CMMUNITY BASED MEDICAL

COLLEGE,BANGLADESH

DEPARTMENT OF MEDICINE

DR.TOFAYEL UDDIN AHMED

REGISTRAR MU-2

CASE HISTORY PARTICULARIS OF THE PATIENT HISTORY PHYSICAL EXAMINATION

A . PARTICULARIS OF THE PATIENT NAME AGE SEX RELIGION OCCUPATION MARITAL STATUS ADDRESS DATE OF ADMISSION DATE OF EXAMINATION

B. HISTORY PRESENTING COMPLAINTS HISTORY OF PRESENT ILLNESS HISTORY OF PAST ILLNESS TREATMENT HISTORY DRUG AND TRANSFUSION HISTORY FAMILY HISTORY SOCIOECONOMIC HISTORY / INCLUDING OCCUPATION PERSONAL HISTORY/ habit, hobby, diet, sleep, bowel,

bladder etc HISTORY OF TRVELLING HISTORY OF IMMUNIZATION

C. PHYSICAL EXAMINATION GENERAL EXAMINATION SYSTEMIC EXAMINATION

GENERAL EXAMINATION

APPEARANCE DECUBITUS Posture of patient in bed INTELLIGENCEEducational and occupational history COOPERATION BODY BUILDHeavy/average/small NUTRITIONHEIGHT WEIGHT

GENERAL EXAMINATION ANAEMIA – type/site/eg

JUNDICE CYANOSIS OEDEMA CLUBBING KOILONYCHIA SKIN AND BODY HAIR NECK VEINE LYMPHNODES PULSE BP TEMP DEHYDRATION

SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM GASTROINTESTINAL SYSTEM NERVOUS SYSTEM

CARDIOVASCULAR SYSTEM PULSE

- RATETachycardia >100bpm-

fever,anaemia,thyrotoxicosisCCF,shock,drug-sulbitamol

bradycardia<50/bpm-in.MI,myxoedema,hypothermia,obstructive jundice,drug-beta-blockers,amioderon,vrapamil

- RHYTHM

- VOLUME- SYMMETRY- CHARACTER- CONDITION OF VESSEL WALL- RADIO-FEMORAL DELAY

CARDIOVASCULAR SYSTEM BP NECK VEINE OTHER PULSATION

INSPECTION

SHAPE

CARDIAC IMPULSE

OTHER VISIBLE PULSATION

ANY SWELLING OR SCAR MARK

PALPATION

APEX BEAT

THRILLS

LEFT PARASTERNAL LIFT/HEAVE

PALPABLE HEART SOUND

OTHER PALPATION

PERCUSSION

AREA OF SUPERFICIAL CARDIAC DULLNESS

AUSCULTATION

- HEART SOUND

- MURMUR

- pericardil rub

- other sound

RESPIRATORY SYSTEM

- SHAPE OF THE CHEST- MOVEMENT OF THE CHEST- SINGS OF RESPIRATORY DISTRESS- VISIBLE PULSATION- ANY SCAR MARK- RATE AND RHYTHM OF RESPIRATION

PALPATION

- POSATION OF TRACHEA- POSATION OF APEX BEAT- EXPANTION OF THE CHEST WALL- VOCAL FREMITUS- LOCALISED TENDERNESS

PERCUSSION

- POSATION OF TRACHEA- POSATION OF APEX BEAT- EXPANSION OF THE CHEST WALL- VOCAL FREMITUS- LOCALISED TENDERNESS

PERCUSSION

PERCUSSION NOTE ON

- MID CLAICULAR LINE

- MID AXILLARY LINE

- INFACSCAPULAR LINE

LIMITS OF CARDIAC DULLNESS

UPPER BORDER OF LIVER DULLNESS

AUSCULTATION BREATH SOUND

- INTENSITY

- CHARACTER

VOCAL RESONANCE

ADDED SOUNDS

- RHONCHI

- CREPITATION

- PLEURAL RUB

GASTROINTESTINAL SYSTEMMOUTH AND PHARYNXABDOMAN PROPER- INSPECTION - SIZE AND SHAPE - MOVEMENT - SKIN- SCAR,PROMINENT VEINE,SPIDER NAEVIA - POSATION AND SHAPE OF UMBILICUS - VISIBLE MASS - VISIBLE PERISTALSIS - EPIGASTRIC PULSATION - PUBIC HAIRS,GROIN,GENITALIA - HERNIAL ORIFICES : IMPULSE ON COUGHING

PALPATION SUPERFICIAL START IN THE LEFT ILIAC REGION AND THEN

GO ANTICLOCKWISE- TENDERNESS- RIGIDITY- HYPERASETHESIA- RIGIDITY- FLUID THRILL DEEP

PALPATION DEEP- LEFT KIDENY- SPLEEN- RIGHT KIDENY- LIVER- URINARY BLADDER- AORTA AND PARA-AORTIC GLAND AND COMMON

FEMORAL VESSELS- INGUINAL LYMPH GLANDS- GENITALIA : PEINS/SCROTUMA/SPERMATIC

CORD/VULVA- PER RECTAL EXAMINATION

PERCUSSION SHIF TING DULLNESS PERCUSSION OVER ENLARGED

ORGAN AND OTHER MASSES UPPER BORDER OF THE LIVER

DULLNESS

AUSCULTATION BOWEL SOUND BRUITS

NERVOUS SYSTEM MENTAL FUNCTION CRANIAL NERVES MOTOR FUNCTION SENSORY FUNCTION

MENTAL FUNCTION APPEARANCE , BEHAVIOUR AND

COMMUNICATION EMOTIONAL STATE ORINTATION IN PLACE AND TIME MEMORY SPEECH AND LANGUAGE SLEEP HALLUCINATION/DELUSION INTELLIGENCE

CRANIAL NERVES

OLFECTORY OPTIC OCLOMOTOR, TROCHLEAR AND ABDUCENT TRIGEMINAL FACIAL NERVE VESTIBULOCOCHLERA GLOSSOPHARYNGEAL AND VAGUS ACCESSORY HYPOGLOSSAL

1 OLFECTORY TEATING OF SMELL EG. EFFECT

– ANOSMIA

- PAROSMIA

- OLFACTORY HALLUCINATION

2 OPTIC VISUAL ACUITY – SNELLEN,S CHART

IS USED – DISTANT VISION,NEAR VISION

FIELD OF VISION – CONFRONTATION TEST

2 OPTIC COLOR VISION OPTHALMOSCOPIC EXAMINATION PUPILLARY REFLEXES

3,4,6 OCLOMOTOR, TROCHLEAR AND ABDUCENT

Ocular movement Pupil

- size

- shape

- light reflex

- accommodation reflex

5 TRIGEMINAL Sensory function

- pain, touch, temp

- Corneal reflex Motor function

- muscle of mastication- clench

Teeth, open mouth aginst pres.

- jaw jerk

7 FACIALMOTOR Wrinkling of forehead – frontal belly of occipito –

frontalis Close eye , don`t let me open – orbicularis occuli Ask to whistle – orbicularis oris Puff your cheek out – buccinator Show me your teeth and a smile

-levator anguli oris and risorius

7 FACIAL

SENSORY TEST

- ANTERIOR 2/3 OF TOUNG

8 VESTIBULOCOCHLERA

VESTIBULAR –

VERTIGO,DIZZINESS

COCHLEAR DIVISON –

RUB FINGER

RINNE`S TEST

WEBER`S TEST

9,10 GLOSSOPHARYNGEAL AND VAGUS

OPEN MOUTH AND SAY AAA…. ASK THE PATIENT TO COUGH SEE THE PALATAL REFLEX SENSATION IN THE POSTERIOR 1/3 OF

TOUNG

11 ACCESSORY

SHRUG YOUR SHOULDER AGAINST REGISTANCE

TURN YOUR HEAD TO OTHER SIDE AGAINST RESISTANCE

12 HYPOGLOSSAL

LOOK AT THE TOUNG

- WASTING

- FASICULATION

WAGGLE YOUR TOUNG FROM SIDE TO SIDE

MOTOR FUNCTION BULK OF MUSCLE TONE OF MUSCLE STRENGTH OF MUSCLES REFLEXS COORDINATION OF MOVEMENT INVOLUNTARY MOVEMENTS GAIT

EXAMINATION OF REFLEXES TENDON/DEEP REFLEX SUPERFICIAL REFLEXES

TENDON/DEEP REFLEXES KNEE JERK- L3,4 ANKLE JERK-S1,2 BICEPS JERK-C5,6 TRICEPS JERK-C6,7 SUPINATOR JERK-C5,6 JAW JERK- CLONUS :PATELLAR/ANKLE

CLONUS PATELLAR CLONUS – SHARPLY PUSH

THE PATELLA TOWARDS THE FOOT ANKLE CLONUS – SUPPORT THE

FLEXED KNEE WITH ONE HAND IN POPLITEAL FOSSA

SUPERFICIAL REFLEXES ABDOMINAL REFLEX CORNEAL REFLEX ANAL REFLEX PALATAL REFLEX CREMASTERIC REFLEX

COORDINATION OF MOVEMENT

TEST FOR COORDINATION OF UPPER LIMB

- FINGER NOSE TEST- RAPID ALTERNATING MOVEMENT

TEST FOR COORDINATION OF LOWER LIMB

- HEAL SHIN TEST

INVOLUNTARY MOVEMENTABSENT IN NORMAL INDIVIDUALS- - TREMOR - – CHOREA- – ATHETOSIS - – DYSTONIA - – MYOCLONUS - – TICS – DYSKINESIA – HEMIBALLISMUS – EPILEPSY – TETANY - CRAMP

GAITmanner of walking

Spastic gait Stamping gait Drunken gait Wadding gait High steping gait Fastinate gait Scissor gait Dancing gait Hemiplegic gait

SENSORY FUNCTION TACTILE SENSATION: LIGHT

TOUCH,PRESSURE,TACTILE LOCALIZATION AND TACTILE DISCRIMINATION

P0SITION SENSE RECOGNITION OF SIZE,SHAPE,WEIGHT

AND FORM OF OBJECT APPRECIATION OF VIBRATION PAIN TEMPERATURE