or radio-femoral delay/peripheral pulsations, blood pressure – upper limb/lower limb, -- supine and standing, respiration –, rate/type/rhythm temperature, 3.height –, 4.weight –, 5. a)body mass index – weight(kg)/height(m)2, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 7 : 7, b)body surface area -6.scalp –, 7.eyes – palpebral conjunctiva, upper part of sclera, sclera on either side of the cornea, cornea, pupils, any other, 8.nose –, 9.oral cavity – lips, angular stomatitis, teeth and gums, tongue, oropharynx, any other, 10.ears – external pinna, external acoustic canal, 11.facies, 12.neck – thyroid, lymph nodes, jugular venous pressure, any other, 13.upper limbs – nails – clubbing/cyanosis/pallor, oedema, pigmentations, axillary lymphadenopathy, any other, 14.chest and abdomen, 15.lower limbs – nails, oedema, pigmentations, popliteal and inguinal lymphadenopathy, whenever there is pigmentation, it is to be described in terms of, distribution/type/any other, whenever there is lymphadenopathy it is to be described in terms of, group/number/size/consistency/tenderness/fixity(to each other and surrounding, structures)/catchment area, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 8 : 8, 16.markers of congenital heart disease – high arched palate/cleft lip/cleft, palate/polydactyly etc., 17.neurocutaneous markers – short neck/low hairline/vascular naevi/neurofibromata, 18.signs of liver cell failure – foetor hepaticus/spider naevi etc., 19.joints – swelling / erythema / deformity / effusion / tenderness – grade1- pt says, joint is tender; grade 2 – winces on touch; grade 3 – withdrawal of limb; grade 4 –, does not allow to touch, 20. sternal tenderness, , systemic examination: (affected system to be examined first), respiratory system, upper respiratory tract:, a)nose and nasal cavity, b)sinus points – frontal(right and left), ethmoidal(right and left), maxillary(right and left), c)oropharynx, lower respiratory tract:, a)inspection :, shape – lie of ribs, -- shoulder drooping, -- intercostals spaces, -- subcostal angle, -- distance between iliac crest, and costal margin, -- spine, -- supraclavicular fossae, -- spinoscapular distance, -- flattening / hollowing / fullness, conclusion regarding the shape and symmetry of the chest, movements with respiration – type of respiration, -- respiratory rate, position of mediastinum – traile’s sign(present/absent), -- apical impulse, , b)palpation:, confirmation of respiratory movements, position of mediastinum – trachea, -- apical impulse, conclusion regarding position of mediastinum, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 9 : 9, , tenderness – intercostals spaces, -- ribs, measurements:, - anteroposterior diameter(cm), - transverse diameter(cm), - AP diameter: Transverse diameter ratio, - chest circumference(cm), during deep inspiration –, during l expiration –, expansion =, - right hemithorax, circumference deep inspiration, – expiration –, expansion =, - left hemithorax, circumference deep, inspiration – expiration –, expansion =, - spinoscapular distance –, - spinoacromion distance –, tactile vocal fremitus, friction fremitus, c)percussion, identical areas on both sides – supraclavicular, clavicular, infraclavicular, mammary,, axillary, infraaxillary, suprascapular, upper, interscapular, lower interscapular, infrascapular, upper border of liver dullness, tidal percussion, kronig’s isthmus, traube’s space, superficial cardiac dullness(present/obliterated), note: whenever lower part of the chest wall is dull to percuss:, -- upper border of liver dullness – type of line, -- shifting dullness, -- percussion note above the level of dullness, d)auscultation, intensity of breath sounds, type of breath sounds – vesicular, -- vesicular with prolonged expiration, -- bronchial –, tubular/cavernous/amphoric adventitious sounds – wheeze, -- crepitations, -- rub, vocal resonance –, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 10 : 10, e)special tests, for cavity – post tussive crepitations, -- post tussive suction, -- whispering pectiroloquy, -- egophony/bronchophony, for hydropneumothorax – succussion splash, -- coin test(over pneumothorax part), , cardiovascular system, peripheral CVS, pulse – rate, -- rhythm, -- volume, -- force, -- tension, -- character of vessel wall, -- any special character of pulse, -- radial-radial comparison, -- radial-femoral comparison, -- other peripheral arterial pulsations, dorsalis pedis, posterior tibial, popliteal, femoral, brachial, carotid, , right, , left, , signs of CCF – jugular venous pressure-height of column, -- waveforms and character, -- liver, -- dependent oedema, -- hepato-jugular reflux, , blood pressure – upper limb, -- lower limb, -- supine and standing, others – clubbing, -- cyanosis, -- markers of congenital heart disease(arachnodactyly/, hyperteleorism/high arched palate/radial deformity of, forearm/low hair line etc), -- signs of infective endocarditis, -- s/o ischaemia I)asymptomatic II)intermittent claudication III)pain at rest, IV)tissue loss, -- peripheral signs of AR, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 11 : 11, -- s/o of thromboembolism, -- s/o hyperlipidemia – xanthelasma / xanthoma, -- features of acute rheumatic fever, -- optic fundi, central CVS, inspection:, - shape of chest – pectus excavatum / kyphoscoliosis, - precordial bulge, - location of apical impulse, - pulsations other than apical impulse, -epigastric, -left parasternal pulmonary area suprasternal supraclavicular scars / sinuses, palpation:, - location of apical impulse and character, - left parasternal heave, - epigastric pulsations, - diastolic shock, - supraclavicular pulsations, - thrills, - any other pulsations, - tracheal tug, percussion:, - left border, - right border, - left 2nd space, - right 2nd space, - upper part of sternum, - lower part of sternum, auscultation:, heart sounds, - 1st heart sound, - 2nd heart sound, - splitting of heart sounds, - added sounds, murmurs, - site where best heard, - timing, - character, - grade, - pitch, DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 12 : 12, -, , conduction, which body position best heard, relation to phase of respiration, better heard with bell or diaphragm, special manoeuvres to alter the murmur(dynamic auscultation), , pericardial rub –, note: auscultation should proceed in the following manner, mitral, area>tricuspid area>neoaortic area>pulmonary area>aortic area, note:never comment on the 2 nd heart sound in the mitral and tricuspid areas,, never comment on the 1st heart sound in the pulmonary and aortic areas, , per-abdominal examination, inspection, - shape, - visible peristalsis, - movements with respiration(quadrants of the abdomen), - engorged veins(which part of abdominal wall/direction of flow), - umbilicus, - hernial orifices (epigastric/umbilical/incisional/inguinal/femoral), - divarication of recti, - skin of abdominal wall (operation scars/branding marks/pigmentations etc), - scrotum, - signs of chronic hepatocellular failure, palpation, superficial – tenderness, --- rigidity, deep – liver (size/surface/margin/consistency/tenderness), -- spleen (size/surface/margin/consistency/tenderness), -- kidneys (size/surface/margin/consistency/tenderness), , Percussion, For free fluid in the abdomen, - fluid thrill (grade 4), - horse-shoe shaped dullness (grade 3), - shifting dullness (grade 2), - percussion around umbilicus with patient in knee-elbow position (grade 1), - puddle’s sign (minimal fluid), organ percussion, - liver, - spleen, - other lumps, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 13 : 13, , auscultation, - peristaltic sounds, - arterial bruits, - paraxiphoid venous hum, - rubs – hepatic/splenic, - foetal heart sounds and uterine souffle, per rectal / per vaginal examination -, , central nervous system, higher, -, , mental functions, consciousness – if impaired document using Glasgow-coma scale, memory, intelligence, mood/emotion, concentration and calculation, intelligence / logical thought, apraxias, hallucinations and delusions, orientation to time/place/person, speech, - spontaneous speech - comprehension, - fluency, - word output, - neologisms, - rending, - writing, - repetition, - naming objects, - phonation, - aphasia, - dysarthria, conclusion:, cranial nerves, 1st nerve(olfactory) – sense of smell, 2nd nerve(optic), - visual acuity (finger counting), - field of vision (confrontation method), - colour vision, - optic fundi, 3rd , 4th, 6th nerves(oculomotor,trochlear,abducens), inspection, - diplopia, - squint, - nystagmus, - ptosis, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 15 : 15, 9th and 10th nerves(glossopharyngeal and vagus), palate, - nasal twang of voice, - nasal regurgitation of food, - position of uvula, - ‘aah’ test, - palatal reflex, pharynx, - secretions pentup in oropharynx, - dysphagia, - pharyngeal reflex, larynx, - hoarseness of voice, - indirect laryngoscopy, tongue, - taste sensation from the posterior 1/3 of tongue, 11th nerve(accessory), - sternocleidomastoid, - trapezius, 12th nerve(hypoglossal), - appearance of tongue in oral cavity (wasting etc), - deviation of tongue on protruding it, - power in muscles of tongue, - tone of tongue, - fasciculations, , motor system, nutrition, - small muscles of the hand, - forearm(above styloid process), - upper arm(above medial epicondyle), - leg(above medial malleolus), - thigh(above adductor tubercles), conclusion:, , right, , left, , tone (spasticity/rigidity – cogwheel,leadpipe), - wrist, - elbow, - knee, - ankle, - any other – focal dystonia etc., , right, , left, , power (MRC grade), shoulder – flexors, -- extensors, -- abductors, -- adductors, , right, , left, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 17 : 17, -- wartenberg’s sign, primitive / release reflexes -, , sensory system, touch, - crude touch, - pressure, pain, - superficial, - deep, temperature, - hot, - cold, posterior column sensations, - vibration sense (128 hz), - muscle and joint sense, - fine touch(discriminative), - rhomberg’s sign, cortical sensations, - tactile localization, - stereognosis, - cerebral extinction/inattention, - dermatography, - sensory inattention, cerebellar signs, - nystagmus, - staccato/scanning speech/dysarthria, - hypotonia, - dysmetria, - rebound phenomenon, - intentional tremor, - pendular knee jerk, - attitude, - gait, - ataxia, - titubation, - any other, stance / gait / attitude, miscellaneous, − skull and spine –, − signs of meningeal irritation – neck rigidity, -- head Brudzinski’s sign, -- leg Brudzinski’s sign, -- Kernig’s sign, -- straight leg raising sign of Lasegue, , DR.VISHWA MEDICAL COACHING, WHATSAPP +919930788955..

Page 18 : 18, −, , neurocutaneous markers :-, , -, , vascular naevi, neurofibromata, low hairline, short neck, , −, −, −, , peripheral nerves and A.N.S., sphincters, carotid artery pulsations/auscultation, , PROVISIONAL DIAGNOSIS, (should contain ANATOMICAL,PATHOLOGICAL and AETIOLOGICAL, considerations, and whenever applicable – COMPLICATIONS)