PERSONAL DATA

Bed + MRN
Full Name
Gender & Race
DOB
Ht/Wt/BMI
Date/Time Admit
Date/Time Clerk
Husband/Wife
(Name/Age/Occp)
9. Total Income
10. Address/House Type
1.
2.
3.
4.
5.
6.
7.
8.

DDx = Trauma # Infection # Neoplasm # Congenital # Autoimmune # Metabolism # Blood # Endocrine # Drugs
Hx Taking Guidelines Surgery Ver. 3

1.
2.
3.
4.
5.
6.
7.

PCs & HPCs

Pain
1. Site
2. Onset
3. Characteristic
(burn,throb,stab,constrict,
colicky,aching)
4. Radiation
5. Associated Sympt
6. Time/Duration
7. Exacerbating/Relieving
8. Severity/Score
9. Progression/Ending
Lumps/Ulcer
When & how noticed?
Changes/Development
Symptoms
At other sites on the
body?
5. Idea what cause it?
1.
2.
3.
4.

Fever
1. Type (Cont./Remit/
Intmint./Relapse)
2. Character
3. Duration
(sudden/gradual)
4. Nocturnal Variation
5. Chills/Rigor?
6. Rashes/Joint Pain
7. Frequency/Recurrent
8. Temperature
9. Medication
10. Hx Contact
11. Hx Travel
12. Fits
1.
2.
3.
4.
5.
6.
7.
8.
9.

Vomitting
Frequency
Characteristics
Volume
Projectile/NonProjctle
Hematemesis (colour)
Duration
Exacerbating/Relieving
Timing
Nausea

1.
2.
3.
4.
5.
6.
7.
8.

Diarrhea
Character/Consistency
Colour
Frequency
Amount
Blood/Mucous
Pain
Abd. Distension
Flutulance

1.
2.
3.
4.
5.

Constipation
Onset
Time
Bleeding
Straining/Prolapse
Tenesmus

Loss of Weight
1. How much?
2. Period of time?
3. Diet (type & intake)
Cough
1. Duration
2. Sound
3. SOB?
4. Cyanosis
5. Type (Productive?)
6. Sputum Character
7. PostTussive (Condition)
8. Runny nose
9. Frequency
10. Exacerbating/Relieving
11. Medication

PCs & HPCs (Cont.)

Hernia
Location
Direct/Indirect?
Simple / Obstructed /
Strangulate?
Complete/ Incomplete
(What level?)
Reducible ?
Assoc. Symptom
Hx of straining (heavy
lifting, cough,
constipation,
micturation problems)

SYSTEMIC REVIEW
RESPI - runny nose, cough,
wheeze, SOB, activity
limitation
ENT throat infections,
snoring, noisy breathing
CVS - sweating, cyanosis,
pallor, SOB, exercise
tolerance, murmur
GIT - appetite, diet,
vomiting, pain, abdominal
distention, bowel habit,
stools,
MSK - gait, limb pain, joint
pain @ swelling,
CNS - headaches, fits,
hearing, vision
GnUr - pain, colour,
frequency, training
H&L - anemia, bleeding
tendency or clotting
tendency.

Systemic Review Gynae

1. Menstrual Hx
a. LMP
b. Lenght/Delay
c. Volume
d. 1st Period (Age)
e. Irregular bleed?
2. Discharge
a. Colour
b. Amount (# pads)
c. Duration
d. Pain/Itch/Rash
3. Obstetric
a. # of pregnancy
b. # of miscarriages
c. Complications?
4. Contraception
a. Type/Name
b. For how long?
5. Menopause
a. When
b. Bleeding?
c. HRT?
PAST Med Hx
6. Pass Illnesses
7. Hospitalizations
8. Surgery
9. Medications
10. Allergies
Family Hx
1. Parents
2. Siblings
3. Partner (if releveant)

1.
2.
3.
4.
5.
6.

Social Hx
Smoking/Drink/Drugs
Diet
Occupation
Income
Education
House type &
environment

Prepared & Improved by Group 3 9th Batch UiTM 2013/2014 * Please add on if theres anything missing and improve this guideline

General Examination
Bed 45 Stand @ Right Hand Side of Pt
1.
Appearence, Alertness,
Activity(movements)
2.
Is the patient in pain?
3.
Hydrational/Nutritional Status
Sunken orbits
Dry buccal mucosa
Skin turgor
Capillary refill
Anterior fontanelle
4.
Attachment/Equipment
5.
Temperature
6.
Respiratory Distress
Rate
Nasal flaring
Accesory Muscle Use
7.
BP & Pulses (Rt/Ry/Vol)
Radial
Brachial
Femoral
Popletial
Dorsalis Pedis
Posterior Tibial
8.
Colour
Pink
Blue/Cyanose
Yellow/Jaundice
Pale
9.
Skin
Rash
Bruises
Scratch Marks/Scars
Eczema
10.
Hands
Nails shape & colour
(clubbing,splinter H)
Temperature
Moisture
Colour
11.
Edema
12.
Neck
Trachea
JVP
Thyroid
Lymph Nodes
Cervical
Occipital
Axillary
Inguinal
Abdominal Examination

1.

2.
3.

4.

5.
6.

7.

8.

General Abdominal
Activity
Lie still appndcts/pritonits
Moving acute cholangitis
Inspection
(Supine + Hips Flexed)
Contour, peripheral vasuclar
irregularities, skin markings
Skin (dermatitis
herperiformis, erytherma
nodosum, palmar
eryhterma, spider angioma,
caput madusae)
Abdomen (distention,
schaphoid abdomen,
peristaltic waves, scars,
protrusions in hernia)
Palpate (superficial > deep)
Tenderness, liver, spleen,
kidney, detect masses
Groin adenopathy, inguinal
hernias
Percussion
Hepatomegaly,
Spleenomegaly,
Acites (shifting dullness,
fluid thrill)
Auscultate
P
Abdominal sounds (active,
decreased, absent)
Bruit

CVS Examination

1.
2.
3.

4.
5.
6.

7.
8.
9.

10.

11.
12.
13.
14.
15.
16.

17.

General CVS
Pallor Sweating Cyanosis
SOB Palpitations Edema
Dysmorphic features
Vital Signs
(HR,RR,BP,Ht,Wt, Head
Circumfrence)
Inspection
Nails (clubbing, splinter
hemorrhages, cyanosis)
Capillary refill time
Eyes (pallor, scleral
icterus, xanthomata,
senile arcus)
Mouth (central cyanosis,
hydration)
JVP
Chest (shape, precordial
bulge, pectus carinatum/
excavatum, scars, visible
impulse)
PPeripheral Palpation
Pulses brachial & femoral,
Brachial femoral delay
Precordium Palpation
Apex beat & all 4
auscultatory areas
Thrills
Liver
Spleen
Edema
Auscultation
Heart sounds/Murmurs at
4 Areas
- Aortic (2nd R ICS)
- Pulmonic (2nd L ICS)
- Tricuspid (Low L Strnl
Bordr)
- Mitral (Apex)
*Diaphragm (high
pitch:rubs, S1,S2) & Bell
(low pitch: gallop, S2 spilit)
Lungs (pulm congestion)

CNS Examination

1.
2.

3.
4.

5.

6.

1.

2.

3.

4.

Respiratory Examination

1.

2.

3.
4.
5.
6.

7.

8.
9.
10.

11.
12.

13.

General Respiratory
Respiratory Rate, depth,
ease and rhythm of
respiration
Inspection
Thorax Anterior &
Posterior
(symmetry,retractions,
accessory muscles, shape,
vertebral column)
Nose (nasal flaring)
Lips/Mucus membrane
(cyanosis)
Oropharynx (Inflamed?)
Nail bed (peripheral
cyanosis, clubbing)
PPalpation
Trachea at supra sternal
notch (mobility and
deviation)
Lymph nodes (head &
neck)
Anterior & Posterior
Tactile Fermitus (99 test)
Pulsus Paradoxus
(decrese in systolic BP
during inspiration)
Apex Beat
Percussion
Chest (dull,
hyperresonant,flat)
Auscultation
For each lobes (compare
R&L)
- Air Entry
- Breath Sound
- Additional Sounds
- Vocal Resonance

5.

6.

7.

8.

9.

1.
2.
3.
4.

Higher Function Test

Alertness, attention &
activity
Speech & Language
(fluency, comprehension,
naming, repetition,
writing)
Sleep
Memory
Past Events
Present Events
Orientation
Name & Time (day,
month)
Place (hospital, country,
city)
Intelligence
Cranial Nerve Test
CN 1 (Olfactory)
Odor test (seperate
nostrils)
CN 2 (Optic)
Acuity
Colour Vision
Visual Fields
Retinal Examination
CN 3 (Occulomotor)
CN 4 (Trochlear)
CN 6 (Abducens)
Eyelid & Pupil
Light Reflex (Direct &
Consensual)
Accommodation (Near &
Far object)
Extraocular Movement
(H test)
Nystagmus
Convergance
CN 5 (Trigeminal)
Motor clenching muscle
(Palpate temporal &
masseter muscle)
Asses pain, temperature
and light touch of 3
trigeminal areas
Corneal reflex
CN 7 (Facial)
Symetrical movement of
face
Smile, Frown, Show teeth,
Puff cheeks
Close eyes tightly and try
to open againts force
CN 8 (VestibularCochlear)
Whisper/Finger Rub test
Rinnes (f 512)
Webbers
CN 9 (Glossopharyngeal)
CN 10 (Vagus)
Gag Reflex
Ahhhh look at elevated
soft palate
CN 11 (Accessory)
SCM Muscle test (turn
head againts force)
CN 12 (Hypoglossal)
Protrusion of tounge
Meningeal Irritation Test
Nuchal Rigidity
Spinal Rigidity
Kernigs Sign (resistance in
knee extension)
Brudizinskis Sign (neck
flexion involuntary hip
flexion)

Describing Lumps
8. Site + Size + Surface
9. Colour + Contour(Shape) + Consistency
10. Tender? + Temperature + Transilluminable
11. Fluid filled + Fixed? + Fields (of lymph drainage)
12. Pulsatile?
13. Expansible?
14. Reducible

CNS Examination

1.
2.
3.
4.
5.

6.

1.

2.

3.
4.
5.

1.

2.

3.

Motor Function Test

Inspection
Hypertrophy
Wasting
Tremor
Chorea
Palpate
Bulk, Tone & Power
Fingers
Wrist
Elbow
Shoulder
Hip
Knee
Foot
Relfex
Biceps
Brachioradialis
Triceps
Finger
Knee jerk
Posterior tibialis
Ankle jerk
Babinski sign
Crossed adduction
Sensory Test
Modalities
Touch
Pain
Temperature
Vibration
Proprioception
Areas
Perineal
Sole of Foot
Dorsum of foot
Medial ankle and shin
Anterior mid thigh
Lateral thigh
Medial arm
Stereognosis
Tactile Discrimination
Graphesthesia
Cerebellar Function Test
Cerebellar System
Finger to Nose
Heel Knee Shin
Rapid thumb index finger
tapping
rapid hand tapping againts
examiner
screw light blub action
rapid alternate
movements (dorsum palm
tapping)
Balance & Gait
Romberg Test (stand feet
together open/closed
eyes)
Gait
Posture
Blance
Arm swing
Leg movement
Tandem Walking (Heel
to toe walk)
Heel walking
Toe walking
Hop in place
Stand one leg and knee
bend

Describing Ulcer
4. Base
a. Solid brown/grey
b. Yellow grey
c. Bluish
d. Underlying structures bare
5. Edge
a. Sloping
b. Punched out
c. Undermined
d. Rolled
e. Everted
6. Discharge
7. Relations