PERSONAL DATA1. Bed + MRN2. Full Name3. Gender & Race4. DOB5. Ht/Wt/BMI6. Date/Time Admit7. Date/Time Clerk8. Husband/Wife

(Name/Age/Occp)9. Total Income10. Address/House Type

PCs & HPCs

Pain1. Site2. Onset3. Characteristic

(burn,throb,stab,constrict,colicky,aching)

4. Radiation5. Associated Sympt6. Time/Duration7. Exacerbating/Relieving8. Severity/Score 9. Progression/Ending

Lumps/Ulcer1. When & how noticed?2. Changes/Development3. Symptoms4. At other sites on the

body?5. Idea what cause it?

Fever1. Type (Cont./Remit/

Intmint./Relapse)2. Character3. Duration

(sudden/gradual)4. Nocturnal Variation5. Chills/Rigor?6. Rashes/Joint Pain7. Frequency/Recurrent8. Temperature9. Medication10. Hx Contact11. Hx Travel12. Fits

Vomitting1. Frequency2. Characteristics3. Volume4. Projectile/NonProjctle5. Hematemesis (colour)6. Duration7. Exacerbating/Relieving8. Timing9. Nausea

Diarrhea1. Character/Consistency2. Colour3. Frequency4. Amount5. Blood/Mucous6. Pain7. Abd. Distension8. Flutulance

Constipation1. Onset2. Time3. Bleeding4. Straining/Prolapse5. Tenesmus

Loss of Weight1. How much?2. Period of time?3. Diet (type & intake)

Cough1. Duration2. Sound3. SOB?4. Cyanosis5. Type (Productive?)6. Sputum Character7. PostTussive (Condition)8. Runny nose9. Frequency10. Exacerbating/Relieving11. Medication

SYSTEMIC REVIEWRESPI - runny nose, cough, wheeze, SOB, activity limitationENT – throat infections, snoring, noisy breathingCVS - sweating, cyanosis, pallor, SOB, exercise tolerance, murmurGIT - appetite, diet, vomiting, pain, abdominal distention, bowel habit, stools,MSK - gait, limb pain, joint pain @ swelling,CNS - headaches, fits, hearing, visionGnUr - pain, colour, frequency, trainingH&L - anemia, bleeding tendency or clotting tendency.

Systemic Review Gynae1. Menstrual Hx

a. LMPb. Lenght/Delayc. Volumed. 1st Period (Age)e. Irregular bleed?

2. Dischargea. Colourb. Amount (# pads)c. Durationd. Pain/Itch/Rash

3. Obstetrica. # of pregnancy b. # of miscarriagesc. Complications?

4. Contraceptiona. Type/Nameb. For how long?

5. Menopausea. Whenb. Bleeding?c. HRT?

Family Hx1. Parents2. Siblings3. Partner (if releveant)

Social Hx1. Smoking/Drink/Drugs2. Diet3. Occupation4. Income5. Education6. House type &

environment

Hx Taking Guidelines Surgery Ver. 3

DDx = Trauma # Infection # Neoplasm # Congenital # Autoimmune # Metabolism # Blood # Endocrine # Drugs

Please add on if theres anything missing and improve this guideline

PCs & HPCs (Cont.)Hernia

1. Location2. Direct/Indirect?3. Simple / Obstructed /

Strangulate?4. Complete/ Incomplete

(What level?)5. Reducible ?6. Assoc. Symptom7. Hx of straining (heavy

lifting, cough, constipation, micturation problems)

PAST Med Hx6. Pass Illnesses7. Hospitalizations8. Surgery9. Medications10. Allergies

General ExaminationBed 45° Stand @ Right Hand Side of Pt1. Appearence, Alertness,

Activity(movements)2. Is the patient in pain?3. Hydrational/Nutritional Status

Sunken orbitsDry buccal mucosaSkin turgorCapillary refillAnterior fontanelle

4. Attachment/Equipment5. Temperature6. Respiratory Distress

RateNasal flaringAccesory Muscle Use

7. BP & Pulses (Rt/Ry/Vol)RadialBrachialFemoralPopletialDorsalis PedisPosterior Tibial

8. ColourPinkBlue/CyanoseYellow/JaundicePale

9. SkinRashBruisesScratch Marks/ScarsEczema

10. HandsNails shape & colour (clubbing,splinter H)TemperatureMoistureColour

11. Edema12. Neck

TracheaJVPThyroidLymph Nodes

Cervical Occipital Axillary Inguinal

CVS Examination

General CVS1. Pallor Sweating Cyanosis

SOB Palpitations Edema2. Dysmorphic features3. Vital Signs

(HR,RR,BP,Ht,Wt, Head Circumfrence)Inspection

4. Nails (clubbing, splinter hemorrhages, cyanosis)

5. Capillary refill time6. Eyes (pallor, scleral

icterus, xanthomata, senile arcus)

7. Mouth (central cyanosis, hydration)

8. JVP 9. Chest (shape, precordial

bulge, pectus carinatum/ excavatum, scars, visible impulse)

P Peripheral Palpation 10. Pulses brachial & femoral,

Brachial femoral delayPrecordium Palpation

11. Apex beat & all 4 auscultatory areas

12. Thrills 13. Liver14. Spleen15. Edema

Auscultation16. 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)

17. Lungs (pulm congestion)

Respiratory Examination

General Respiratory1. Respiratory Rate, depth,

ease and rhythm of respirationInspection

2. Thorax – Anterior & Posterior (symmetry,retractions, accessory muscles, shape, vertebral column)

3. Nose (nasal flaring)4. Lips/Mucus membrane

(cyanosis)5. Oropharynx (Inflamed?)6. Nail bed (peripheral

cyanosis, clubbing)P Palpation

7. Trachea at supra sternal notch (mobility and deviation)

8. Lymph nodes (head & neck)

9. Anterior & Posterior Tactile Fermitus (99 test)

10. Pulsus Paradoxus (decrese in systolic BP during inspiration)

11. Apex BeatPercussion

12. Chest (dull, hyperresonant,flat)Auscultation

13. For each lobes (compare R&L) - Air Entry- Breath Sound- Additional Sounds- Vocal Resonance

Abdominal Examination

General Abdominal1. Activity

Lie still – appndcts/pritonitsMoving – acute cholangitisInspection(Supine + Hips Flexed)

2. Contour, peripheral vasuclar irregularities, skin markings

3. Skin (dermatitis herperiformis, erytherma nodosum, palmar eryhterma, spider angioma, caput madusae)

4. Abdomen (distention, schaphoid abdomen, peristaltic waves, scars, protrusions in hernia)Palpate (superficial > deep)

5. Tenderness, liver, spleen, kidney, detect masses

6. Groin adenopathy, inguinal herniasPercussion

7. Hepatomegaly, Spleenomegaly, Acites (shifting dullness, fluid thrill)

P Auscultate8. Abdominal sounds (active,

decreased, absent)Bruit

CNS Examination

Higher Function Test1. Alertness, attention &

activity2. Speech & Language

(fluency, comprehension, naming, repetition, writing)

3. Sleep4. Memory

Past EventsPresent Events

5. OrientationName & Time (day, month)Place (hospital, country, city)

6. Intelligence

Cranial Nerve Test1. CN 1 (Olfactory)

Odor test (seperate nostrils)

2. CN 2 (Optic)AcuityColour VisionVisual FieldsRetinal Examination

3. CN 3 (Occulomotor)CN 4 (Trochlear)CN 6 (Abducens)Eyelid & PupilLight Reflex (Direct & Consensual)Accommodation (Near & Far object)Extraocular Movement (H test)NystagmusConvergance

4. CN 5 (Trigeminal)Motor – clenching muscle (Palpate temporal & masseter muscle)Asses pain, temperature and light touch of 3 trigeminal areasCorneal reflex

5. CN 7 (Facial)Symetrical movement of faceSmile, Frown, Show teeth, Puff cheeksClose eyes tightly and try to open againts force

6. CN 8 (VestibularCochlear)Whisper/Finger Rub testRinne’s (f 512)Webber’s

7. CN 9 (Glossopharyngeal)CN 10 (Vagus)Gag Reflex“Ahhhh” look at elevated soft palate

8. CN 11 (Accessory)SCM Muscle test (turn head againts force)

9. CN 12 (Hypoglossal)Protrusion of tounge

Meningeal Irritation Test1. Nuchal Rigidity2. Spinal Rigidity3. Kernig’s Sign (resistance in

knee extension)4. Brudizinski’s Sign (neck

flexion – involuntary hip flexion)

CNS Examination

Motor Function TestInspection

1. Hypertrophy2. Wasting3. Tremor4. Chorea

Palpate5. Bulk, Tone & Power

FingersWristElbowShoulderHipKneeFoot

6. RelfexBicepsBrachioradialisTricepsFingerKnee jerkPosterior tibialisAnkle jerkBabinski signCrossed adduction

Sensory Test1. Modalities

TouchPainTemperatureVibrationProprioception

2. AreasPerinealSole of FootDorsum of footMedial ankle and shinAnterior mid thighLateral thighMedial arm

3. Stereognosis4. Tactile Discrimination5. Graphesthesia

Cerebellar Function Test1. Cerebellar System

Finger to NoseHeel – Knee – Shin Rapid thumb index finger tappingrapid hand tapping againts examinerscrew light blub actionrapid alternate movements (dorsum palm tapping)

2. Balance & GaitRomberg Test (stand feet together open/closed eyes)

3. GaitPostureBlanceArm swingLeg movementTandem Walking – (Heel to toe walk)Heel walkingToe walkingHop in placeStand one leg and knee bend

Describing Lumps1. Site + Size + Surface2. Colour + Contour(Shape) + Consistency3. Tender? + Temperature + Transilluminable4. Fluid filled + Fixed? + Fields (of lymph

drainage)5. Pulsatile?6. Expansible?7. Reducible

Describing Ulcer1. Base

a. Solid brown/greyb. Yellow greyc. Bluish d. Underlying structures bare

2. Edgea. Slopingb. Punched outc. Underminedd. Rollede. Everted

3. Discharge4. Relations