CENTRAL NERVOUS SYSTEM INTRODUCTION
1. Name Name 2. Age Age 3. Sex 4. Handed Handednes ness s 5. Reside Resident nt of 6. Educat Education ion 7. Oc Occup cupati ation on 8. Inform Informant ant 9. Reliab Reliabili ility ty CHIEF COMPLAINTS
1. Xxxxxx Xxxxxx – Onset Onset and course course 2. Yyyyyy Yyyyyy – onset onset and course course 3. Zzzzz Zzzzzzz zz – onset onset and course course H/O PRESENT ILLNESS
1. LOC/Se LOC/Seiz izure ure a. Onse Onsett b. Activity Activity at the the time time of incident incident c. Prec Preced eded ed by i. Chest Chest pain/Palp pain/Palpitati itationswe onsweating ating/nau /nausea sea// vomiting/ vomiting/ ii. headache headache/gidd /giddiness iness/pre /presynco syncope/ pe/visua visuall disturbance. disturbance.
d. Associ Associate ated d with with i. Involunta Involuntary ry movt/Ton movt/Tonic/cl ic/clonic/ onic/foca focal/gen l/general eralize ized d ii. Rolling Rolling up of of eyes/st eyes/stare/ are/tong tongue ue bite/gru bite/grunting nting noise
iii. iii. Sphin Sphincte cterr incont incontine inence nce/ab /abnor normal mal breath breathing ing patter pattern n
e. Lasted Lasted for (Duration) (Duration) f. Reco Recove vere red d aft after er – Spon Spont/ t/tr trea eatm tmen entt g. Post recovery recovery – drowsiness drowsiness/con /confusion/ fusion/weakn weakness ess h. Numbe Numberr of episod episodes es i. Sensor Sensorium ium in between between episod episodes es j. Last episode k. Any inju injury ry susta sustained ined..
2. Disorient Disorientation ation a. To T/P/ T/P/P P b. Episodic Episodic or contin continuous uous c. Orientatio Orientation n between between the episode episodes s d. Any abnormal abnormal behavior behavior e. Reco Recove very ry
3. Speech Speech disturbanc disturbance e a. Onse Onsett b. Compre Comprehen hensio sion n c. Any spontan spontaneous eous speech/w speech/word ord outflow outflow d. Slur Slurri ring ng e. Reading/w Reading/writin riting/repet g/repetition ition f. Pro Progre gress ssio ion n g. Any stress stress during during speaking speaking h. Tightness Tightness/loos /looseness eness in tongue tongue i. Paraphasias
4. Cranial Cranial Nerves Nerves I.
Sme Smell to comm commo only nly us used ite items soap/shampoo/toothpaste
II.
III.
Decrea reased vi visual acu acuity Colo Colorr visi vision on Color desaturation Scotoma/Field defect IV and VI i. Doubl ouble e vis visio ion n 1. Monooc Monoocula ular/b r/bino inocul cular ar 2. On prima primary ry gaze gaze or evoked evoked gaze 3. Horion Horiontal tal/ve /verti rtical cal 4. Disappear Disappears s by by (Closing (Closing eye) ii. Pain Pain in eyes eyes on movem movement ents s iii. iii. Ptosi Ptosis s – Fatig Fatiguab uabili ility ty/di /diurn urnal al vari variati ation on iv. Featu Features res of Horn Horner ers s syndr syndrome ome
IV. V. VI. VII. II.
VIII.
IX.
Same as above Decr Decrea ease sed/ d/ab abno norma rmall sensa sensati tion ons s over over face, face, diff diffic icult ulty y in mastication. Same as above Dev Deviati iatio on of of ang angle le of mout mouth h Facial asymmetry Drooling of saliva Difficulty in closing eyes Difficulty in speaking Taste impairment Hearing im impairement Giddiness Vertigo Tinnitus H/O CSOM And X Dysphagia Dysphagia – solid/liqu solid/liquid/bot id/both h Dysphonia
Dysarthria Nasal regurgitation Hoarseness of voice/Nasal twang X. Same as above XI. Neck movements Shrugging of shoulders XII. XII. Abil Abilit ity y to to mak make e the the bolu bolus s of of foo food d Ability to maneuver maneuver the food bolus inside the mouth mouth Tongue deviation Dysarthria
5. Moto Motor r a. Weakne Weakness ss (UMN) (UMN) i. ii. iii. iv. v. vi. vii. viii. ix. x.
Reaching Reaching overhead overhead object objects/ta s/taking king comb to the the head head Lifting Lifting a bucket bucket of water water/bre /breaking aking the chapaties chapaties Holding Holding a glass of water water/writ /writing ing task task in detail detail Holdin Holding g the pen/ pen/gra graspi sping ng the the comb comb Difficulty Difficulty in getting getting up from from a chair/sq chair/squatti uatting ng positio position n Climbing Climbing up/dow up/down n the stairs/ stairs/grip gripping ping the the chapp chappals als Chappals Chappals slips away away with/with with/without out the the knowl knowledge edge Getting Getting up from from lying lying down down position position/Tur /Turns ns in the the bed Liftin Lifting g the the head head off off the bed Breathles Breathlessnes sness/pto s/ptosis/f sis/facial acial weakness/c weakness/chew hewing ing
b. Dext Dexter erit ity y i. ii. iii. iii. iv. iv.
Butto Buttonin ning/u g/unbu nbutto ttonin ning g the shirt/ shirt/ Breaki Breaking ng the the chap chapat aties ies Tie the nada nada of payj payjama ama/sh /shoe oe lace lace Negoti Negotiati ating ng the the foot foot into into the chapp chappal al Also Also ask ask abou aboutt 1. Prox Proxim imal al/d /dis ista tall 2. Symmetric Symmetrical/as al/asym ymmetr metrical ical 3. Spas Spasti tici city ty/w /was asti ting ng – whic which h is more more? ? 4. Onset Onset and progres progression sion of the the weaknes weakness s 5. Pres Presen entt statu status. s.
c. Weak Weakne ness ss (LMN (LMN)) i. ii. iii. iii. iv. v. vi. vi. vii. vii.
Loosen Looseness ess/fa /fasci scicul culati ation ons/w s/wast asting ing Which Which is earlie earlierr – weakne weakness ss or wastin wasting g Prox Proxim imal al/d /dis ista tall Symme Symmetri trical cal/as /asym ymmet metric rical al Periodici Periodicity/di ty/diurna urnall variat variation ion,, fatigu fatiguabili ability ty Sele Select ctiv ivit ity y of mus muscl cles es Onset/ Onset/cou course rse/pr /progr ogress ession ion
d. Cere Cerebe bell llar ar i. ii. iii. iii. iv.
Smearing Smearing of face/ face/targe targett oriente oriented d activit activities ies Tremors/ Tremors/Gait/ Gait/Spee Speech/V ch/Verti ertigo/Lo go/Loosen oseness ess of limbs limbs Diffic Difficult ulty y in reachi reaching ng the the objec objects ts Incoordin Incoordination ation during during pickin picking g up water/dur water/during ing drinking drinking..
e. EPS i. ii. iii. iv.
Tremors Tremors at at rest/St rest/Stiffn iffness/e ess/expres xpressionl sionless ess face Brady Bradykin kinesi esia a – during during bath/ bath/dre dressi ssing ng etc. etc. Sleep/Me Sleep/Memory mory/Hand /Handwr writing iting/Hypo /Hypophoni phonia/Gai a/Gaitt Difficulty Difficulty in walking walking narrow narrow paths paths (Pede (Pedestria strian n strip) strip)
f. Gait i. ii. iii. iv. v.
Broad Broad based/ based/Nar Narrow row base base Speed/An Speed/Antalgi talgic c gait/Free gait/Freezing/ zing/Park Parkinso insons ns gait features features Recurren Recurrentt falls/Bu falls/Bucklin ckling……… g………/Clim /Climbing bing up/down up/down Difficulty Difficulty in walkin walking g in dark/ dark/Pain Pain while walking walking Stiff Stiffnes ness/c s/cros rossin sing g of legs legs
6. Sens Sensor ory y a. Onset/pro Onset/progres gression/ sion/prese present nt status b. Poster Posterior ior colu column mn i. ii. iii. iv. v.
Unab Unable le to to feel feel clo cloth the es over over the the bod body y Difficulty Difficulty in walking walking in the dark/w dark/wash ash basin basin (Sink) (Sink) sign sign Slipping Slipping of slippers slippers withou withoutt knowled knowledge ge Cotton Cotton wool wool sens sensati ations ons over over the the feet feet Band like sensation sensation/En /Encasem casement ent of limbs limbs
vi. Pins and and needles/n needles/numbn umbness/ ess/tingl tingling/p ing/parae araesthe sthesias sias vii. Lhermitt Lhermittes es phenomen phenomenon/ on/wate waterr flowing flowing undernea underneath th the feet
c. Spin Spinot otha hala lami mic c i. ii. iii. iii. iv.
Hot and cold cold water water during during bath bath Burni Burning/ ng/sho shooti oting/ ng/pri pricki cking ng pain Funic Funicula ularr pain/s pain/sens ensory ory level level Root pain is is a sharp sharp shoot shooting ing pain pain in in a particu particular lar n dermatomal pattern which increases on coughing/sneezing. coughing/sneezing. It is recurrent and more severe.
d. Cortic Cortical al sensatio sensations ns i. Abili Ability ty to feel feel the the coin coins s in the the pocket pocket ii. ii. Feel Feel wal walle lett in the the poc pocke kett
7. Autono Autonomic mic a. Blad Bladde der r i. ii. iii. iv. v.
Urgency/ Urgency/urge urge incont incontinen inence/fr ce/frequen equency/he cy/hesitan sitancy cy Precipita Precipitancy/R ncy/Reten etention tion (Painful/ (Painful/less less & aware/u aware/unawar naware) e) Overflow Overflow incontine incontinence/i nce/incom ncomplete plete evacuati evacuation on Dribbling Dribbling of urine/ urine/los loss s of social social inhibiti inhibition on Postural Postural giddin giddiness/p ess/presy resyncop ncope/er e/erectil ectile e dysfunctio dysfunction n
b. Bowel Bowel – Frequency/ Frequency/consi consistency stency/cont /continenc inence e c. Faintn Faintness ess/pa /palpi lpitat tations ions d. Abnormal Abnormal sweating/Dec sweating/Decrease reased d lacrimation e. Horner Horners s syndr syndrome ome f. Gastro Gastropar paresi esis/n s/nause ausea/v a/vomi omitin ting/di g/diarr arrhea hea ETIOLOGICAL HISTORY 1. Headac Headache he
(Mnemo (Mnemonic nic – OLD CAARTS CAARTS))
a. Onset/location/duration/diurnal Onset/location/duration/diurnal variation/Ch…….
b. Associated with(Nausea/vomiting/photo with(Nausea/vomiting/photophobia/ phobia/ phonophobia/ 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 episodes in a day)/abnormal da y)/abnormal sweating g. Pain anywhere in the body 2. Injury/RTA/Trauma
to the neck 3. Abnormal behavior/nausea/vom behavior/nausea/vomiting iting 4. Fever/chest pain/palpitations/cough/ dyspnea/hemoptysis 5. Bowel symptoms/Jaundice symptoms/Jaundice 6. Oliguria/dysuria/hematuria/high colored urine 7. Joint pain/rash/photosensitivity/oral pain/rash/photosensitivity/oral ulcers /hair fall/seizures 8. Dog bite/animal bite/vaccination/injection bite/vaccination/injection 9. Alternative drugs/well water drinking/insecticides drinking/insecticides exposure 10. Carrying weight in head for long/neck pain for long 11. Skin lesions/Nodules lesions/Nodules 12. 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 bite/vaccination/injection in the past 4. Blood transfusion/jaundice transfusion/jaundice 5. Major surgery PERSONAL HISTORY
1. Veg/Non
veg/Well water drinking/food habits 2. Smoking/Tobacco/Alcohol/Substanc Smoking/Tobacco/Alcohol/Substance e 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 dye/paint/glasswares/med eqpts/jwellery 3. Plumbing/farming/insecticides Plumbing/farming/insecticides 4. Vibrating eqpts/repeated trauma FAMILY HISTORY
Pedigree charting of possible genetic disease 2. h/O similar illness in the family
1.
TREATMENT HISTORY SUMMARY at the end of history and four tier diagnosis 1. Functional
2. Physiological Physiological 3. Anatomical
4. Etioloical 1, 2, 3, 4…… GENERAL EXAMINATION 1. Conscious/oriented/coopera Conscious/oriented/cooperative/comfo tive/comfortably rtably lying……… 2. Ht/Wt/BMI/Arm length/upper segment/lower segment/neck:ht ratio. 3. Pulse Rate/rhythm/volume/char Rate/rhythm/volume/character/periphe acter/peripheral ral 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/rhy rate/rhythm/ thm/type type 6. P/I/C/C/L/E/JVP P/I/C/C/L/E/JVP 7. Neurocutaneous markers 8. Nerve thickening 9. Vitamin deficiencies 10. Xanthoma/xanthelasma/arcus Xanthoma/xanthelasma/arcus senilis 11. Congenital anomalies anomalies – arms/foot/chest/gums/teeth/ha arms/foot/chest/gums/teeth/hair ir change 12. acanthoma nigricans/scars/sinus nigricans/scars/sinus 13. Features of hypo/hyper hypo/hyper thyroidism 14. acromegaly/marfans 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. CVS a. Apical Impulse/chest wall symmetry/anomalies b. S1/S2/S3/S4/murmur/pericardial rub/knock
2. RS a. Chest wall symmetry b. Air entry/Breath sounds/adventitious sounds/pleural rub
3. P/A a. 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. Lang Languag uage-S e-Spe peech ech (Mnemo (Mnemonic nic – CNS R3) R3) i. Comprehension ii. Naming iii. Spontaneous speed iv. Reading v. Writing vi. Repetition g. Language Language – Dysarthria Dysarthria i. UMN/Pseudobulb UMN/Pseudobulbar ar – “British constitution” constitution” ii. Bulbar Bulbar – Pa Ta Ka iii. Cerebellar – Rashtrapaty Rashtrapaty Amritsar se Hyderabad Hyderabad gaye Ask to repeat “Yellow “Yellow Lorry”. Lorry”. iv. Tongue muscles fasciculations/flaccidity. fasciculations/flaccidity. v. NMJ – Fatiguab Fatiguability ility/Nasa /Nasall voice. voice. 2. Cranial
Nerves
I - Coffe powder/soap/shampoo/t powder/soap/shampoo/tooth ooth paste II - Acuity uity/C /Co olor lor/fie /field ld/p /pu upils pils/R /RA APD/Fu D/Fund ndus us.. III/IV & VI - Posi Positi tion on of the the eye eye at prim primar ary y gaz gaze e
- Conj Conjug ugat ate e eye eye mov movemen ements ts a. convergence/divergence/saccad convergence/divergence/saccades/pursuits es/pursuits - Individua Individuall eye moveme movements nts - Nyst Nystag agmu mus s V -
Facia Faciall sensat sensation ions s touch touch/pa /pain/ in/tem temp/v p/vibr ibrati ation on Musc Muscle les s of of mas masti tica cati tion on-- clen clench ch the the tee teetth Movem vements nts of of man mand dible ible Corneal reflex Jaw reflex
-
Wrin rinklin kling g of of for foreh ehe ead Frow Frowni ning ng of of eyebr eyebrow ows/ s/ey eyel elid id clos closur ure e Bells Bells phenom phenomeno enon/f n/faci acial al expres expressio sion/n n/naso asolab labial ial fold fold Angle Angle of mouth mouth deviat deviation ion/bu /bucci ccinat nators ors Tast Taste e sens sensat atio ion n ant ant 2/3 2/3rd – sugar/vinegar/salt sugar/vinegar/salt Paro Paroti tid d swel swelli ling ng/t /ten ende dern rne ess Herpe erpes s zost zoste er in EAM
VII
VIII - Rinn Rinnes es/w /web eber ers/ s/AB ABC C/Ear /Ear exam examin inat atio ion n IX & X - Uvular po position - On sayin saying g “AH” “AH” uvula uvula/pa /palat latal/ al/pos postt phar. phar. wall mov moveme ement nt - Gag reflex - Taste on on po post 1/ 1/3rd of tongue - Dysp Dyspho honi nia/ a/dy dysp spha hagi gia a test testin ing g (??? (????? ??)) XI - Shrugging Shrugging of shoulde shoulders rs - Left/r Left/righ ightt turn turn of of neck neck (SCM) (SCM) XII - Tongu Tongue e posit position ion in rest resting ing state/ state/on on prot protru rusio sion n - Flacci Flaccidit dity/f y/fasc ascicu iculat lation ions/t s/trem remors ors/sp /spast astici icity ty - Myoton Myotonia/ ia/mov movem ement ents/D s/Devi eviati ation on of tongu tongue e
3. Motor
system examination
Position/attitude of limbs a. Position/attitude b. Bulk (wasting/hypertrophy) c. Tone i. Spastici Spasticity ty – clasp knife ii. Rigidity Rigidity – cog wheel/le wheel/lead ad pipe iii. Flaccidity iv. Fasciculations d. Power i. Shoulder – Abduction/adduction/flexion/ex Abduction/adduction/flexion/extension tension (5/5) ii. Elbow – Flexion/e Flexion/exte xtensio nsion n (5/5) iii. Wrist – Dorsiflexion/Palmar Dorsiflexion/Palmar flexion (5/5) iv. Hand grip – Percentage (25/50/75), Myotonia Myotonia (+/-) v. Individual muscles of hand – Normal or weak. vi. ------vii. Hip - Abduction/adduction/flexion Abduction/adduction/flexion/extension /extension (5/5) viii. Knee Knee - Flexion/extension Flexion/extension (5/5) ix. Ankle – Dorsiflexion/Plantar Dorsiflexion/Plantar flexion (5/5) x. EDP muscle wasting – Present/not xi. Truncal Truncal weakness – Percentage (25/50/75) (25/50/75) xii. Neck Neck muscle muscle weakne weakness ss - Percentag Percentage e (25/50/7 (25/50/75) 5) (Flexion/extension/lateral (Flexion/extension/lateral flexion) e. DTR i. Biceps/triceps/supinator/kn Biceps/triceps/supinator/knee/ankle ee/ankle ii. Clonus (+/-) iii. Myotonia (+/-) iv. Pseudomyotonic reflex
f. Superficial Reflexes i. Plantar ii. Abdominal iii. Cremastric
iv. Perianal reflex g. Whartenburg sign
h. Koffma Koffman n sign sign j. Release reflexes reflexes i. palmo mental ii. Glabellar tap iii. Rooting reflex iv. Suckling reflex v. Grasping reflex k. Coord Coordin inat atio ion n – UL/L UL/LL L 4. Sensory
System Examination
a. Superficial sensations i. First test pin prick sensation ii. Touch b. Deep sensations i. Pain ii. Temper Temperatur ature e – Cold (Tuni (Tuning ng fork) fork) and and warm
c. Combined i. Vibration - Forehead/Mastoid/Ste Forehead/Mastoid/Sternum/Verteb rnum/Vertebral ral spine - Clavicle/E Clavicle/Elbow lbow/wris /wristt - ASIS/PSIS/Tibial ASIS/PSIS/Tibial tuberosity/ankle ii Joint position - Great Great toe/index toe/index finger finger d. Cortical sensations I all the peripheral peripheral sensations sensations are intact, then, check for cortical sensations. e. Lhermittes phenomenon f. Rhombergs sign g. determine pattern of sensory loss
i. Symmetrical/asymmetrica Symmetrical/asymmetricall ii. Glove stocking/Patchy stocking/Patchy iii. Root level
5. Cerebellum a. Nystagmus i. Primary gaze ii. evoked gaze iii. Horizontal/vertical/torsional Horizontal/vertical/torsional iv. Fatiguable/not
b. Intention tremor c. Rebound phenomenon (Holmes) d. Dysmetria (these tests to be done 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 knee with heel heel to r/o sensory sensory loss - Then excursion excursion along skin of the tibia (Cereb (Cerebell ellar ar – broken broken movem movement ents) s) (Sensory – waving of heel here here & there) 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 Pronation – supination (Disdiadochokinesia) (Disdiadochokinesia) iv. Alternating opening and fisting of both hands v. Screwing like movements movements vi. Door knob opening like movements vii. Opposition of thumb and fingers viii. Tap out simple rhythm with finger. finger.
g. Speech h. Hypotonia j. Pendular knee knee jerk k. Titubation l. Gait and how the patient stands m. Drift i. Cerebe Cerebellar llar – Upward Upward ii. Pyramida Pyramidall – Down and prona pronated ted iii. Parietal Parietal lesion – Upward and and wavy wavy
6. Gait 7. EPS a. Rigidity
b. Tremor c. Mask like face d. Gait e. Micrographia f. Hypophonia g. Hypomimia
8. ANS a. Postural hypotension b. Sweating
examination SUMMARY At the end of examination FOUR TIER DIAGNOSIS
CARDIOVASCULAR SYSTEM INTRODUCTION 1. Name Name 2. Age Age 3. Sex 4. Handed Handednes ness s 5. Reside Resident nt of 6. Educat Education ion 7. Oc Occup cupati ation on 8. Inform Informant ant 9. Reliab Reliabili ility ty
CHIEF COMPLAINTS 1. Xxxxxx Xxxxxx – Onset Onset and course course 2. Yyyyyy Yyyyyy – onset onset and course course 3. Zzzzz Zzzzzzz zz – onset onset and course course
H/O PRESENT ILLNESS 1. Ches Chestt Pain Pain (Mne (Mnemo moni nic c – OLD OLD CAAR CAARTS TS)) a. Onset/location/duration/diurnal variation/Ch……. b. Associated with(Nausea/vomiting/photo with(Nausea/vomiting/photophobia/ phobia/ phonophobia/ phonophobia/ abnormal ab normal behavior/LOC /blurring of vision c. Red flag signs d. Preceded by aura e. Aggravated by/relieved by/timing/severity/ f. Frequ Frequency ency (No of epis. epis. in a day)/abn day)/abn sweating sweating
g. Pain anywhere in the body/ h. Diurnal variation/progress/present status j. NYHA Class
2. Palpitati Palpitations ons a. Onset Onset – Rest/e Rest/exer xertio tional, nal, Dura Duratio tion n b. Regula Regular/i r/irre rregu gular lar c. Aggrav Aggravate ated/r d/reli elieved eved by d. Associ Associate ated d with with i. Presyn Presyncop cope/s e/sync yncope ope/swe /sweati ating/ ng/anx anxiety iety ii. Post Post palpi palpitat tation ions s dier dieresi esis s e. Progress/P Progress/Presen resentt status f. NYHA Class
3. Dyspno Dyspnoea ea a. Onse Onsett b. Prog Progre ress ssio ion n c. Dura Durati tion on d. Rest same same as as for Palpita Palpitations tions e. Any Orthopne Orthopnea/PN a/PND/Platy D/Platypnea pnea/Trep /Trepopnea opnea f. Present status/NYHA Class
4. Easy Fatigua Fatiguabili bility ty a. Quantity and quality of the fatigue in terms of patient p atient activity activity which he he used to to do before before and now. now. b. Progress/Present status c. NYHA Class
5. Syncope Syncope and pre-synco pre-syncope pe a. As Described in CNS
6. Cough and expectoration/Hemop expectoration/Hemoptysis tysis a. As described in Respiratory system
7. Feve Fever r a. Onset/ Onset/dur durati ation on b. Continuou Continuous/int s/intermitte ermittent/re nt/remitte mittent nt c. Any evenin evening g rise rise d. Subsides Subsides on on medication medication/not /not e. Chills Chills/ri /rigo gors rs f. Associate Associated d headache/b headache/bodya odyache/ che/sweat sweating ing
8. Anor Anorex exia ia and and wei weigh ghtt los loss s 9. Recurrent respiratory tract infections 10. Failure to thrive 11. Cyanosis a. Location Location – Sclera/lips/ Sclera/lips/tong tongue/ti ue/tip p of nose/ear nose/ear lobule/ lobule/ finger/toes b. Onset c. Lasted for d. Relieved by e. Any associated pain/paraesthesias pain /paraesthesias
12. Clubbing 13. Hoarseness of voice 14. Edema a. Onset b. Progress c. Extent d. Any involvement of UL/Abdomen/Face/Sacral
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 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 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/Constipation iv. Weight gain/Poor appetite b. Hyperthyroidism i. Heat intolerance/palpitation intolerance/palpitations/fatigue s/fatigue ii. Increased appetite/weight loss iii. Tremor/restlessness/Hyperdefecation
iv. Loss of libido
21. CTD history
PAST HISTORY 1. 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/Substanc Smoking/Tobacco/Alcohol/Substance e abuse 3. Marriage/Children 4. High Risk behavior
MENSTRUAL HISTORY 1. Menarche/Cycles/Menopause
2. LMP/Post menopausal bleed 3. any surgery
FAMILY HISTORY 1. H/O simila similarr illness illness in the family family 2. Socioeconomic status/Poverty/overcrowded place
TREATMENT HISTORY 1. Penicillin prophylaxis/digoxin/diuretics prophylaxis/digoxin/diuretics 2. Surgery/intervention
SUMMARY at the end of history. 1. D/ D/D 1, 2, 2, 3, 3, 4… 4……
GENERAL EXAMINATION 1. Conscious/oriented/coopera Conscious/oriented/cooperative/comfo tive/comfortably rtably lying……… 2. Ht/Wt/BMI/Arm length/upper segment/lower segment/neck:ht ratio. 3. Pulse Rate/rhythm/volume/char Rate/rhythm/volume/character/periphe acter/peripheral ral 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, difference, Take all four limbs 5. RR – rate/rhy rate/rhythm/ thm/type type 6. P/I/C/C/L/E 7. JVP – Height/waveform/promin Height/waveform/prominent ent wave/H-J wave/H-J reflex 8. Peripheral signs of AR/IE/RF AR/IE/RF 9. Marfanoid features/WHR features/WHR 10. Xanthoma/xanthelasma/Pseudoxanthoma elasticum/arcus senilis 11. Hypertelorism/low Hypertelorism/low set ears/micrognathia/orange ears/micrognathia/orange f……… 12. Telengiectasias/bronze Telengiectasias/bronze discoloration/acanthoma discoloration/acanthoma nigricans 13. Features of hypo/hyper hypo/hyper thyroidism 14. acromegaly/marfans 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 Scars/sinuses/lupus perenio/erythema perenio/erythema nodosum/lipemia nodosum/lipemia retinalis 19. Spin Spine e – K/S/KS K/S/KS
SYSTEMIC EXAMINATION 1. CVS a. Inspection i. Chest wall symmetry/deformity/Precordial symmetry/deformity/Precordial bulge ii. Apical Apical Impulse Impulse – site/no. site/no. of of spaces spaces visible visible iii. Pulsation in precordium/epigastric/s precordium/epigastric/supraster./sup upraster./supracla. racla. iv. Scars/sinus/dilated veins b. Palpation i. Apical Impulse Impulse – site/no. of spaces visible/character 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 A2/P2/lo /loudn udnes ess/s s/spli plitt iii. S3/S4 iv. OS/Ejection click/tumor plop/valve click v. Pericardial rub/knock vi. Murmur (Described below…later) below…later)
2. RS a. Chest wall symmetry b. Trachea/resp movts/ c. Percussion b. Air entry/Breath sounds/adventitious sounds/pleural rub
3. P/A a. 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
a. HMF/CN/Motor/Sensorycerebellar b. EPS/ANS
Murmurs Description 1. Middiastolic Murmur a. Low pitched/Ru pitched/Rumbli mbling/M ng/MDM DM 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 MR a. 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 Murmur a. In case case of ruptu rupture re of tendi tendinae nae or or prima primary ry invo involve lvemen mentt of posterior mitral leaflet, a murmur mistaken as AS murmur, radiating radiating to to base of heart. heart. b. Has a musical quality.
4. PSM in TR a. Left parasternal region b. Increased by leg raising c. well heard during inspiration d. Grade 3/6
5. AS Murmur a. 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 murmur/duration of murmur j. Dynamic auscultation auscultation
6. Graham Steel Murmur a. 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 Murmur a. High pitched/systolic 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 murmur is delayed and and is decreased decreased in intensity intensity i. Squatting ii. Isometric exercise iii. Any intervention which increases LV volume
8. AR Murmur
a. High pitched b. EDM with blowing and decrescendo character c. Best at 3 rd Lt ICS along sterna border d. With diaphragm of stethoscope e. Pt sitting up and leaning forward f. Breath held in expiration g. Loudness of murmur/duration of murmur
NOTE a. Right Right sternal sternal border border heave heave – aneurysma aneurysmall dilatatio dilatation n of aortic aortic r………
SUMMARY At the end of examination examination DIAGNOSIS
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/ Day/Night/ Postural/seasonal Postural/seasonal variation, variation, associated associated
with, aggravated by / relieved by, present status 2) Expectoration- Color, Consistency, Consistency, Quantity, Smell, Diurnal/ Postural Postural variation, More in the the early morning, morning, Aggravated by / Relieved by, Present status status 3) Hemoptysis- Color, Quantity, Quantity, Frequency, Frequency, Postural Postural variation, Associated with, Last episode, episode, Postural symptoms, Aggravated by / Relieved by, Present status 4) Dyspnoea- Onset, Onset, Progression Progression (descri (describe be wrt activiti activities), es), Associa Associated ted with, with, Aggravat Aggravated ed by / Relieved by, Present Present status, status, MMRC gradin grading g (0-4), PND, PND, Orthopnoea 5) Wheeze- Duration Duration , Periodicit Periodicity, y, Season Seasonal/ al/ Diurnal Diurnal variation, variation, Associat Associated ed allergic allergic features features like allergic rhinitis, rhinitis, urticaria, urticaria, recurrent recurrent sneezing, sneezing, Aggravat Aggravated ed by / Relieved by, Present status 6) Chest pain-( OLD
CAARTS)
Onset, Location, Duration,
Character,
Associated features, Aggravating Aggravating and Relieving factors, Radiation, Time, Severity 7) Fever -
Grade, Grade,
Max Temp,
Type,
Associat Associated ed with chills& chills& rigors, rigors, Diurnal Diurnal
variation, Evening rise of temp., night sweats, relieved by, present status
8) Anore norex xia 9) Weight
loss-
Quan Quanti tifie fied/ d/Un Unqu quan anti tifi fied ed,,
Significant/insignificant
lnte lntenti ntion onal al
/Uni /Unint nten enti tion onal al,,
10) Hoarseness Hoarseness of voice voice 11) Ptosis 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 Bladder / Bowel symptoms symptoms 16) Swelling 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 Smoking - pack years/smoking 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 hi history TB/ Similar illness in the family
VII. II. Treat reatme ment nt hist histo ory VIII. VIII. Summar Summary y at the end of the the histo history ry IX.
Impression/ DD
General physical examination ∑
Conscious/oriented/comfortable
∑
Ht-
∑
Pulse- (Rate, (Rate, Rhythm, Rhythm, Volume, Volume, Characte Character, r, Peripheral Peripheral pulses. pulses. R-R/ R-F delay, Pulse
Weight-
BMI- Temp-
deficit, Vessel wall, wall, Carotid bruit) ∑
BPBP-
mmHg mmHg,,
Resp Respir irat atio ion n - Rate Rate,, Rhyt Rhythm hm,, Type Type (Abd (Abdom omin inoo-Th Thor orac acic ic / Thor Thorac acoo-
Abdominal) ∑
SpO2-
BCG scar
∑
P/J/Cy/Cl/LNE/PE/JVP/rash/facial P/J/Cy/Cl/LNE/PE/JVP/ras h/facial plethora/neck veins/puffiness of face/ Pemberten sign /Lt supra clavicular LN /Voice/asterixis
∑
Signs of of Malnutritio Malnutritionn- Temporal Temporal / Buccal Buccal fat wasting, wasting, Hollowness Hollowness of supraclavi supraclavicular cular – infraclavicular fossae, Emaciated look
∑
Nicotine Nicotine stainstain- lips, Nail, Nail, teeth, teeth, gums, gums, Vitamin Vitamin deficiencie deficienciess
∑
Spine – Kyphosis / Scoliosis Scoliosis /Gibbus, Skull
∑
Peripheral Peripheral signs signs of TB / Sarcoid / HIV
∑
Marfan Marfanoid oid featur features, es, Thyroi Thyroid, d, Testes Testes,, Low hair hair line, line, Horner Hornerss Featur Features, es, Congen Congenita itall anomalies
Systemic Examination Respiratory System: Upper Respiratory Tract ∑ ∑
Ear, Nose Nose ( polyps, polyps, postnasa postnasall drip, DNS ) Throat ( tonsils, oral hygiene, nicotine stain )
Inspection ∑
Chest symmetry, Pectus excavatum/ Carinatum
∑
Shape of chest
∑
Respiratory movements movements - equal / decreased
∑
Tracheal Tracheal position position / Trail sign
∑
Signs of volume loss – shoulder droop/wasting droop/wasting ( supra/infra clavicular)/Nipple clavicular)/Nipple position/ Spino scapular distance/ Rib crowding/ Intercostal spaces
∑
Intercostal space space indrawing / Hoover’s sign/Respiratory paradox/ paradox/ Respiratory Respiratory alternans 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
∑
Harrison’s sulcus / Hoover’s sign
Measurements Chest Circumferance Right Left
Expansion
Hemithorax
Hemithorax expansion
Spino Scapular Distance
AnteroPosterior Diameter
Transverse Diameter
Supra Clavicular Respiratory Movement
Rt
Percussi on
Rt
Kronig’s Isthmus
Rt
Percussion over clavicle
Rt
Infra clavicular
Mammary
Axillary
Infra Axillary
Supra Scapular
Inter Scapular
Infra Scapular
Infra Axillary
Supra Scapular
Inter Scapular
Infra Scapular
Lt
Lt
Lt
Lt
Percussion Percussion over Traube Traube Space Liver Dullness, Dullness, Tidal Percussion Percussion
Auscultation Supra Clavicular Rt Air Entry Lt Rt VF, VR Lt VBS
Rt Lt
Bronchial Breathing
Rt
Wheeze/ Rhonchi
Rt
Lt
Lt Rt
Crackles Lt Whispering Pectroloquy
Aegophony Pleural Rub
Infra clavicular
Mammary
Axillary
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, Horner’s Syndrome, Planters
Summary after Examination
Diagnosis/DD
Investigation
Treatment
Abdomen I.
Introduction Name:
Age:
Sex:
Handedness:
Resident of:
Education:
Occupation:
Religion:
Informant:
Reliability:
II.
Chief Complaints Complaints (in chronological chronological order)
III.
HOPI Dysphagia- Onset, Solids/Liquids/Both, Odynophagia, progression 1. Dysphagia-
2. Heart Heart burn,Reflu burn,Reflux,Ind x,Indigest igestion,F ion,Flatule latulence nce
Vomiting-Onset,Duration,Projectile/Non 3. Vomiting-Onset,Duration,Projectile/Non projec projectil tile,B e,Bilio ilious/ us/Non Nonbil biliou ious,C s,Cont ontent ent,Pr ,Prece eceded ded
by
nausea nausea,As ,Asso. so.
with with
hematemesis, Frequency,Aggravated Frequency,Aggravated by,Releived by, Last episode
4.
Hematemesis-On Hematemesis-Onset set,,
Color, Color,Qua Quandi ndity, ty,
Prece Preceded ded
by by
nausea, nausea,
Frequ Frequenc ency, y,
Aggravated by, Releived by, Last episode 5. MelenaMelena- Frequency, Color, Consistency, Consistency, Odour, Lasted Lasted for, Last episode
6. Abd.Pain-(OLDCAARTS)Onset, Location, Duration, Character,Colicky/Noncolicky, Character,Colicky/Noncolicky, Associated features, Aggravating and Relieving factors,Relation with food Radiation, Time, Severity
7. Abd.
DistensionDistension-
Onse Onset, t,
Diff Diffus use/ e/Lo Loca calis lised ed,,
Pain/Fever/Constipation/Diarrhoea/Altered
bowel
Prog Progre ress ss,,
Asso Asso.w .wit ithh-
habits/Nausea
&
Vomiting/Hematemesis/Melena/BleedingPR/Jaundice/Menstrual Irregularities/Oliguria/Anuria/Hematuria/Anorexia/Wt
loss/Periorbital
puffiness[To r/o Fat,Fluid,Faeces,Flatus Fat,Fluid,Faeces,Flatus,Foetus,Fatal ,Foetus,Fatal growth,Liver
& Kidney
diseases], Releived by [diuretics/fluid tapping etc…], Intermittent/persistent
8. Fever -
Grade, Grade,
Max Temp,
Type,
Associate Associated d with chills& chills& rigors, rigors, Diurnal Diurnal
variation, Evening rise of temp., night sweats, relieved by, present status
9. Anor Anorex exia ia & Weig Weight ht loss loss-- Quantified Quantified/Unqu /Unquantif antified, ied, lntentiona lntentionall /Unintenti /Unintentional, onal, Significant/insignificant 10. Constipa Constipationtion- Frequency, Frequency, Fluid intake intake
11. DiarrhoeaOnset,Duration,Frequency,Consistency,Q Onset,Duration,Frequency,Consistency,Quantity,Color,Odour,Pa uantity,Color,Odour,Painful/Painless,Te inful/Painless,Te nesmus,Stickyness,Steatorrhoea, Feeling of incomplete evacuation,Mixed with blood/mucus/undigested blood/mucus/undigested food,Abd. Pain, Abd. Distension
12. Bleeding Bleeding Per Rectum Rectum
13. Oliguria/Anuria/Dysuria Oliguria/Anuria/Dysuria/Hematuria/Urine /Hematuria/Urine color/Periorbital color/Periorbital puffiness/loin pain pain
Jaundice- Onset, Sites [skin, 14. Jaundice[skin, eyes, urine], Urine color, stool stool color, Preceded 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, sensorium, Lasted for, Releived by
failure -Alopecia/Jaundice/parotid swelling/loss of hair in 15. Symptoms of Liver cell failure-Alopecia/Jaundice/parotid axilla illa,P ,Pu ubis/L is/Lo oss
of
lib libido/ ido/Gy Gyn naec aecomas omasti tia a/pa /palmar lmar
eryt erythe hem ma/
Contratures/Testicular Contratures/Testicular atrophy/Ascitis/Spider nevi/Hematemesis/Melena
16. Altered Altered Bowel Bowel habits 17. Joint
pain/Rash/Photosensitivity/oral pain/Rash/Photosensitivity/oral
ulcers/Excessive ulcers/Excessive
hair hair
loss/Seizure/Abnormal behavior
18. Cough/Hemoptysis/Chest Cough/Hemoptysis/Chest pain/Palpitation/dyspnoea pain/Palpitation/dyspnoea 19. Well water water drinking/Alternative drinking/Alternative medicine intake/Chronic drug intake 20. Blood Blood transfusion transfusion 21. Pedal Pedal edema-Ons edema-Onset, et, Progression Progression,, Extension, Extension, Preceded/al Preceded/along ong with/after with/after Abd. 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 Smoking - pack years/smok years/smoking ing index/ index/ Chula Chula smoking smoking Alcohol –Quandity in gm/day X yrs, Type of liquor,last consumed, Binge drinking Tobacco/Substance Tobacco/Substance abuse Veg / Non veg Marital status/ Children High risk behavior Bladder/Bowel/Sleep Menstrual Menstrual History History in detail Occupation /Residence/Heavy metal exposure Immunization history Socio-economic status/ over crowding
VI.
Family hi history Similar illness in the family
VII.
Treatment history
VIII VIII.. Summ Summar ary y at the the end end of the the his histo tory ry
IX.
Impression/ DD
Examination General physical examination ∑
Conscious/oriented/comfortable
∑
Ht-
∑
Pulse- (Rate, (Rate, Rhythm, Rhythm, Volume, Volume, Characte Character, r, Peripheral Peripheral pulses. pulses. R-R/ R-F delay, delay, Pulse
Weight-
BMI- Temp-
deficit, Vessel wall, wall, Carotid bruit) ∑
BP- mmHg, mmHg,
Respir Respirati ation on - Rate, Rate, Rhythm Rhythm,, Type Type (Abdom (Abdomino ino-Th -Thora oracic cic / Thorac Thoracoo-
Abdominal) ∑
P/J/Cy/Cl/LNE/PE/JVP/rash/Lt P/J/Cy/Cl/LNE/PE/JVP/ras h/Lt supra clavicular LN /asterixis
∑
Signs of Liver Cell Failure-Alopecia, Failure-Alopecia, Jaundice, Bitot’s spots, 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, gums, Vitamin deficiencies deficiencies
∑
Spine – Kyphosis / Scoliosis Scoliosis /Gibbus, Skull
∑
Peripheral signs of TB / HIV
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 Scars/Sinuses/Dilated/Pro minent veins
∑
Visible peristalsis/Pulsations
∑
Hernial orifices
Palpation ∑
Inspectory findings confirmed
∑
Soft/ Guarding/ Rigidity
∑
Tenderness-Localised/Diffuse/Dull/Severe/Specific Tenderness-Localised/Diffu se/Dull/Severe/Specific area tenderness/Signs
∑
Liver-Size/Extend/Border/Surface/Consistency/Tend Liver-Size/Extend/Border/Su rface/Consistency/Tenderness/Moves erness/Moves with respiration/intercostal tenderness
∑
Spleen- Size/Extend/Border/Sur Size/Extend/Border/Surface/Consistency/Tendern face/Consistency/Tenderness/Notch/Moves ess/Notch/Moves with respiration
∑
Kidney- Above + Bimanually palpable, palpable, ballotability ballotability
∑
Any other mass
∑
Direction of venous flow
∑
Hernial Orifices
∑
Testicular examination
∑
Sister Joseph Nodules
∑
Pulsations
Percussion ∑
Fluid thrill/Shifting dullness/Puddle sign
∑
Liver span
∑
Traube’s Space
∑
Colonic band of resonance on the lt side
∑
Various methods of percussion percussion of Spleen- Nixon/Castell/Traube space 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 Percussion-- any e/o PE PE
∑
Air entry/NVBS/BB/Crackles/Rhonchi/Pl.Ru entry/NVBS/BB/Crackles/Rhonchi/Pl.Rub b
Cardio-Vascular System ∑
Apical Impulse
∑
Precardial buldge, Parasternal heave
∑
Palpable sounds, Thrill
∑
S1,S2,S3,S4
∑
Murmurs
Central Nervous System ∑
Consciousness,Orientation
∑
FND, Horner’s Syndrome, Planters
Summary after Examination Examination
Diagnosis/DD
Investigation
Treatment
