[TYPE THE COMPANY NAME]

MEDICINE HISTORY AND

CASE PRESENTATION
BY—ANUBHAV MISHRA
ANUBHAV MISHRA
The patient_______________________(Married/Unmarried)
____years old, Male/Female, ____________(education)
_____________by occupation, a resident of ______________
_________________, reliable informant being ____________
Came to the OPD/Emergency on ______________ with the
C/C of –
The patient was apparently well _____________ ago until
he/she developed-

1) COUGH
Onset

Duration

Progression

Variation

--diurnal

--seasonal

--postural

Aggravating factors

Relieving factors

Associated factors

2) Headaches
Onset

Duration

Site

Type

Severity

Frequency

Radiation
Aggravating factors

Association w/ nausea/ vomiting/ tearing of eyes/ redness in eyes

Precipitating factors

3) Seizures
Onset

Duration

Frequency

Precipitated by

Confusion

Motor deficit

Sensory deficit

Cognitive defects

Muscles spasms

H/ head trauma

4) Expectoration
Onset

Duration

Progression

Variation

--diurnal

--seasonal
 --postural

Aggravating factors

Relieving factors

Quantity of sputum

Color

Smell

Blood

Associated factors

5) Palpitations
Onset

Duration

Fast/slow

Regular/irregular

Precipitating factors

Presence of Stoke Adams

Post palp. Diuresis

6) Syncope
Onset

Duration

Number of attacks

Precipitating factors
Associated symptoms

7) Pedal edema
Onset

Duration

Progression

Aggravating factors

Relieving factors

Facial puffiness(before/after)

8) Dyspnea
Onset

Duration

Grade

Progression

Aggravating factors

Relieving factors

Orthopnea(dypnea in supination)

Trepopnea(when lying on one side)

Platypnea (when sitting/standing)

Paroxysmal nocturnal dyspnea(dyspnea in sleep)

Associated factors
9) Pain
Onset

Duration

Type

Site

Radiation

Diurnal variation

Progression

Aggravating factors

Relieving factors

Associated factors

--(nausea, vomiting, sweating)

Dyspepsia

Local tenderness

10) Nausea and vomiting

Episodes

Contents

Blood

After how many hrs of meal

11) Wheeze
Onset

Duration

Progression

Episodic / continuous

Variations

Allergy

Skin rashes

Aggravating factors

Relieving factors

12) Fever
Type(INTMT, RMT, CNTNS, RLPS, hectic with 1.4 deg variation)

Grade

Onset

Chills and rigor

Aggravating factors

Relieving factors

Variation

--Diurnal
ANY H/ OF
Nasal discharge

Recurrent cold/epistaxis

Recurrent headaches

Anorexia

Evening rise of temp

Belching

Regurgitation of food

Hoarseness of voice

Hemoptysis

Fatigability

Dysphagia

Past medical history Family h/

Surgery

TB

DM

HPTN

IHD

COPD

Emphysema

Blood transfusion
Sickle cell disease

Anemia

Asthma

Seizure disease

Personal h/ Menstrual and obstetric H/

Diet

Bowel

Bladder

Appetite

Wt loss

Sleep

Substance abuse

General examination
The patient is conscious, cooperative, obeying commands
and well oriented to time, place and person.

1) Anthropometry

Ht- wt- BMI-

Build- arm span- mid arm cirm.-

2) Vitals
Pulse Respiration
Rate Rate

Rhythm Type

Volume Use of accessory muscles

Character

Vessel wall condition Blood pressure

Radio radial / radio femoral delay

Peripheral pulses JVP

Body temp

Sp O2
3) Physical examination
Pallor

Icterus

Cyanosis

Clubbing

Lymphadenopathy

Edema (with grading and type)

RESPIRATORY SYSTEM EXAMINATION

Upper tract examination
Nostrils

Nasal septum

Nasal polyps

Sinus tenderness

Tonsils

Post-pharyngeal wall

Lower tract examination

Inspection—

Shape and symmetry Visible pulsations/

Spine scars/ sinus

Trachea

Respiratory movements
Palpation—

Position and tenderness of spine

Trachea

Respiratory movements in Rt Lt

Supraclavicular

Infraclavicular

Mammary

Infra and supra scapular

Transverse diameter

AP diameter

Chest expansion

Tenderness

Percussion— Auscultation—

Shifting dullness Vesicular sounds

Tidal percussion Bronchial sounds

Traube’s space Vocal resonance

Liver dullness Vocal fremitus

CVS EXAMINATION
INSPECTION—

Shape and symmetry of chest

Scars
Precordial prominence

Distended veins

Apex beat

PALPATION—

Parasternal heaves

Thrills

Apex beat

PERCUSSION—

Borders of heart

AUSCULTATION-

S1, S2

S3, S4

MURMURS-(in all areas)

Timing

Grade

Quality

Pitch

Radiation

Diaphragm/bell

With breath holding in inspiration or expiration

GIS EXAMINATION
INSPECTION—

Shape and symmetry

Umbilicus

Movements

Dilated veins

Scars

Visible peristalsis

Visible pulsations

PALPATION--

Warmth

Tenderness

Rigidity

LIVER
Palpable or not

Size

Shape

Border

Tenderness

SPLEEN
Palpable or not

Size

Shape

Border

Tenderness
GALL BLADDER

KIDNEY
Palpable or not

Location

Size

Shape

Tenderness

PERCUSSION— AUSCULTATION--

Liver Bowel sounds

Spleen

Traube’s space

Shifting dullness

Fluid thrills

CNS EXAMINATION
Motor dysfuntion
Weakness—

Type(proximal/distal)

Distribution

Onset

Progression
Bulk of muscle—

Wasting

Fasciculations

Stiffness

Heaviness

Gait

Involuntary movements—

Type

Symmetry

Site

Sensory dysfuntion
NEGATIVE(w/ grade) POSITIVE
Pain Tingling
Temp Prickling
Touch Aching
Vibration Itching
Proprioception Cold
Tactile localization Burning
Tactile discrimination

Sterognosis

Graphesthesia
REFELXES

Biceps jerk

Triceps jerk

Supinator jerk

Knee jerk

Ankle jerk

Jaw jerk

Planter reflex

CEREBELLAR DYSFUNCTION

Ataxia

Swaying sidewise

Romberg sign

Tremors

Coordination

Overshooting

Involuntary eye movements

CRANIAL NERVE EXAMINATION

Olfactory

Optic

Occulomotor
Trochlear

Trigeminal

Abducent

Facial

Vestibulocochlear

Glossopharyngeal

Vagus

Accessory

Hypoglossal

HIGHER MENTAL FUNTION

Consciousness

Orientation

Memory

Intelligence

Mood

Focus and calculation

Speech—

1. Fluency
2. Repetition
3. Reading and writing
4. Naming
5. Phonation
6. Aphasia

Hallucination and delusions