STUDENTS CASE SHEET – MEDICAL

Case No: Unit:

DOA: DOD:

Patient's Bio-data:
Name: Age: Sex:

Address: Religion: Occupation:

Chief complaints & duration:

History of presenting complaints:

Past History:

Family History:
Personal History:

Appetite: Sleep:

Bowel & Bladder habits:

Diet:

Alcohol: Smoking:

Other substance abuse:

Sexual history:

Menstrual & Obstetric History : (in case of female)

Medication History:

GENERAL PHYSICAL EXAMINATION:

Patient is conscious co-operative and well oriented Yes / No (specify)

Build & Nourishment: Decubitus

Weight: Height: BMI :

Vital Signs :
a) Pulse:
Rate: Rhythm: Volume :
Character:
Synchronicity : Radio-radial
Apex pulse deficit (if rhythm irregularly irregular):
Peripheral Pulses: Left: Right:
Radial
Brachial:
Carotid:
Femoral :
Popliteal
Dorsalis Pedis :
Posterior Tibial:
b. Blood Pressure : Supine: Standing:

c. Respiratory rate:

d. Temperature:

Hair & Scalp Facies (if any)

Eyes: Eyebrows: Conjunctiva: Sclera:

Any other observation:

Nose and nasal Cavity:
Oral cavity:
Lips: Tongue:
Teeth: Pharynx:
Neck: Thyroid: Other swellings:
Jugular venous pressure cm of H2O
Jugular venous pulse ‘a’wave: ‘V’wave:

Chest & Abdomen:

Swellings: Rash: Scars/Sinuses:

Spine (kyphosis / scoliosis gibbus etc):

Any other observations:

Lymphadenopathy: Right: Left:

• Cervical:
• Axillary:
• Epitrochlear:
• Inguinal:

Upper limb: Swellings: Rash:

Nails: Clubbing:

Any other observation:

Lower limb: Edema:
Swellings: Rash:

CARDIOVASCULAR SYSTEM:

Inspection :
Precordium: Apical impulse:
Epigastric pulsations: Y/N Parasternal pulsation: Y/N
Second intercostal space pulsations: Y/N

Palpation :Y/N
Apex beat: Location: Character:
Left parasternal heave: Y/N
Epigastric pulsation: RV type / Aortic / Liver
Left second Intercostal space : Palpable P2 (Diastolic shock): Y/N
Thrills:
Any other palpable events:

Percussion:
Left heart border
Right heart border
Le second Intercostal space
Lower Sternum

Auscultation :
First heart sound: Mitral area: Normal Loud / Soft

Tricuspid area: Normal/ Loud/soft

Second heart sound: Pulmonary area: Normal/ Loud / Soft
Aortic area: Normal/Loud/soft

Added sounds: S3
Election click
Opening Snap
Opening Snap
Pericardial rub
Murmurs: Should include the following
{Type (diastolic/systolic) Timing (early/mid/late/PAN); Grade, Character,
Conduction Specific actions that enhance or attenuate the murmur: (phase of
respiration posture, any other)

Mitral area:

Tricuspid area:

Pulmonary area:

Aortic area:

RESPIRATORY SYSTEM

Upper Respiratory Treat

Nose:
Sinus point tenderness: Frontal Maxillary / Ethmoid

Lower Respiratory Tract:

Inspection:
Shape of the chest:
Respiratory Rate: Type:
Trachea: Trail’s sign:
Apex impulse:
Accessory muscles of respiration:
 Dilated veins:
Chest wall movement:
Local asymmetries:; (Hollowing or retraction Bulging)
Scars / Sinuses:

Palpation :
Trachea:
Apex Beat:
Chest Expansion:
1. By Grip Method
Anterior: Upper:
Lower:
Posterior: Upper:
Lower:

2. By measurement
Measurement Inspiration Expiration

Chest circumference

Hemithorax Left

Hemithorax Right

Chest expansion: cms

Anteroposterior diameter: Transverse diameter : AP/Tr ratio:

Vocal Fremitus (in corresponding areas):

Chest wall tenderness:

Percussion: Left: Right

(Tympanic, Hyperresonant Normal resonant, Dull or Stony dull)

Direct percussion (over clavicles)

Indirect percussion (corresponding area):

Supraclavicular (including Kronig's isthmus):

Infraclavicular
 Mammary

Axillary

Infra-axillary

Suprascapular

Interscapular

Infrascapular

Upper border of liver dullness:

Tidal percussion:

Superficial Cardiac Dullness (left 3 and 4"ICS)

Traube's Space:

Shifting dullness (to diagnose hydropneumothorax):

Auscultation (mention findings with respect to area)

Breath Sounds:

Vesicular/Bronchial (mention the type)/(Normal with prolonged expiration):

Intensity:

Adventitious sounds

Crepitation (crackles; rates):

Rhonchi (wheeze):

Pleural rub:

Any other:

Vocal Resonance:

Whispering Pectoriloquy;
 Aegophony/Bronchophony;

Post tussive suction sound: Sucursion splash:

ALIMENTARY SYSTEM:

Inspection:

Shape of the abdomen: Flanks: Movement:

Umbilicus:

Dilated Veins

Visible Pulsations: Visible swellings/mass:

Visible Peristalsis

Palpation

Superficial: Tenderness: Guarding: Rigidity:

Deep:

Liver (describe in detail)

Spleen (describe in detail)

Other masses

Abdominal girth (in case of ascitis):

Percussion:
Liver span

Shifting dullness

Fluid Thrill

Auscultation :

Bowel sounds: Bruit:

Hernial orifices & External genitalia:

CENTRAL NERVOUS SYSTEM

Higher Functions

Consciousness: Alert / Drowsy / Stupor / Como Glasgow Coma Scale:

Orientation in time, pace & person:

Handedness:

Memory: Immediate: Recent: Remote:

Intelligence:

Behaviour and appearance:

Speech & Language:

Delusion and Hallucinations:

MMSE (In selected case)

Cranial Nerves: Right: Left:

I Nerve (Olfactory):

Sense of smell:

II Nerve (Optic):

Visual Acuity

Visual Fields (confrontation method)

Colour vision

III, IV & VI Nerves (Oculomotor, Trochlear & Abducent)

Ptosis: Strabismus

Extra Ocular Movements

Nystagmus

Pupils:
Size:
Shape:
Reaction to light:
Direct:
Consensual:
 Reaction to accommodation:

V Cranial nerve (Trigeminal):

Motor: Masseter
Temperature
Pterygoids :
Sensory: Ophthalmic:
Maxillary:
Mandibular:
Superficial Reflex: Corneal: Conjunctival

Jaw Jerk:

VII Nerve (Facial):

Motor:
Frontalis
Orbicularis Oculi
Buccinator
Zygomaticus
Orbicularis Oris
Levator anguli oris
Platysma

Sensory: Taste - Anterior 2/3 of tongue

Hyperacusis: Right: Left:

VIII Nerve (Vestibulocochlear)

Test of Hearing:

Rinne's Test:

Weber's Test:

Absolute bone conduction:

IX & X (Glossopharyngeal & Vagus ):

Position of Uvula (Ah Test): Nasal Twang of voice:

Palatal reflex

Gag reflex

Pharyngeal sensation :
XI Nerve: (Spinal Accessory)

Sternocleidomastoid Right Left

Trapezius

Xll Nerve (Hypoglossal):

Movement of the longue

Wasting of the langue : +/-

Fasciculation : +/-

Motor System
Attitude:

Nutrition & Bulk: Right Leſt

Arm:

Forearm:

Thigh:

Leg:

Tone Upper Limb Lower Limb

Power

Upper Limb Right Left

Shoulder:
Adduction

Abduction

Flexion

Extension
Elbow:

Flexion

Extension
Wrist:
Dorsiflexion

Palmar Flexion
Hand grip

Lower Limb Right Left

Hip:
Abduction

Adduction

Flexion

Extension

Knee

Flexion

Extension

Ankle:

Dorsiflexion

Plantar Flexion

Extensor hallucis longus

Reflexes: Right Left

Superficial reflexes

Corneal reflex

Conjunctival reflex:

Abdominal reflex (T7 to T 12

upper
Cremasteric (L1&2)
lower

Plantar (L6, S1)

Deep reflexes
 Jaw Jerk (C5)

Biceps (C5&6)

Supinator (C5 & C6)

Triceps (C6 &)

Knee jerk (12.3 & 4)

Ankle jerk (S1 & 2)

Clonus - Patella -Ankle

Co-ordination
Finger nose
Heel knee test

Abnormal movement :

Galt & Stance :

Sensory System: Right Left

Light touch

Crude touch

Pain

Temperature

Position

Joint sense

Vibration

Rhomberg's sign

Cortical Sensations
Tractile localisation

Two point discrimination

Stereognosis

Graphesthesia:

Cerebellar Signs
Titubation

Nystagmus
Speech :

Dysdiadochokinesia

Rebound phenomenon

Finger Nose/Finger-Finger test

Knee heel shin test

Pendular knee jerk

Signs of Meningeal Imitation

Neck rigidity Kernig's sign

Brudzinskis sign

Skull and Spine :

Carotid and Vertebral bruit:

Peripheral Nerve Thickening:

Galt & Stance :

Provisional Diagnosis :

Laboratory Investigations :

Blood: CBC: ESR

Blood sugar

LFT

Peripheral semear: MP

Blood Urea : Creatinine

Sputum: AFB Culture

Urine: Albumin Sugar: Microscopy:

Stool : Microscopy Occult Blood

ECG

Radiology

X Ray chest PA:

USG - Abdomen

CT/MRI Brain:

Other tests:

Final Diagnosis: