PERSONAL DETAILS VITAL SIGNS

NAME Pulse Rate

Rate:
R/N Age DOA Volume:
Nationality Ethnicity DOC Rhythm:

Marital Status Occupation Respiratory

Rate
Address
BP
Weight
O2 Sat
Height Temp

DOA
When were you
admitted
Emergency or
Referral?
Why were you
referred here
CHIEF COMPLAINT (in Pt own words)
Why were you
admitted here

How long have

you had this
problem

HISTORY OF PRESENTING ILLNESS (HOPI)

S – Site
O – Onset, freq
C – Character
R – Radiation
A – Assoc Symp
T – Timing/Trigger
E – Exacerbating F
(relieving f)
S – Severity

Krishna Ganesh Rajan Batch 17

Taylor’s University 2019/2024
PAST MEDICAL HISTORY
Diseases: (T2DM / HT / Asthma / TB)
When was it
diagnosed
Are you currently
on any medication
Any complications
from the illness
How frequent is
your check ups
Any fluid or diet
restrictions
Have you been told
of any
complications
Surgery:
When, Where,
Why, How long
ago, Investigations
done, Treatment
Hospitalization:
When, Where,
Why, How long
ago, Investigations
done, Treatment

SOCIAL HISTORY
Smoking: (YES/NO)
Alcohol: (YES/NO)
Recreational Drugs:
Multiple sexual
partners
Any domestic
violence
Partners:
Quality of Life:
Education Level

Occupation

DRUG AND ALLERGY HISTORY

DRUG INDICATION(why) DOSE FREQUENCY DURATION

TCM/Herbal
Medications
Allergies

Krishna Ganesh Rajan Batch 17

Taylor’s University 2019/2024
FAMILY HISTORY

Family tree,
Malignancy, familial
diseases
Parent Status: Father:
(alive, age, any diseases)
Mother:

Siblings Status:
How many siblings
Patient what child no.?
Alive, age, any similar
diseases, any diseases
Anyone with: Heart
disease, HT, DM,
Asthma, HepB, TB,
Congenital issues,
inherited issue

REVIEW OF SYSTEMS
CVS
Chest pain, SOB, oedema,
PND, orthopnoea
RS
SOB, wheeze, cough,
haemoptysis

ENT
Rhinitis, sinusitis, laryngitis,
hearing
GIT
Abd pain, diarr/cons,
naus/vom, dysphagia, jaun
GUS
Menses, obs & sexual
history, discharge, uri, freq,
genitals
MSK
Aches, pain, joint swelling,
joint prob

CNS
Sleep, heaches, vision,
hearing, tremor, faints, fits
SKIN, Optho
Rashes, scars, eyesight,
ENDO
Weight loss/gain, appetite,
heat cold tolerance, etc

Krishna Ganesh Rajan Batch 17

Taylor’s University 2019/2024
PHYSICAL EXAMINATION
General Examination
Drips, drains, inhalers, o2
mask, ECG, aids, parents,

Mental status, pale, jaundice,

pain, SOB, body build

Tone, bruises, rashes, lumps,

scars
VS: Temp, HR, RR, BP, SaO2

Examination of the
Hands
General inspection (colour,
tobacco staining, clubbing,
peripheral cyanosis, skin
changes, joint
swelling/deformities)
Finger Clubbing,
Finger nails(loss of normal
angle, ↑nail bed fluctuation, ↑
bulk of soft tissue over terminal
phalanges, ↑ nail curvature)
Fine tremors
Flapping tremors
IE: Splinter haemorrhages,
Osler node, Janeway les
Pulse: radial, HR, radia-radial
delay, collapsing pulse
Examination of the
Head and Neck
Sclera, eyes à jaundice,
pallor, or ptosis, anaemia,
corneal arcus, face, symmetry
mouth, tongue, lips à
glossitis, central cyanosis(L to
R shunt)
JVP(raised/invisible): HJ reflex,
carotid pulses
LN
Veins, thyroid
Accessory muscle usage
Examination of the
Chest
Pectus excavatum & pectus
carinatum
Scars
Axillary hair, gynaecomastia
Apex beat
Chest cavity expansion,

Examination of the
Lower Limbs
Pedal oedema, wasting,
tenderness

Krishna Ganesh Rajan Batch 17

Taylor’s University 2019/2024
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection
IE, CRT, pulse, JVP

Chest shape, scars

Palpation

Apex, parasternal and

ventricular heaves, thrills,
suprasternal notch, sacral
oedema

Auscultation
(Valves: APT M)
Heart Sounds, murmur,
manoeuvre

Examination of the
Peripheral Vascular
System

RESPIRATORY SYSTEM
Inspection
Asterixis, Horner’s, JVP,
nodes

Chest deformities, scars,

accessory muscles,
movements
Palpation

Trachea, apex, chest

expansion

Percussion

Resonant/dull (6ant,5post),
vocal fremitus

Auscultation

Breath sounds, vocal

resonance

Krishna Ganesh Rajan Batch 17

Taylor’s University 2019/2024
GASTRIINTESTINAL SYSTEM

Inspection
Nails, asterixis, nodes

Shape, scar, umb, mass,

movement

Palpation

(9 quadrants, Superficial
and deep)
Liver, spleen, kidney,

Percussion
(liver and spleen)

Fluid trills, shifting dullness

Auscultation

Bowel sounds, renal and

aortic bruits

CNS AND MSK EXAMINATION

Krishna Ganesh Rajan Batch 17

Taylor’s University 2019/2024
PROVISIONAL DIAGNOSIS

Features Supporting Features Against

DIFFERENTIAL DIAGNOSIS

Features Supporting Features Against

Features Supporting Features Against

Features Supporting Features Against

MANAGEMENT PLAN

Krishna Ganesh Rajan Batch 17

Taylor’s University 2019/2024