EXAM CASES FOR GENERAL MEDICINE PRACTICALS

ABDOMEN
1. Chronic liver disease
2. Hepatosplenomegaly
3. Abdominal Lump + Lymphadenopathy
4. Jaundice
5. Ascites
6. Wilson’s
7. Hemochromatosis
8. Jaundice+Anaemia
9. Extra Hepatic Portal Vein Obstruction
RESPIRATORY
1. Consolidation
2. Pleural Effusion
3. Pneumothorax
4. Hydropneumothorax
5. Collapse
6. Fibrosis
7. Cavity
8. COPD
9. ILD
10.Bronchiectasis
11.Carcinoma Lung
12.Corpulmonale
CVS
1. MS
2. MR
3. AS
4. AR (mixed valvular heart disease )
5. Infective Endocarditis
6. ASD + Eisenenger syndrome
7. VSD
8. PDA
9. TOF
10.Cardiomyopathy
11.Peripheral Vascular disease +DM/IHD
12.Takayasu arteritis
13.Coarctation of Aorta
14.Constrictive Pericarditis
CNS
1. Monoplegia/ Hemiplegia/ Paraplegia/ Quadriplegia
2. Stroke in Young, Post partum Stroke
3. Cerebellar Ataxia/ Post. Circulation stroke
4. Sensory Ataxia
5. Spinocerebellar Ataxia
6. Freidrich’s Ataxia
7. Cranial Nerve palasies
8. Motor Neuron Disease
9. Multiple Sclerosis
 10.Peripheral Neuropathy
11.AIDP/CIDP
12.Acute Demyelinating Encephalomyelitis-ADEM
13.Acute Transverse Myelitis
14.Cauda/Conus/Cauda-Conus Syndromes
15.Compressive Myelopathy
16.Cervical Spondylosis + Myelopathy
17.PIVD
18.Lateral & Medial Medullary Syndromes
19.Myasthenia gravis
20.Parkinson’s,Parkinson’s plus syndromes
21.Muscular Dystrophies, Myopathy
22.Spinomuscular Atrophy
23.Dermatomyositis,Polymyositis
24.Syringomyelia
25.Cerebral Venous sinus Thrombosis
26.Craniovertebral Junction Anomalies
RENAL
1. Polycystic Kidney Disease
2. Glomerulonephritis
3. Nephrotic Syndrome
4. Chronic Renal Failure

ENDOCRINE
1. Hyper/Hypothyroidism + Goitre
2. Cushings
 3. Addisons
4. Acromegaly

RHEUMATOLOGY
1. Rheumatoid Arthritis
2. SLE
3. Scleroderma
4. Systemic scelerosis

MISCELLANEOUS
1. SVC,IVC Obstruction
2. Periodic Palsy
3. Hemolytic Anaemias
4. HIV,DM-Multisystem Involvement
5. Anasarca
6. Leprosy-Thickened nerves,patch
7. Sarcoidosis
8. Lymphadenopathy

VIVA &WARD ROUNDS

CHEST X-RAY, CT, MRI

DRUGS

INSTRUMENTS + PROCEDURES

ECG

ABG, PFT, HEMATOLOGY CHARTS

 RESPIRATORY SYSTEM

I. INTRODUCTION:
Name: Age: Sex: Residency:
Occupation: Education: Religion: Socioeconomic status:
Informant: Reliability:

II. CHIEF COMPLAINTS (IN CHRONOLOGICAL ORDER)

III. HOPI
1) Cough- Onset, Duration, Dry/Wet, Character, Day/Night Variation,
Postural/Seasonal Variation, , Aggravating /Relieving Factors, Present
Status, Associated With Any Other Symptoms

2) Expectoration- Onset, Duration, Quantity, Colour, Consistency,

Smell, Diurnal/ Postural Variation, , Blood Tinged Sputum,
Aggravating /Relieving Factors Present Status

3) Hemoptysis- Onset, Duration, Color, Quantity, Frequency, Postural

Variation, Last Episode, Postural Symptoms, Aggravating /Relieving
Factors Present Status, Associated Symptoms

4) Breathlessness- Onset, Duration, Progression, MMRC Grading (0-

4)(Describe With Activities), Associated Symptoms, Aggravating
/Relieving Factors, Present Status, Pnd, Orthopnoea.
5) Wheeze- Duration , Periodicity, Seasonal/ Diurnal Variation,
Associated Allergic Features Like Allergic Rhinitis, Urticaria,
Recurrent Sneezing, Aggravating /Relieving Factors

6) Chest pain- Onset, Location, Duration, Character, Associated

features, Aggravating and Relieving factors, Radiation, Time,
Severity

7) Fever- low/high Grade, Max Temp, Type, Associated with chills&

rigors, Diurnal variation, Evening rise of temp., night sweats, relieved
by, present status

8) Weightloss-Significant/insignificant.
9) Loss of appetite
10) Hoarseness of voice, dysphagia, dysphonia
11) Ptosis, muscle thinning in hands
12) Joint pain/rash/oral ulcers/seizures/excessive hairfall
13) Palpitation /Easy fatiguability/syncope
14) Oliguria, hematuria,Swelling of face/ edema
15) Nausea ,vomiting, abdominal pain/ distension,
16) Yellow discolouration
17) Nasal discharge/ear pain/throat pain
18) Sleep disturbance/ day time sleepiness
19) Altered speech/Sensorium/involuntary movement
20) Chest wall injury
IV. PAST HISTORY
Similar illness in the past
TB (Duration,Treatmeent)
DM/ HTN / TB/ Bronchial Asthma/COPD
CAD/CKD/CVA/Obesity
Exanthematous Fever
Seizure, Drowning, Recent LOC
Recurrent Respiratory Infection/ Allergies/ FB Inhalation
Jaundice/ Blood Txn
Trauma/ Surgeries

V. PERSONAL HISTORY
Marital status/ Children
Veg / Non veg diet / obesity
Smoking - pack years/smoking index,( Cigar/pipe smoking)
Alcohol / Tobacco / needle sharing /High risk behavior
Bladder/Bowel/Sleep pattern
Immunization history
Socio-economic status/ over crowding
Exposure to birds/pet animals
Recent travel to places with endemic ds

VI. FAMILY HISTORY

Similar illness in the family(parents/siblings/childrens)
Consanguineous marriage
Passive smoking
Any genetic disease in family/ death due to respiratory ds
VII. MENSTRUAL HISTORY
Menarche-
Cycles- regularity, frequency,duration
Flow-
Menopause –

VIII. TREATMENT HISTORY

For the current illness & past drug intake
Prolonged intake of steroid/ immunosuppressants

IX. OCCUPATION HISTORY

Exposure to dust/hazards, duration ,

X. CONTACT HISTORY (IF TB IN FAMILY) & DEVELOPMENTAL

HISTORY (IF GENETIC DS)

XI. SUMMARY:
With findings supporting respiratory system
Acute /chronic
U/L or B/L
Right/left
Airway/parenchyma/pleura
Congenital / acquired
If possible etiology
GENERAL PHYSICAL EXAMINATION

 Conscious/oriented/comfortable/ preferred position

 Ht- Weight- BMI-
 Pallor/ Icterus/ Cyanosis
 Clubbing (grade)
 Lymphadenopathy
(site/size/number/tenderness/matted/mobility/consistency/surface/skin)/
 Pedal edema(pitting/upto what level)

MARKERS

 Temporal / Buccal Fat Wasting, Hollowness Of Supraclavicular/

Infraclavicular Fossae, Emaciated Look-- CHRONIC MALNUTRITION
 Lupus/ Scrofuloderma/ Phlyten/ Chroid Tubercle/ Erythema Nodosum/
Matted LN/ Cold Abscess/ Epididymo-Orchitis/ Tinea Versicolor --TB
 Clubbing / Emaciation/ LNE/ Small Muscle Wasting/ Horners –
MALIGNANCY
 Rash,Joint Swelling -- RHEMATOLOGICAL DISORDERS
 Facial Plethora/ Neck Veins/ Puffiness Of Face/ Pemberten Sign – SVC
OBSTRUCTION
 Halitosis / Asterixis / Accessory Muscles Of Respiration/ -- RS
FAILURE
 Nicotine Staining Of Lips, Nail, Teeth, Gums, -- CHRONIC SMOKING
 Congested eyes/ pursed lips/ barrel chest/ smoking markers-- COPD
 Kyphosis / Scoliosis /Gibbus, Skull –SKELETAL DEFORMITY
 Candidiasis/ molluscum/ herpes/ LNE/ genital ulcer/ oral hairy
leucoplakia-- HIV
VITALS

 PULSE - (Rate, Rhythm, Volume, Character, Peripheral pulses, R-R/

R-F delay, Pulse deficit, condition of Vessel wall.
 BLOOD PRESSURE - in mm of Hg,at which limb and which position.
 RESPIRATION - Rate, Rhythm, type
 JVP-
 TEMP-
 SPO2-

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:

UPPER RESPIRATORY TRACT

 Ear(canal/wax/ discharge/tympanic membrane)

 Nose ( polyps,discharge, DNS, hypertrophy of turbinates )
 Throat (teeth,buccal mucosa, tonsils, oral hygiene, post nasal drip )

1.INSPECTION

 Tracheal position / Trail sign

 Apical impulse
 Shape of chest ,Chest symmetry,
 Respiratory movements - equal / decreased
 Signs of volume loss – shoulder droop/wasting or hallowing ( supra/infra
clavicular)/Nipple position/ Spino scapular distance/ Rib crowding/ fullness
of Intercostal spaces/ winging of scapula
 Accessory muscles of respiration/ Intercostal space indrawing
  Pectus excavatum/ Carinatum/ Harrison sulcus/ Kyphosis / Scoliosis
 Dilated veins/Scars/Sinuses/Visible pulsations over skin
 Litten Sign, Hoover Sign, Flial Chest

2. PALPATION:

 Warmth / tenderness(intercostals/ rib/ sternal)

 Tracheal position/Apical impulse
 Tracheal tug/descent
 Movement of chest (upper/anterior/posterior)
 Tactile fremitus/ friction fremitus/ subcutaneous crepitations

MEASUREMENTS:

Full Hemi
Spino Antero-
Chest Expansion Hemi thorax Transverse
Scapular Posterior
Circumferance at deep thorax expansio Diameter
Distance Diameter
inspiration n
Right
Left
Ap diameter : Transverse diameter –

Supra Infra Infra Supra Inter Infra

Mamary Axillary
Clavicular clavicular Axillary Scapular Scapul. Scapu.

Rt
Vocal
fremitus
Lt
3.PERC Supra Infra Infra Supra Inter Infra
Mamary Axillary
USSIO Clavicular clavicular Axillary Scapular Scapul. Scapu.
N
Rt
(indirect
percussi
Lt
on)
Percussi
Rt
on
over
clavicle Lt

Kronig’ Rt
s
Isthmus Lt

Percussion over Traube Space :

Liver Dullness, Tidal Percussion :
Crackpot resonanace :
Percussion tenderness :
Shifting dullness :
Straight line dullness :
Skodiac resonance :
4.AUSCULTATION
Supra Infra Infra Supra Inter Infra
Mamary Axillary
Clavicular clavicular AxilL. Scapu. Scapu. Scapu.
Air Entry Rt
(N/absent/
Lt
decreased/)
Vesicular Rt
BS Lt
Bronchial Rt
BS(type) Lt
Wheeze/ Rt
Rhonchi Lt
Crepitations/ Rt
crackles Lt
Vocal Rt
Resonance Lt
Bronchopho.
Whispering
Pectroloquy
Aegophony
Pleural Rub
Succusion.sp
Coin sound
Post tussive
suction
CARDIO-VASCULAR SYSTEM

For MS,Pulm.hypertension, congenital heart ds

ABDOMEN

For ascitis, hepatospleenomegaly,

CENTRAL NERVOUS SYSTEM

 Consciousness,Orientation
 FND, Horner’s Syndrome,
 Flapping trmors

EXAMINATION OF BREAST AND THYROID

SUMMARY AFTER EXAMINATION

DIAGNOSIS/DD

Acute /chronic
U/L or B/L
Right/left
Airway/parenchyma/pleura
Congenital / acquired
If possible etiology (TB/NON TB)
Corpulmonale/ pulm. HTN/ respiratory failure/ secondaries

INVESTIGATION

TREATMENT
 ABDOMEN

XII. INTRODUCTION
Name: Age: Sex: Handedness:
Resident of: Education: Occupation: Religion:
Informant: Reliability:

XIII. CHIEF COMPLAINTS (IN CHRONOLOGICAL ORDER)

XIV. HOPI
1. Abd.Pain-Onset, Duration, diffuse/localized, site, Timing, Severity
Character,(Colicky/Noncolicky), Associated
features(vomiting/constipation/loose stool), Aggravating and
Relieving factors, Relation with food Radiation,

2. Abd. Distension- Onset, duration, Progress Diffuse/Localised, ,

Asso.with-Pain/Fever/Altered bowel habits/Nausea &
Vomiting/Jaundice/Menstrual Irregularities/Oliguria, Periorbital
puffiness),aggravated/ Releived by

3. Vomiting-Onset, Duration, Projectile/Non projectile,

Bilious/Nonbilious, no.of episodes, amount, Content, Preceded by
nausea, (Asso. with hematemesis, tinnitus),Aggravated by, Releived
by, Last episode , last food intake and from where.

4. Hematemesis- Onset, Color, Quantity, Preceded by nausea,

Frequency, Aggravated by, Releived by, Last episode, associated with
(epistaxis,hemoptysis/malena/bleeding gums or bleeing PV)
5. Diarrhoea-
Onset,Duration,Frequency,Consistency,Quantity,Color,Odour,Painful/
Painless, Feeling of incomplete evacuation, Mixed with
blood/mucus/undigested food, associated with any symptoms or
isolated Bleeding Per Rectum

6. Melena- Frequency, Color, Consistency, Odour, Last episode

7. Constipation- duration, Frequency, hard stools, Fluid intake

8. Dysphagia- Onset, duration, progression , for Solids/Liquids/Both,

Associated with (Heart burn,Reflux,Indigestion,Flatulence)

9. Jaundice- Onset, yellow discoloration sites [skin, eyes, urine], Urine

color, stool color, Preceded by any Prodrome/Pain abd / Abd.
Distension, Progress, Persistent/Intermittent/Fluctuating,
associated (Pruritus, Bone pains, night blindness. Bleeding
manifestations, Altered Sensorium,right hypochondriac pain, recent
drug intake), Lasted for how long, Releived by

10.Fever- Grade, Max Temp, Type, Associated with chills& rigors,

Diurnal variation, Evening rise of temp., night sweats, relieved by,
present status

11.Anorexia & Weight -, Significant/insignificant

 12. Swelling of legs-Onset, Progression, Extension, Preceded/along

with/after Abd. Distension, relieved by

13.Genital ulcer, discharge, increased frequency of micturition, white

discharge
14.Oliguria/ Anuria/ Dysuria/ Hematuria/ turbid urine/ cola colored
urine/ Periorbital puffiness/ loin pain
15.Cough/ expectoration/ wheeze

16.Chest pain/ Palpitation/ dyspnoea/ sweating/ syncope

17.Joint pain/ Rash/ Photosensitivity/ oral ulcers/ Excessive hair loss/

Seizure/ Abnormal behavior
18.Sleep disturbance, altered behavior
19.Well water drinking/Alternative medicine intake/Chronic drug intake

20.Blood transfusion

21.Pigmentation of skin,change in colour if skin, loss of hair

XV. PAST HISTORY

Similar illness in the past
Childhood Jaundice/ Jaundice/
DM/ HTN / TB/ Bronchial asthma/IHD/ Associated autoimmune disease
CAD/CKD/CVA/Obesity/Seizure
Hemetemesis/ Blood Transfusion/ Trauma/ Surgeries
Needle sharing/ tattoo marks/ ear pricking / STD
Prolonged drug intake/ native medicine/
Umbilical cord sepsis in childhood
V. PERSONAL HISTORY

Smoking - pack years/smoking index/ Chula smoking

Alcohol –Quantity in gm/day X yrs, Type of liquor, last consumed,
Tobacco/Substance abuse/ drug addiction
Obesity ,Veg / Non veg
Marital status/ Children/ High risk behavior
Bladder/Bowel/Sleep pattern
Water source for drinking/ mosquito prevalence/ rat exposure
Immunization history/ Socio-economic status/ over crowding

VI. FAMILY HISTORY

Similar illness in the family

Family history of liver disease/ infections/ carcinoma/ genetic disease

Consanguineous marriage (3 generation family pedigree chart)

VII. TREATMENT HISTORY

Native medicine/ prolonged drug intake(ATT/ OCP/ETC)

VIII. OCCUPATIONAL H/O - for health care worker/ hazard exposure

IX. MENSTURAL & DEVELOPMENTAL

X. SUMMARY AT THE END OF THE HISTOR & IMPRESSION

Acute/chronic
Liver/ liver with associated organ involvement
Possible etiology.
GENERAL PHYSICAL EXAMINATION

 Conscious/oriented/comfortable/ preferred position

 Ht- Weight- BMI-
 Pallor/ Icterus/ Cyanosis
 Clubbing (grade)
 Lymphadenopathy
(site/size/number/tenderness/matted/mobility/consistency/surface/skin)/
 Pedal edema(pitting/upto what level)

MARKERS

 Signs of Liver Cell Failure-Alopecia, Jaundice, Bitot’s spots, Parotid

swelling, Foetor hepaticus, Spider nevi, Gynaecomastia, Loss of axillary/

pubic hair, Palmar erythema, Deputuryn contracture, Asterixis , Ascitis,

Testicular atrophy, halitosis

 Invountary movement, KF ring , sunflower cataract

 Petechiae, purpura, pigmentation, scratch marks

 Peripheral signs of TB / HIV

VITALS

 PULSE - describe in detail.

 BLOOD PRESSURE - in mm of Hg, at which limb and which position.
 RESPIRATION - Rate, Rhythm, type
 JVP-, hepatojugular reflex
 TEMP-
UPPER GI EXAMINATION

-oral cavity, teeth, gums, cheek, buccal mucosa, (staining, carries,

bleeding, patches, pigmentation)

ABDOMEN
INSPECTION
 Shape
 Symmetry
 Distension- Generalised/Localised
 Flanks
 All quadrants moves with respiration
 Umblicus (middle/shifted),(inverted/flat/everted)
 Skin over the Abdomen- Striae/pigmentation/Injection marks/Ascitic
tapping/Petechiae/Ecchymosis
 Scars/Sinuses/Dilated/Prominent veins
 Visible peristalsis/Pulsations
 Divarication of recti, external genitalia
 Hernial orifices

PALPATION
Superficial palpation

 Inspectory findings confirmed

 warmth
 Soft/ Guarding/ Rigidity
 Tenderness-Localised/Diffuse/Dull/Severe/Specific area tenderness/Signs
 Direction of flow in distended veins
  Pareitel wall edema
 Cough impulse
 External genitalia

Deep palpation

 Liver-Size palpable below costal margin/ Extend of left lobe/ Border/

Surface/ Consistency /Tenderness/ Moves with respiration/ intercostal
tenderness
 Spleen- Size/ direction of extension/ Border/ Surface/ Consistency/
Tenderness/ Notch/ Moves with respiration(by all 3 method)
 Kidney- Above +,get above the swelling, Bimanually palpable, ballotability,
renal angle tenderness
 Any other mass (gall bladder/ urinary bladder/ colonic mass)
 Fluid thrill
 Pulsations
 Measurement
o Abdominal circumference (at umbilicus level)
o Umbilicus location(xip-umblicus & umbilicus- pubis)
o Spino umbilical distance

PERCUSSION
 Shifting dullness/Puddle sign
 Liver span(upper border of liver)
 Traube’s Space
 Colonic band of resonance on the lt side
 Various methods of percussion of Spleen- Nixon/Castell/Traube space
 Bladder dullness
AUSCULTATION
 Bowel sounds
 Hepatic & spleenic rub/ Hepatic bruit/ Renal bruit/ Venous hum
 Succusion splash

Per Rectal Examination:

Per Vaginal Examination:

EXAMINATION OF LYMPHORETICULAR SYSYEM

 Gum ,oral cavity

 Cervical, axillary, inguinal nodes
 Sternal tenderness

RESPIRATORY SYSTEM

 Air entry/NVBS/BB/Crackles/Rhonchi/Pl.Rub

CARDIO-VASCULAR SYSTEM

 S1,S2,Murmurs

CENTRAL NERVOUS SYSTEM

 Consciousness,Orientation
 Flapping tremor & test for hepatic encephalopathy
SUMMARY AFTER EXAMINATION

DIAGNOSIS/DD

Acute/chronic(duration)

Hepatospleenomegaly/ hepatitis/ cirrhosis/ mass(pathology)

Alcohol/viral/congenital/others(etiology)

Portal hypertension/ ascitis/ encephalopathy/ UGI bleed/ spont.bac

peritonitis/ hpatorenal syndrome/ liver cell failure(complications)

INVESTIGATION

TREATMENT
 CARDIOVASCULAR SYSTEM

INTRODUCTION:

Name: Age: Sex: Residency:

Occupation: Education: Religion: Socioeconomic status:
Informant: Reliability:

CHIEF COMPLAINTS:

HOPI
1. Breathlessness- Onset, Duration, Progression, NYHA
Classification(describe With Activities), Associated
Symptoms(cough,sputum,whezee), Aggravating /Relieving Factors,
Present Status, PND, Orthopnoea.

2. Palpitation
Onset – Rest/exertional,/ Duration,/ Regular/irregular,
frequencyAggravated/relieved by/ Associated with
(giddiness/syncope/sweating/anxiety/Post palpitations dieresis)
Progression/ Present status

3. Chest Pain
Onset/ location/ duration/ progression/ diurnal variation / character of
pain/ Aggravated by/ relieved by/ timing/ severity / Frequency (No of
episodes/ day)/abn. Sweating/ Pain radiation to anywhere in the body
4. Easy Fatiguability
Quantity and quality of the fatigue in terms of patient activity which
he used to do before and now./ Progress/Present status
5. Syncope and pre-syncope
Onset/ precipitated by/ no of episodes/ duration/ associated (tongue
bite,involuntary movement, injury)
6. Cough
Onset, Duration, Dry/Wet, Character, Day/Night Variation,
Postural/Seasonal Variation, , Aggravating /Relieving Factors, Present
Status, Associated With Any Other Symptoms

7.Expectoration

Onset, Duration, Quantity, Colour, Consistency, Smell, Diurnal/

Postural Variation, , Blood Tinged Sputum, Aggravating /Relieving
Factors Present Status

8.Hemoptysis

Onset, Duration, Color, Quantity, Frequency, Postural Variation, Last

Episode, Postural Symptoms, Aggravating /Relieving Factors Present
Status, Associated Symptoms

9.Fever

low/high Grade, Max Temp, Type, Associated with chills& rigors,

Diurnal variation, Evening rise of temp., night sweats, relieved by,
present status
 10. Swelling of legs

Onset / duration/ which side/ progression / upto what level/ positional

or postural variation /associated (facial puffiness/ascitis)
Painful/painless

11. Nausea / vomiting/ abdominal fullness/ anorexia /right hypochondrial

pain

12. Any joint pain/redness/ Subcutaneous nodules /. Involuntary movements

13. Joint pain/Petechiae/Puprpurae/ecchymoses /. Painful nodules over

finger tips/Rash/ Hges under nail beds/discoloration of digits / Prolonged
fever/Pain abdo/Visual disturbance/ Hematuria
14.Bluish discoloration of skin, squatting episodes,recurrent respiratory
infections.
15.Hoarseness of voice/ dysphagia
16.Abnormal pulsations over body
17.Oliguria/anuria/dysuria
18.Loose stools, excess sweating, flusing of face.
19.Constitutional symptoms/ LOA/LOA
20.Intermittent claudication/ discoloration of toes or limbs
20. History s/o hypo/hyperthyroidism
a. Hypothyroidism(Tiredness/weakness/dry skin,Cold intolerance/hair
loss/memory loss/ Hoarseness of voice/Constipation/ Weight gain/Poor
appetite)
b. Hyperthyroidism(Heat intolerance/palpitations/fatigue/Increased
appetite/weight loss/ Tremor/restlessness/Hyperdefecation/ Loss of libido)
21. CTD history
PAST HISTORY
Similar illness in the past
Rheumatic heart ds( Joint pain/nodules/abnormal movt/rash/ Recurrent
sore throat/penicillin prophylaxis/ Digoxin therapy)
Congenital heart ds/surgery/ procedures/ implants
DM/ HTN / TB/ Bronchial Asthma/COPD
Dyslipidemia / Thyroid disorder
CAD/CKD/CVA/Obesity/Seizure
Recurrent Respiratory Infection
Dental extraction/ abdominal surgery
Jaundice/ Blood Txn
Trauma/ Surgeries

PERSONAL HISTORY
Marital status/ Children
Veg / Non veg diet / obesity
Smoking - pack years/smoking index,( Cigar/pipe smoking)
Alcohol / Tobacco / needle sharing /High risk behavior
Daily exercise/ physical activity
Bladder/Bowel/Sleep pattern

MENSTRUAL HISTORY
Menarche/Cycles/Menopause
LMP/Post menopausal bleed
any surgery
FAMILY HISTORY
Similar illness in the family(parents/siblings/childrens)
Consanguineous marriage (3 generation family pedigree chart)
Passive smoking
Co morbid illness in family
Any genetic disease in family/ death due to cardiac ds/ sudden death
Socioeconomic status/Poverty/overcrowded place

DEVELOPMENTAL HISTORY
Antenatal – fever, drug intake, immunization, infection,
Birth –mode of delivery, cried after birth, admission after birth
Post natal-milestones, school performance/ playing, recurrent hospitalization

TREATMENT HISTORY

1. Penicillin prophylaxis/digoxin/diuretics
2. Surgery/intervention
SUMMARY
Congenital /acquired
Right /left heart
Valvular / non-valvular
Stenosis /regurgitant
GENERAL EXAMINATION
 Conscious/oriented/comfortable/ preferred position
 Ht- Weight- BMI-
 Pallor/ Icterus/ Cyanosis/Clubbing (grade)
 Lymphadenopathy
 Pedal edema(pitting/upto what level)
 Arm length: height ratio
 upper segment/lower segment
 Thyroid swelling
MARKERS
Hypertelorism/low set ears/micrognathia/mangoloid slant/high arched
palate/single palmar crease/sandle gap/clinodactyly/squint-DOWNS
Webbed neck/shield chest/high carrying angle- TURNERS
Arachinodactly /Arm > height/ US<LS/ lens dislocation/wrist sign/ thumb
sign—MARFANS
Elfin facies- WILLIAM SYNDROME
Fever / janway lesion/osler nodes/ palloe/ petechiae/purpurae-IE
Joint swelling/ rash/ erythema marginatum/ subcut.nodules--RF
Xanthoma/xanthelasma/arcus senilis-HYPERLIPIDEMIA/ATHEROGENIC
Madarosis/ dry skin/ hoarse voice/dull face/obesity/delayed
reflex/myotonia/pallor/ myxedema- HYPO THYROIDISM
Eye signs/warm & wet hands/ tremor-HYPER THYROIDISM
Peripheral signs of AR
FUNDUS-
DENTAL EXAMINATION-
VITALS

 PULSE - (Rate, Rhythm, Volume, Character, Peripheral pulses, R-R/

R-F delay, Pulse deficit, condition of Vessel wall)
 BLOOD PRESSURE - in mm of Hg in all 4 limbs/ hills sign
 RESPIRATION - Rate, Rhythm, type
 JVP- how many cm increased, kusmall s sign, hepatojugular reflex
 TEMP-
 SPO2-

CVS -SYSTEMIC EXAMINATION

a. INSPECTION
Tracheal position
Chest wall symmetry/deformity/Precordial bulge
Apical Impulse – site/no. of spaces visible
Pulsation in precordium/epigastric/suprasternal/etc...
Scars/sinus/dilated veins
b. PALPATION
Warmth/tenderness
Apical Impulse – site/no. of spaces visible/character
Palpable heart sounds
Thrill
Parasternal heave ,grading
Epigastric & other palapable pulsation
c. PERCUSSION
Mark cardiac borders
Pulm.artery dullness
 d.AUSCULTATION
S1(soft/loud/variable)
S2 – A2/P2/loudness/split
S3/S4(+/-)
OS/Ejection click/tumor plop/valve click
Pericardial rub/knock
Murmur (location/ grading/ timing(systole/diastole)/ character / pitch/
phase of respiration/ best heard with bell or diapharm/ position of
patient/ conduction / radiation/ physical manouer)
2. RS
Breath sounds/added sounds/
3. P/A
Ascitis/ hepatospleenomegaly
4. CNS
Focal neurological signs
SUMMARY

DIAGNOSIS
Congenital /acquired
Valvular / non-valvular(which valve),if more than 1(which is dominant)
Stenosis /regurgitant
Rheumatic /non- rheumatic
Ass (rheumatic fever/ IE/ CCF/ sinus rhythm )

Investigation

Treatment
 CENTRAL NERVOUS SYSTEM

XVI. INTRODUCTION:
Name: Age: Sex: Residency:
Occupation: Education: Religion: Socioeconomic status:
Informant: Reliability:

XVII. CHIEF COMPLAINTS (IN CHRONOLOGICAL ORDER

XVIII. HOPI

7. LOC/Seizure
a. Onset
b. Activity at the time of incident
c. Preceded by
i. Chest pain/Palpitation/sweating/nausea/ vomiting/
ii. Headache/giddiness/presyncope/visual disturbance.
d. Associated with
i. Involuntary movt/Tonic/clonic/focal/generalized
ii. Rolling up of eyes/stare/tongue bite/grunting noise
iii. Sphincter incontinence/abnormal breathing pattern
e. Lasted for (Duration)
f. Recovered by – Spont/treatment
g. Post recovery – drowsiness/confusion/weakness
h. Number of episodes
i. Sensorium in between episodes
j. Last episode
k. Any injury sustained.
8. Confusion
a. Orinentation to Time / Place/ Person
b. Episodic or continuous
c. Orientation between the episodes
d. Any abnormal behavior
e. Recovery

9. Speech disturbance
a. Onset
b. Comprehension
c. Any spontaneous speech/word outflow
d. Slurring
e. Reading/writing/repetition
f. Progression
g. Any stress during speaking
h. Any difficulty for particular word
i. Tightness/looseness in tongue

10.Cranial Nerves
CN 1.Smell to commonly used items soap/shampoo/toothpaste
CN 2.Decreased vision (near/ distant)/ Color vision
CN 3,4 &6
i.Double vision
Monoocular/binocular, primary gaze or evoked gaze
Horiontal/vertical, Distance between objects
ii.Pain in eyes on movements
iii.Ptosis – Fatiguability/diurnal variation
CN 5. Decreased/abnormal sensations over face, difficulty in mastication.
CN 7. Deviation of angle of mouth
Facial asymmetry/ Drooling of saliva/ Difficulty in closing eyes
Difficulty in speaking/ Taste impairment
CN 8. Hearing impairement, Giddiness/ Vertigo/ Tinnitus
CN 9/10 Dysphagia – solid/liquid/both/ Dysphonia/ Dysarthria
Nasal regurgitation /Hoarseness of voice/Nasal twang of speech
CN 11. Neck movements/ Shrugging of shoulders
CN 12. Ability to make the bolus of food/ Ability to protrude tongue
Tongue deviation
11.Motor
i. Reaching overhead objects/taking comb to the head
ii. Lifting a bucket of water
iii. Holding a glass of water/Holding the pen & writing
iv. Difficulty in getting up from a chair/squatting position
v. Climbing up/down the stair/bukling of knees
vi. Chappals slips away with/without the knowledge
vii. Turns in the bed
viii. Lifting the head off the bed
ix. Breathlessness/ptosis/facial weakness/chewing
x. Thinning of limbs/ enlargement/ prominent bony
promineneces
xi. Looseness/tightness
xii. Fasciculations/ Involuntary movements
b. EPS
i. Tremors at rest/Stiffness/expressionless face
ii. Slow activity
12.Sensory
a. Onset/progression/present status
b. Spinothalamic
i. Hot and cold water during bath
ii. Mosquito bite for pain
iii. Able to appreciate cloth over body for touch
iv. Burning/shooting/pricking pain
v. Funicular pain
vi. Root pain / dermatomal pattern / increases on
coughing/sneezing.
c. Posterior column
i. Difficulty in walking in the dark/wash basin (Sink) sign
ii. Slipping of slippers without knowledge
iii. Cotton wool sensations over the feet
iv. Band like sensation/Encasement of limbs
v. Pins and needles/numbness/tingling/paraesthesias
d. Lhermittes phenomenon/ electric shock like sensation
e. Cortical sensations
i. Ability to feel the coins in the pocket
ii. Feel wallet in the pocket
13.Cerebellum
i. Smearing of face/target oriented activities
ii. Giddiness, shaking movements on reaching objects
iii. Speech problem
iv. Swaying to one side while walking
v. Incoordination during picking up water/during drinking.
14.Autonomic
a. Bladder
i. Able to initiate urination
ii. Able to hold till reaching bathroom
iii. Passing urine in the dress
iv. Frequency of urination
v. Inability stop while micturition
vi. Incomplete emptying
vii. Overflow incontinence
viii. Dribbling of urine/loss of social inhibition
ix. Postural giddiness/presyncope
x. Impotence/ erectile dysfunction
b. Bowel – Frequency/consistency/continence
c. Faintness/palpitations
d. Abnormal sweating/Decreased lacrimation
e. Horners syndrome
f. Gastroparesis/nausea/vomiting/diarrhea

9.Headache (Mnemonic – OLD CAARTS)

a. Onset/location/duration
b. Associated with(Nausea/vomiting/photophobia/
phonophobia
c. abnormal behavior/LOC/blurring of vision
d. Preceded by aura
e. Aggravated by/relieved by/timing/severity/
f. Frequency (No of episodes in a day)/abnormal sweating
g. Pain anywhere in the body
 10. Fever/neck pain/photophobia/ vomiting
11. Memory disturbances/ abnormal thinking/ Sleep disturbances
12. Chest pain/palpitations/syncope/palpitation
13. Cough/dyspnea/hemoptysis
14. Yellow discoloration of eyes
15. Oliguria/dysuria/hematuria/high colored urine
16. Joint pain/rash/photosensitivity/oral ulcers /hair fall/seizures
17. Dog bite/animal bite/vaccination/injection
18. Ear discharge/ ear pain/ throat pain/ nasal discharge
19. Carrying weight in head for long/neck pain for long
20. Injury/RTA/Trauma to the neck

PAST HISTORY
Similar illness in the past
DM/ HTN / TB/ Bronchial Asthma/COPD
CAD/RHD/CKD/TIA/CVA/Obesity
Seizure
Exanthematous Fever
Recent history of fever/ URI/ AGE
Recent dog bite/ vaccination
Jaundice/ Blood Txn
Exposure to neurotoxinx (petrol/ TOCP/ OPP/ kesari dhal)
Trauma/ Surgeries
PERSONAL HISTORY
Marital status/ Children
Veg / Non veg diet / obesity
Smoking - pack years/smoking index,( Cigar/pipe smoking)
Alcohol / Tobacco / needle sharing /High risk behavior
Bladder/Bowel/Sleep pattern
OCP intake, bleeding disorder/ hypercoagulable state

FAMILY HISTORY
Similar illness in the family(parents/siblings/childrens)
Consanguineous marriage
Any familial CNS disease in family(tremor, chorea, migraine,
stroke,ataxia)
Death due to brain problem

OCCUPATIONAL HISTORY
Nature/duration/intensity of exposure to neurotoxins
H/O exposure to dye/paint/glasswares/medical eqpts/jwellery
Plumbing/farming/insecticides
Vibrating eqpts/repeated trauma
TREATMENT / CONTACT / DEVELOPMENTAL/ MENSTURAL H/O

SUMMARY at the end of history and four tier diagnosis

1. Functional (hemiplegia)
2. Physiological()
3. Anatomical(INTERNAL CAPSULE)
4. Etioloical 1, 2, 3, 4……(CVA)
GENERAL EXAMINATION

 Conscious (MMSE SCORE)/oriented/comfortable/ attitude of limbs

 Ht- Weight- BMI-
 Pallor/ Icterus/ Cyanosis
 Clubbing (grade)
 Lymphadenopathy
(site/size/number/tenderness/matted/mobility/consistency/surface/skin)/
 Pedal edema(pitting/upto what level)
 Arm length/upper segment/lower segment & neck:ht ratio.

MARKERS
-Neurocutaneous markers
Adenoma sebaceum/ ash leaf macules/ shagreen patch –TS
Neurofibroma/ café-au-lait spot/ freckling - NF
Facial nevus/port wine stain - struge weber syndrome
Hemangioma – von hippel landau syndrome
Tuft of hair amd lipoma over spinal column- spina bifida
Telangiectasia – ataxia Telangiectasia
-Peripheral nerve thickening
-Thyroid enlargement
-Short neck/ low hair line/ restriced neck movements- CVJ anamoly
-Xanthoma/xanthelasma/arcus senilis- atherosclerosis
-Congenital anomalies – arms/foot/chest/gums/teeth/hair change
-Peripheral stigmata of TB/HIV
VITALS

 PULSE - (Rate, Rhythm, Volume, Character, Peripheral pulses, R-R/

R-F delay, Pulse deficit, condition of Vessel wall.
 BLOOD PRESSURE - in mm of Hg,at which limb and which position.
 RESPIRATION - Rate, Rhythm, type
 JVP-
 TEMP-

CNS EXAMINATION
1. HIGHER MENTAL FUNCTION
a. Consciousness/ drowsy/ stupor/ coma
b. Oriented to time/place/person
c. Registration
d. Attention/calculation/ Recall
e. Handedness
f. Language-Speech
i. Comprehension
ii. Naming
iii. Spontaneous speed
iv. Reading/ Writing/ Repetition
g. Language – articulation
i. UMN/Pseudobulbar – “British constitution”
ii. Bulbar – Pa Ta Ka
iii. Cerebellar – Rashtrapaty Amritsar se Hyderabad gaye
Ask to repeat “Yellow Lorry”.
iv. NMJ – Fatiguability/Nasal voice.
2. CRANIAL NERVES (CHECK SEPARATELY FOR BOTH SIDES)
I -conform patency both sides
-Coffee powder/ peppermint/soap/ clove oil- for smell

II - Acuity (snellens chart for far 6/6), (jaegar card for near vision)
-Color (ishihara chart).(holmgram wool test)
-Field of vision -confrontation method, perimetry
-Fundus(disc/ macula/ vessels)

III, IV & VI
- Position of the eye at primary gaze
- Individual eye movements
- Conjugate eye movements
a. convergence/divergence/saccades/pursuits
- red glass test
- Squint/ Nystagmus
- Size of the palpaberal fissure
- Pupils- size, shape, symmetry,
-reaction to light(direct/indirect)
- accommodation reflex

V -Facial sensations touch/pain/temp/vibration (all 3 divisions)

-Muscles of mastication- clench the teeth and palpate
masseter/temporalis
-Movements of mandible/ jaw devaition
-Corneal, conjunctival reflex
-Jaw jerk
VII - Asymmetry of face/ Wrinkling of forehead
- Frowning of eyebrows/eyelid closure tightness
- Bells phenomenon/facial expression/nasolabial fold
- Angle of mouth deviation/ holding air in mouth
- Whistling / pursing out mouth/
- Parotid swelling/tenderness
- Herpes zoster in EAM
- Taste sensation ant 2/3rd –(sweet/salt sour/bitter)
- Lacrimation – schirmers test
- Excess salivation
- Hyperacusis
- Sensation over tragus & EAC
VIII -Voice test/ watch test
-Rinnes/webers/ABC
-Ear examination
-fistula test / caloric test
IX & X-Uvular position
- On saying “AH” uvula/palatal/post phar. wall movement
- Gag reflex
- Sensation of post 1/3rd of tongue
- Taste on post 1/3rd of tongue(galvanic current)
XI - Shrugging of shoulders (trapezius)
- Left/right turn of neck (Sternomastoid)
XII - Tongue position in resting state/on protrusion
- Flaccidity/ spasticity /fasciculations/tremors/
-Myotonia/movements/Deviation of tongue
- Ulcers / furrows / wasting
3. MOTOR SYSTEM EXAMINATION
a. Position/attitude of limbs
b. Bulk
Inspection - wasting/ hypertrophy/ fasiculattions
Palpation – flabbiness/ hard consistency of muscles
Measurement – mid (arm/ FA/thigh/ leg) & compare with
opposite side
c. Tone
i. Normal
ii. Decreased -. Flaccidity
iii.Increased (Spasticity – clasp knife /Rigidity – cog wheel/lead
pipe)
iv. Clonus/ Myotonia
d. Power
i. Shoulder – Abduction/adduction/flexion/extension (5/5)
ii. Elbow – Flexion/extension (5/5)
iii. Wrist – Dorsiflexion/Palmar flexion (5/5)
iv. Hand grip – Percentage (25/50/75), Myotonia (+/-)
v. Individual muscles of hand – Normal or weak
vi. Hip - Abduction/adduction/flexion/extension,rotation (5/5)
vii. Knee - Flexion/extension (5/5)
viii. Ankle – Dorsiflexion/Plantar flexion (5/5)
ix. EDP muscle wasting – Present/not
x. Truncal weakness –
xi. Neck muscle weakness - (Flexion/extension/lateral flexion)
e. Reflexes
Superficial Reflexes
i. Corneal / Conjuctival reflex
ii. Palatal /pharyngeal reflex
iii. Scapular reflex
iv. Plantar reflex
v. Abdominal reflex
vi. Cremastric reflex
vii. Perianal

Deep tendon reflexes

i. Trapezius
ii.Biceps
iii.Triceps
iv.Supinator
v.finger flexion
vi.Knee
vii.Ankle
viii. Clonus (+/-)
ix. Myotonia (+/-)
Visceral reflex ( anal / bulbocavernous reflex)
Primitive reflexes
i. Palmo mental
ii. Glabellar tap
iii. Rooting reflex
iv. Suckling reflex
 v. Avoiding reflex
vi. Grasping reflex
Inverted reflexes
Wartenburg sign
Hoffman sign

f. Coordination – UL-(FNT/ FFNT/ tapping in a circle/

dysdiadochokinesia)
- LL (heel knee shin test/ foot pad test/)
g. Involuntary movements
 Ahetosis
 Ballismus
 Chorea
 Dystonia
 Fibrillation
 Fasciculation
 Tremor
 Titubation
 Myoclnus
 Myokymia

h. Gait
-normal
- abnormal(specific character )
- not able to walk
4. SENSORY SYSTEM EXAMINATION
a. Superficial sensations
i. First test pin prick sensation
ii. Touch with cotton
b. Lateral column sensation
i. Pain (pin)
ii. Temperature – Cold 5-10 o C) and warm(40-45 o C)
c. Posterior column
i. Vibration (128Hz)
- Forehead/Mastoid/Sternum/Vertebral spine
- Clavicle/Elbow/wrist
- ASIS/PSIS/Tibial tuberosity/ankle
ii Joint sense
iii. Position sense
- Great toe/index finger
iv. Rombergs test
d. Cortical sensations
If all the peripheral sensations are intact, then, check for
cortical sensations.
i. Tactile localization
ii. Two point discrimination
iii. Stereognosis
iv. Graphaesthesia
Determine pattern of sensory loss
i. Symmetrical/asymmetrical
ii. Glove stocking/Patchy
iii. Root level
5. CEREBELLUM
a. Nystagmus
i. Primary gaze/ evoked gaze
iii. Horizontal/vertical/torsional
iv. Fatiguable/not
b. Intention tremor
c. Rebound phenomenon (Holmes)
d. Dysmetria
FNT/ FFNT/ HKST
e. Past pointing
f. Alternating movements
i. Draw a circle in air with finger/toe
ii. Alternatively pat the foot steadily on the ground
iii. Pronation – supination (Disdiadochokinesia)
iv. Alternating opening and fisting of both hands
g. Speech
h. Hypotonia
j. Pendular knee jerk
k. Titubation
l. Gait and how the patient stands
7. EXTRA PYRAMIDAL SYSTEM
a. Rigidity
b. Tremor
c. Mask like face
d. Gait
e. Micrographia
 8. AUTONOMIC NERVOUS SYSTEM
a. Postural hypotension
b. Abnormal Sweating

15.MENINGEAL SIGNS
Neck rigidity
Kernig sign
Brudzinski sign
16.PERIPHERAL NERVE THICKENING
17.SPINE & CRANIUM
18. OTHER SYSTEM EXAMINATION
1.CVS
S1/S2, murmur
2.RS
Chest wall symmetry
Air entry/Breath sounds/adventitious sounds/pleural rub
3.P/A
Soft, organomegaly

SUMMARY

FOUR TIER DIAGNOSIS

1. Functional
2. Physiological
3. Anatomical
4. Etioloical
EXAM KIT FOR PRACTICAL
White apron
Stethoscope
Torch light
Thermometer
Inch tape
Coins -2
Scale 1 feet -2
Marker pen
2 pads for chest transverse diameter
BP apparatus

CNS KIT
Soap,asfatida, lavender
Snellen and jager chart
Ishihara colour chart
Ophthalmoscope
Cotton, pin,
Flexible knee hammer
Tuning fork- 128 &512 Hz
Salt & sugar sollitten with swab and name plate
Test tube for hot and cold water
Pair of disposable gloves
Lignocaine jell
Hand sanitizer