Classical medical history And Physical examination template.

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.

Date: ............................ Historian: .................................... Time:............................ Informant: .................................... Reliability: ..................% GENERAL DATA: Name......................................

Age..........................................

Sex................................ ..........

Status...................................... DOB/POB................................

Occupn.....................................

Religion....................................

Nationality............................... Address....................................

Times of Adm................

Adm. Date......................

Adm. Time...................

CHIEF COMPLAINT: ............................................................................................................................. .............................. HPI (PRESENT ATTACK) :

Site: (where? diffuse/localized? maximal pain?)................................................................................................... Onset – When? Sudden or gradual? Progressive/regressive? ...............................................................................

Character – how? What? (Sharp, dull, crushing, burning, tearing, throbbing, constant, intermittent)………………

Radiation – Does? ..................................................................................................................................................

Associations – other S & sx? ...................................................................................................................................

Time -how long (duration- Y/M/W/D/Hr/Min/S)...................................................................................................

o Episodic (better/worse, frequency, duration)..........................................................................................

o Continuous (any change in severity?)......................................................................................................

Exacerbating/Relieving factors – Circumstances (food, meds, posture, sleep).......................................................

Severity - How bad? pain scale O (min) – 10 (max) .................................................................................................

Previous Lab test (include Pertinent Negatives)...................................................................................................... PAST MEDICAL HISTORY:

Measles/ mumps /chicken pox /recurrent tonsillitis/ respiratory disease like pneumonia.................................... Major injuries- trauma /history of fall or operations (date, effects).....................................................................

Previous hospitalizations/ o Hospital date dx , stay duration attending remarks o Eg. hosp. X 10.25.2014 Diabetes 1 Week Dr. X -

Drug History o Name dose(route) frequency duration remarks (compliance) o EG. Aspirin 75mg once daily 2 month No allergy o o

Food & drug allergy .....................................................................................................................

History of asthma, diabetes, HPN, PTB.................................................................................................

History of similar complaint or present problem in the past (chronic/recurrent)................................................... Surgical History (Procedures)

Tonsillectomy 1952 Hospital X COPD since 1990 General practitioner

PERSONAL AND SOCIAL HISTORY: Educational attainment..........................................................................................................................................

Occupation (past & present)........................................................................................................................... ........

Hx. of travel....................................................................................................................... ......................................

Smoking/ Drinking Age started...............................................................................................................................................

Consumption per day / pack year (No of pack per day X yr smoked)......................................................

Reason of stopping (financial or health)...................................................................................................

Drugs (tranquilizers, laxatives), other................................................................................................................. ..... Sleeping habits........................................................................................................................................................

Married

Duration and health of partner/ Compatibility.........................................................................................

No of living children/age/health............................................................................................................


FAMILY HISTORY:

Grandparents (if dead, age & COD).........................................................................................................................

Parents..................................................................................................................................................................... Brothers /sisters...................................................................................................................... ................................

Heredo-familial disease

Asthma

Diabetes HPN

CA

Psychiatric epilepsy

Migraine,

Allergy

Hematologic disease

other

MENSTRUAL AND OBSTETRICAL HISTORY:

Menarche.............................................................

Duration............................................................... Cycle (monthly or irregular)...............................

Menstrual flow (minimal/moderate/ profuse)....

Associated symptoms (dysmenorrhoea, flow, breast pains & headache).....................................

Date of last menstruation (LNMP)......................

Menopause (age last menstruated).....................

Vaginal bleeding/discharges................................

No. Of pregnancies............................................. Route and No. Deliveries....................................

Complications (HPN, eclampsia, abortions)....... .............................................................................

Procedures (CS, BTL, hysterectomy -dates, surgeon).............................................................

Contraceptives Used............................................

REVIEW OF SYSTEMS: Double check of the HPI Skin :

Cyanosis

pallor

jaundice

moisture (cold)

eruption /lesion

distribution

pruritis,

bruishing

bleedingHair :

loss /growth (bladness) premature graying Nails :

cyanosis Clubbing brittleness Head :

headache o location o character o severity o radiation

Migraine

Hx of trauma,

vertigo

convulsive seizures

Eyes:

visual loss

color blindness,

diplopia,

hemianopsia,

trauma,

inflammation,

photophobia,

pain

blurring,

abnormal lacrimation,

Abn discharges(desrice the color),

use of eyeglasses (date when started to use )

use of contact lens.

Ears :

deafness (L/R)

tinnitus

vertigo

discharges (L/R , color )

Pain

Mastoiditis

previous operations (masoidectomy)

hx of infections (otitis)

Nose :

coryza

rhinitis

sinusitis

discharges

epistaxis

No smell Mouth :

soreness of mouth /tongue

symptoms of teeth

bleeding /swelling of gums

taste ulcers ,

hx of recent tooth extraction

complicationsThroat :

hoarseness

sorethroat,

hx of recurrent tonsillitis,

pharyngitis,

voice charges

Neck :

swelling

suppurative lesions (scrofula)

LN enlargement

Goiter,

stiffness,

limitation of movement.


Breast :

development,

lactation,

hx of trauma,

lumps,

pain

discharges from nipple(color),

changes in nipple

gynecomastia,

hx of surgical procedure (mastectomy/biopsy )

Results

Respiratory system:

Pain

SOB o walking short distance o climbing stairs

Wheezing,

Dyspnea o Exertional o At rest

Nocturnal dyspnea

Orthopnea ( No of pillows used)

Cough o hard o paroxysmal o productive o non productive o occasional

Sputum o scanty o copious

Hemoptysis

Night sweats,

Afternoon or night fever,

Hx of pleurisy,

Bronchitis,

TB

Pneumonia,

Asthma,

Hx of X-ray

Result.

Cardiovascular :

palpitation,

Irregularity of rhythm ,

Pain in the chest ,

Exertional dyspnea,

PND,

Orthopnea(how many pillows used),

Cough,

Cyanosis,

Edema,

Easy fatigability ,

Fainting spells,

Legs cramps,

Hx of HPN,

RHD

Rheumatic fever,

Angina pectoris,

MI,

Hx of EKG done,

Drugs (digitalis,nitroglycerin, diuretic )

GIT:

Appetite

increase or loss

changes in weight o Approx. Loss......... o Approx. Grain...... o highest wt............

Dysphagia

Nausea,

Vomiting o Episodes........... o Vomitus........... o Volume............

Flatulence

Abdominal pain o S o O o C o R o A o T o E o S

Hematemesis

Melena

Diarrhea o episodes o volume

Constipation o Duration o Laxatives use

Changes in color

Change calliber of stool

Change in bowel habits,

jaundice

Haemorrhoids,

Hx of operations( appendectomy)

Hx of procedures (GI series on BA-enema)

GUT:

Color of urine.................................

volume of urine (per void) ............

polyuria

oliguria

nocturia(no.of voids)......................

frequency.....................................

dribbing

hematuria

o initial o terminal o all thoughout

dysuria o initial o terminal o throughout

location of pain o hypogastric/ penis

incontinence

pain or colic (passage of stone )

hx of recurrent infection

history procedures like IVP,

hx of STD,

penile discharges

vaginal discharge

Neuromuscular system:

Disturbances in smell

Disturbances in vision,

Parethesiaises,

Weakness,

Convulsions,

Paralysis,

anethesia,

loss of concoiusness,

Numbness,

Malaise ,

joint pain.

Metabolic :

wt . loss wt. Gain fever Neuro psychiatric:

Hallucinations o Visual

o Auditory

insomnia, nervousness

memory loss


PHYSICAL EXAMINATION: (describe, give No diagnosis) Objective Examination using 4 basic maneuvers; inspection , percussion, palpation and auscultation. Gen survey:

Physical appearance

apparent age

Mental state

Distress

Ambulatory /non

Cooperative/non

Undernourished

state of consciousness o conscious o lethargic o stuporous o comatose

Smells

Ht/wt/WC.

febrile /afebrile

emotional state

Vital signs:

BP

RR

PR,

Temp

wt.

BMI Skin :

complexion

color (don’t state normal)

texture

turgor(lost/ senile/ good)

pigmentation and location ,

lesions,

rashes/ eruptions o location o distribution

pallor

severity

Head:

Shape:

normocephalic

Scars o size o location

fractures

asymmetry ,

abn. Movements ,

amount and texture of hair

facie

color changes of face.

Eyes:

Eye lids edema ,

ptosis

lid lag

sclera jaundice

hge.

Conjunctiva pallor

severity,

petechiae, injection

corneal scars,

ulceration,

arcus senillis

corneal opacity,

corneal reflex

Pupils size/ shape,

equality reactive to light and accommodation

vision

acuity confrontation

convergence

xanthelasma,

strabismus,

nystagmus,

palpate for IOP

exopthalmos

Ears :

ext. Ears-defect

ext. Ears- abnormalities

ext. Ears -lesions

hold pinna,

tophi,

discharges( L/R) ,color

foreign body ,

cerumen ,

mastoid tenderness

test for hearing.

Nose:

shape ,

discharge (color)

congestion of turbinates,

polyps,

foreign body,

epistaxis,

palpable septal deviation

sinus tenderness.


Mouth and throat:

inspect from outside

lips symmetry,

color changes like cyanosis,

ulcerations,

swelling lesions

gums swelling ,

bleeding/ color

teeth caries

no. of dental repair

buccal / mucosal pallor,

ulcerations,

lesions like koplick spots in measles

tongue color,

ulceration,

deviation/tremor

palate deviation

tonsils

pharynx congestion,

enlargement,

presence of exudates ,

odor of breath

Neck :

landmarks,

pulsation,

blood vessels engorgement

position (like 45 angle)

palpate thyroid gland

enlarged or not,

tracheal deviation,

palpate lump node

described size, location, tenderness, no.)

note presence of rigidity

auscultate for bruit,

palpate for cupitus.

Breast :

symmetry ,

dimpling,

nipple discharges,

lymph node (axillary)

mass o location, o size, o mobility, o consistency ,

o tenderness , o borders , o no.

CHEST AND LUNGS: Inspection

contour,

symmetry,

expansion ,

rate and rhythm of breathing

bony abnormalities.

Palpation:

tactile or vocal fremitus o equal

o increase/ decrease

note the location , tenderness in chest area/

sternum, Percussion :

changes in remnance/dullnss

note exact location eg. R basal lung field)

Auscultation :

type of breath sounds, o bronchial o vesicular

abnormal sounds o rales, o rhonchi, o wheeze,

rub

exact location

HEART: Inspection

symmetry PMI

(5th L- MCL)

heave

abn. Pulsation

lesion,

bony abnormality.


Palpation :

PMI

location,

thrill(location and timing),

pulse rate,

tenderness.

Percussion :

cardiac dullness Auscultation:

heart sounds

distinct or faint

rate and rhythm,

friction rub

murmur(TLDIPCTQ)

ABDOMEN: Inspection

contour

shape

scars (size/location)

state surgical procedure

engorged veins

spider nevi

visible masses

Striae

Pulsations

bulging like hernia.

Auscultation:

bowel sounds (normo/ hypohyperactive / absent)

metallic sounds ,

bruit, venour hum,

fetal heart ( pregnant )

special maneuvers o puddle sign –ascites o Succession splash-obstruction

Percussion :

Change in tympany

super liver dullness

fluid wave

shifting dullness

RUQ fist percussion

CVA tenderness. Palpation: (area of pain -last )

muscles guarding (voluntary or involuntary)

muscle spasticity

consistency (soft / rigid)

crepitations

tenderness (location, whether on light or deep palpation)

masses (location , size, shape, consistency, mobility, tenderness, borders)

engorgement of liver , spleen , spleen, kidney

bladder distention

fetal parts (female)

aortic pulsation,

rebound tenderness,

direct tenderness,

lmp nodes,

rovsings sign

Psoas sign

obturator sign

BACK AND SPINE

Mobility

Curvature

vertebral tenderness

bony abnormality. EXTREMITIES: (specify whether upper/ lower, R/L)

Color/ cyanosis

moisture

clubbing

joint swelling /deformity

Mobility

Temperature

equality of pulses

Edema

Varicosity

Atrophy/ Hypertrophy

tenderness of muscles

abn. Movements

range of motion

signs of inflammation

congenital


NEUROLOGIC EXAM: 1.cerebral functions

level of consciousness

appearance

gen. Behaviour

emotional status

thought content

intellectual performance

recognize object (yes/no)

Communicate(yes/no)

carry out skills(yes/no) 2. cereblum functions

gait

posture.

Coordination (romberg’s test)

finger to nose

heel to shin

knee pat

3. motor system :

strength (weakness or paralysis) -ranges ( 0/5-5/5)

Right Left

UE (hand grip )

LE (resistance)

muscle tone ( spaticity, rigidity, flaccidity)

spontaneous movements (Tics, tremors, twitching, chorea, athetosis) 4. sensory system (both sides,eye closed)

Sensations of : o pain o touch o temp.

position sense/ vibrations

discrimatory sensation

sensory dysfunction

5. CRANIAL NERVES EXAMINATION: a. olfactory (check both side one at a time|)

smell identify odor (by smelling) b. optic

visual acuity

confrontation test

color vision

visual field.

opthalmoscopic exam

C. Oculomotor

Papillary light reflex

Near response (parasympathetic) o Convergence o accomodatio

d. trochlear/abducents

EOM diplopia e.Trigeminal

corneal rxn

ability to open mouth

pain sensation of face.


f. Facial

symmetry of face

wrinkle forehead ,

smile, frown, raise eyebrows

test for taste (ant 2/3)

chovstek sign

. g. Acoustic

hearing o rhinne test (Air > bone conduction) o weber test (bone conduction)

equilibrium

h. Glossopharyngeal/ vagus

symmetry of uvula with phonation elicit gag reflex

i. accessory

strength of trapezius/

shoulder shrug (strong or week )

Turn head (up- down, L/R)

Check w/ resistance j. hypoglossal

deviation of protruded tongue

tremors and strength

impaired swallowing

6. REFLEX: 1. DTR – result ranges from 0 - ++++

a. biceps b. triceps c.knee jerk d. Achilles or ankle joints

2.Superficial a. cremasteric male – whether (+) or (-) b. abdominal – whether (+) or (-)

3. Pathological

a. ankle clonus + if abn L and R b. babinski + if abn L nd R c. karnigs + if abn d. brudzinski +if abn

report :

Right Left

Biceps ++ ++

Triceps ++ ++

Knee ++ ++

Achilles ++ ++

Ankle clonus ++ ++ Babinski ++ ++


REFERENCES : -Bates physical diagnosis - Macleod's Clinical Examination Acknowledgement :

Dr. Louella Quijano

kalpana shah, Southwestern University

For suggestions and comments : [email protected],

mailto:[email protected]

Classical medical history And Physical examination template.

Health & Medicine

Transcript of Classical medical history And Physical examination template.