Des:CONCORD 1 Page-
Patient sheet Personal History
sex Full Name Age Residence Marital life Occupation M F S M child Special Habit`s 1. 2. 3. 4. 5.
Smoking Alcohol
I.V. addiction Diet habits
Complain Symptom`s [ as own patient word] 1. 2. 3. 4. 5. Onset Course Duration
Past History Surgery 1. T.B. Yes/No Hypertension Yes/No Medication`s 1.
2. Bilharsiasis Yes/No Diabetes Mellitus
Yes/No 2.
3. 3.
4. Hepatitis Yes/No Blood Transfusion
Yes/No 4.
5. 5.
Family History
Then doing: General Examination
Local Examination [according complain]
Des:CONCORD 2 Page-
General Examination [401] I. 0BGeneral condition
1. 9BMental state
2. 10BBody built
3. 11BPosture
a) 15BIn bed-Decubitus
b) 16BOn standing and walk-gait
4. 12BFacial expression
5. 13BComplexion [pallor Jaundice - Cyanosis]
6. 14BVital sign`s [Pulse - Blood pressure - Respiratory rate - Temperature]
II. 1BHead
III. 2BNeck
IV. 3BUpper Limb`s
V. 4BLower Limb`s
VI. 5BLymphatic system
VII. 6BBreast
VIII. 7BSkin
IX. 8BGenitalia
Des:CONCORD 3 Page-
General condition 1- Mental state a- consciousness
b- Attention c- Memory d- Mood e- Intelligence f- Conception & Preception
2- Body Built a- Weight [ kg] b- Height [ m] Dwarfism - normal - Gigantism
c- Body Mass Index = 2
W= weight Kg H= height - m
Underweight < 18.5 Normal 18.5 - 24.9 Overweight 25 - 29.9 Obese 30 - 39.9 Morbid obesity
40
d- Span Extend both hands outward (each arm abducted to 90)-Measure finger tip to Finger tip
e- Upper Segment & Lower Segment
Upper S: Top of head to top of pubic symphysis Lower S: Top of pubic symphysis to floor
3- Posture [ position in bed ]
a- Restleness b- Plexim altiude c- Lateral decubitus d- qaitundus e- Orthopneic posture f- Squatting position g- Prayer posture
4- Facial Expression See Head Examination
5- Complexion a- Pallor b- Bluish discoloration 1- Central Cyanosis
2- Peripheral Cyanosis c- Yellow discoloration 1- Haemolytic jaundice
2- Hepatocellular jaundice 3- Obstructive jaundice
6- Vital Sing`s a- Temperature
Oral Rectal Axillary
b- Blood Pressure c- Respiratory Rate
d- Pulse
1-Rate 2-Rhythm 3-Volume
4-Special character
Water hammer pulse Plateau pulse Pulses bisferiens Pulses alternans Pulses paradoxes
Des:CONCORD 4 Page-
Head Examination 1. Cranium a- Size Hydrocephalus - Microcephaly
b- Local abnormalities Local bulging Local depression
2. Face a- Facial expression Anxiety dull apathetic moon face b- Color change Malar flush discoid lupus
c- Asymmetry of face As in Facial palsy
3. Eye a- Eye brow Fall of outer third b- Eye lid Puffiness yellowish plaques dropping
lid retraction lid lag c- Eye ball Exophthalmos - enophthalmos d- Conjunctiva Discolouration - haemorrhage e- Sclera Jaundice blue colouration f- Cornea Greenish gray white g- Pupil Size shape reaction to light h- Lens Cataract
4. Nose a- Large b- Saddle c- Working alae nasi d- Nasal discharge
5. Ear a- Taphi
b- Yellowish white nodules c- Low set ear d- Ear discharge
6. Mouth a- Lib Color macrocheilia microcheilia tremor
b- Breath odour c- Teeth Delay dentation loosing of teeth
wide spacing Hutchison teeth d- Gums Pyorrhea bleeding hypertrophy
pigmentation e- Tongue Color atrophic macroglossia
scrotal tongue furring strawberry leukoplakia moisture tremor
f- Buccal mucosa Pigmentation stomatitis koplik`s spots
g- Palate Deformities paralysis h- Tonsils
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Neck Examination 1- Abnormalities of
position a- torticollis b- rigidity
2- Abnormal movements a- Parkonisonism b- Aortic incompetence = De Musset`s sign
3- Thyroid gland Inspection Enlargement size shape Palpation Size of the enlargement
Surface [diffuse or nodular] Thrill Lower border of the gland Consistency Pulsation Fixed or mobile
Percusion Detect retrosternal goiter Auscultation
4- Lymph node Cervical L.N. supraclavicular L.N.
5- Pulsation Arterial pulsations Apparent pulsation in supresternal notch Exaggerated carotid pulsation
Venous Pulsation a- Jagular venous pulse b- Jagular venous pressure
6- Thrill
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Upper Limb Examination 1- Skin a- Temperature Warm hand
Cold hand b- Sweating
c- Colour & Trophic changes
Palmer erythema Xanthomatosis Cutaneous haemorrhage Raynaud`s phenomena Hyperkeratosis Gangrene & ulceration Leprosy Jane way macules
d- Nodules
Osler`s nodes Heberden`s node TOPHI Subcutaneous nodules
2- Nails clubbing Pale blue
Koilonychia Leuconychia Nail dystrophies Splinter haemorrhage
3- MusculoSkeletal system Muscles wasting Involuntary movements
tremors
Fine of tremors
Coarse trmors
Static Kinetic Flapping Familial
Hysterical tremors Skeletal changes & deformaities
Polydactyly Syndactyly Arachnodactyly Spade hand Spindle shaped hand Obstetric hand Sclerodermic hand Dupuytren`s contracture
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Lower Limb Examination 1- Edema
a. Generalized
cardiac Respairatory rena Liver nutritional
b. Localized
Venous causes Lymphatic causes Inflammatory causes Allergic causes
2- Clubbing of toes
3- Peripheral arterial system a. Color changes Paroxysmal Persistent
b. Skin change Atrophy ulcer - fungus c. Temperature Ischemia lead to coldness
d. pulsation
dorsalis pedis artery Anterior, posterior
tibial arteries Popliteal artery Femoral artery
4- Venous system a. Deep venous thrombosis b. Varicose veins
5- musculoskeletal a. general appearance Pes cavus b. joint's Arthritis c. muscle's Atrophy
Des:CONCORD 8 Page-
Breast Examination In female: Breast should be palpated for any swelling particularly when secondaries are suspected.
In male: Enlargement of breast in males is know as "gynaecomastia" = means hypertrophy of the glandular tissues of male breast usually with prominence of the nipple and the breast is commonly tender.
1- physiological at puberty
2- neoplastic Feminizing testicular tumor Bronchial carcinoma
Hodgkin`s disease Adrenal tumours hypernephroma
3- endocrinal Thyrotoxicosis Addison`s disease Diabetes mellituse Testicular atrophy Acromegaly Adrenogenital syndrome hypothyroidism
4- metabolic Sever malnutrition Liver cell failure Chronic renal failure Wasting disorders
Des:CONCORD 9 Page-
Lymph node examination using three middle fingers for palpation, the glands are rolled up and down, back and forward with rotatroy motion
- size consistency matting tenderness number - mobility in relation to deep structures - overlying skin
1- cervical Circle group Submental submandibular tonsillar - pre auricular post auricular - occipital
Vertical group Upper & lower deep cervical lymph nodes which lie under cover of the sternomastoid
2- supraclavicular Palpated in supraclavicular fossa
Virchow's gland Scalene lymphe node
3- Axillary lymph node Anterior group Behind pectoralis major Posterior group On posterior wall of axilla
Lateral group Lies along the Axillary vessels
Medial group On chest wall in upper Axillary zone
Apical group High up in the apex of axilla
4- Supratrochlear Flet little above medial epicondyle of the humerus
5- Inguinal Superficial & deep femoral [these deep groups lie on the medial side of the femoral vein
Des:CONCORD 10 Page-
skin examination 1- Pigmentation
General pigmentation
Endocrinal disorder Metabolic disorder Drugs Miscellaneous
localized
Senile pigmentation Neurological pigmentation Stria gravidarum cloasma linea nigra Taenia versicolor lickenplanus Post irradiation Al-bright`s syndrome As a result of friction and scratching
2- vitiligo White skin patches may be primary oe secondary
3- dryness Dehydration Myxoedema
Malnutrition
Old age
4- sweating Nervous excitement Thyrotoxicosis Toxic conditions Respairatory failure
5- elasticity Tense or tight Wrinkled or loose Excessive elasticity
6- thickness Generalized Acromegaly myxoedema
localized Elephantiasis Leprosy
7- atrophy Old age Wasting diseases malnutrition Over ischaemic areas
8- striae Striae alba: pregnancy obesity Striae rubrae: Cushing's syndrome Striae tensea
9- hair Fall of hair excessive growth over the face in female
concordPatient sheet General Examination [401] General condition Head Examination Neck Examination Upper Limb Examination Lower Limb Examination Breast Examination Lymph node examination skin examination
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