CENTRAL NERVOUS SYSTEM

INTRODUCTION
1. Name
2. Age
3. Sex
4. Handedness
5. Resident of
6. Education
7. Occupation
8. 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

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. Comprehension
c. 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

II.

III.

Decreased visual acuity

Color vision
Color desaturation
Scotoma/Field defect
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.
V.
VI.
VII.

VIII.

IX.

Same as above
Decreased/abnormal sensations over face, difficulty
in mastication.
Same as above
Deviation of angle of mouth
Facial asymmetry
Drooling of saliva
Difficulty in closing eyes
Difficulty in speaking
Taste impairment
Hearing impairement
Giddiness
Vertigo
Tinnitus
H/O CSOM
And X
Dysphagia solid/liquid/both
Dysphonia

X.
XI.
XII.

Dysarthria
Nasal regurgitation
Hoarseness of voice/Nasal twang
Same as above
Neck movements
Shrugging of shoulders
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.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.

Reaching overhead objects/taking comb to the head

Lifting a bucket of water/breaking the chapaties
Holding a glass of water/writing task in detail
Holding the pen/grasping the comb
Difficulty in getting up from a chair/squatting position
Climbing up/down the stairs/gripping the chappals
Chappals slips away with/without the knowledge
Getting up from lying down position/Turns in the bed
Lifting the head off the bed
Breathlessness/ptosis/facial weakness/chewing

b. Dexterity
i.
ii.
iii.
iv.

Buttoning/unbuttoning the shirt/ Breaking the chapaties

Tie the nada of payjama/shoe lace
Negotiating the foot into the chappal
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.

c. Weakness (LMN)
i.
ii.
iii.
iv.
v.
vi.
vii.

Looseness/fasciculations/wasting
Which is earlier weakness or wasting
Proximal/distal
Symmetrical/asymmetrical
Periodicity/diurnal variation, fatiguability
Selectivity of muscles
Onset/course/progression

d. Cerebellar
i.
ii.
iii.
iv.

Smearing of face/target oriented activities

Tremors/Gait/Speech/Vertigo/Looseness of limbs
Difficulty in reaching the objects
Incoordination during picking up water/during drinking.

e. EPS
i.
ii.
iii.
iv.

Tremors at rest/Stiffness/expressionless face

Bradykinesia during bath/dressing etc.
Sleep/Memory/Handwriting/Hypophonia/Gait
Difficulty in walking narrow paths (Pedestrian strip)

f. Gait
i.
ii.
iii.
iv.
v.

Broad based/Narrow base

Speed/Antalgic gait/Freezing/Parkinsons gait features
Recurrent falls/Buckling/Climbing up/down
Difficulty in walking in dark/Pain while walking
Stiffness/crossing of legs

6. Sensory
a. Onset/progression/present status
b. Posterior column
i.
ii.
iii.
iv.
v.

Unable to feel clothes over the body

Difficulty in walking in the dark/wash basin (Sink) sign
Slipping of slippers without knowledge
Cotton wool sensations over the feet
Band like sensation/Encasement of limbs

vi. Pins and needles/numbness/tingling/paraesthesias

vii. Lhermittes phenomenon/water flowing underneath the
feet

c. Spinothalamic
i.
ii.
iii.
iv.

Hot and cold water during bath

Burning/shooting/pricking pain
Funicular pain/sensory level
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.
ii.
iii.
iv.
v.

Urgency/urge incontinence/frequency/hesitancy
Precipitancy/Retention (Painful/less & aware/unaware)
Overflow incontinence/incomplete evacuation
Dribbling of urine/loss of social inhibition
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

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

f. Frequency (No of episodes in a day)/abnormal
sweating
g. Pain anywhere in the body
2. 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/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 in the past
4. Blood transfusion/jaundice
5. Major surgery

PERSONAL HISTORY

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
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
3. Anatomical

4. Etioloical 1, 2, 3, 4

GENERAL EXAMINATION
1. Conscious/oriented/cooperative/comfortably lying
2. 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. 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. 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 Nerves
I
- Coffe powder/soap/shampoo/tooth paste
II
- Acuity/Color/field/pupils/RAPD/Fundus.
III/IV & VI
- Position of the eye at primary gaze

- 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

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

VII

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

3. Motor

system examination

a. Position/attitude of limbs

b. Bulk (wasting/hypertrophy)
c. Tone
i. 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

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. Combined
i. 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 for
cortical sensations.
e. Lhermittes phenomenon
f. Rhombergs sign
g. determine pattern of sensory loss

i. Symmetrical/asymmetrical
ii. Glove stocking/Patchy
iii. Root level

5. Cerebellum
a. 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.

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. Micrographia
f. Hypophonia
g. Hypomimia

8. ANS
a. Postural hypotension
b. Sweating

SUMMARY At the end of examination

FOUR TIER DIAGNOSIS

CARDIOVASCULAR SYSTEM
INTRODUCTION
1. Name
2. Age
3. Sex
4. Handedness
5. Resident of
6. Education
7. Occupation
8. 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

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 Palpitations
e. 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 status
c. NYHA Class

5. Syncope and pre-syncope

a. As Described in CNS

6. Cough and expectoration/Hemoptysis

a. As described in Respiratory system

7. Fever
a. 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. Onset
c. Lasted for
d. Relieved by
e. Any associated 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 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/Constipation
iv. Weight gain/Poor appetite
b. Hyperthyroidism
i. Heat intolerance/palpitations/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/Substance 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 similar illness in the family
2. Socioeconomic status/Poverty/overcrowded place

TREATMENT HISTORY
1. Penicillin prophylaxis/digoxin/diuretics
2. Surgery/intervention

SUMMARY at the end of history.

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

GENERAL EXAMINATION
1. Conscious/oriented/cooperative/comfortably lying
2. 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
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 reflex
8. 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

SYSTEMIC EXAMINATION
1. CVS
a. Inspection
i. Chest wall symmetry/deformity/Precordial bulge
ii. 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. 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/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 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 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 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 of murmur
j. Dynamic 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 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 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 3rd 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 sternal border heave aneurysmal dilatation of aortic
r

SUMMARY At the end of examination

DIAGNOSIS

RESPIRATORY SYSTEM
I.

Introduction
Name:
Education:

Age:
Occupation:

Sex:
Religion:

Handedness:
Informant:

Resident of:
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,
Significant/insignificant

lntentional

/Unintentional,

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

General physical examination

Conscious/oriented/comfortable

Ht-

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

Weight-

BMI- Temp-

deficit, Vessel wall, Carotid bruit)

BP- mmHg,

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

Abdominal)

SpO2-

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

BCG scar

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 )

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
Circumferance
Right
Left

Expansion

Hemithorax

Hemithorax
expansion

Spino
Scapular
Distance

AnteroPosterior
Diameter

Transverse
Diameter

Supra
Clavicular
Respiratory
Movement

Rt

Percussi
on

Rt

Kronigs
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 over Traube Space

Liver Dullness, Tidal Percussion

Auscultation
Supra
Clavicular
Air Entry

VF, VR
VBS

Rt
Lt
Rt
Lt
Rt
Lt

Bronchial
Breathing

Rt

Wheeze/
Rhonchi

Rt

Crackles
Whispering
Pectroloquy

Aegophony
Pleural Rub

Lt

Lt
Rt
Lt

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, Horners Syndrome, Planters

Summary after Examination

Diagnosis/DD
Investigation
Treatment

Abdomen
I.

Introduction
Name:
Education:

Age:
Occupation:

Sex:
Religion:

Handedness:
Informant:

II.

Chief Complaints (in chronological order)

III.

HOPI

Resident of:
Reliability:

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,

Pain/Fever/Constipation/Diarrhoea/Altered

bowel

Progress,

Asso.with-

habits/Nausea

&

Vomiting/Hematemesis/Melena/BleedingPR/Jaundice/Menstrual
Irregularities/Oliguria/Anuria/Hematuria/Anorexia/Wt

loss/Periorbital

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. DiarrhoeaOnset,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

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

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-

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

Weight-

BMI- Temp-

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

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

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

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