(1)

CASE SHEET

Date_______________________________ Regd. No. _____________________

Name _______________________________________________ Ward __________ Bed No. _______

Occupation ________________________________________ Sex ________ Religion _____________

Address ___________________________________________________________________________

Date of Admission ______________________ Date of Discharge or Death ______________________

CHIEF COMPLAINTS (With Duration)-

1.

2.

3.

4.

5.

6.

HISTORY OF PRESENT ILLNESS ………………………………………………

HISTORY OF PAST ILLNESS ………………………………………………..

FAMILY HISTORY ………………………………………………………………….

PERSONNEL HISTORY …………………………………………………………….

 (2)

PHYSICAL EXAMINATION
General Examination :

Decubitus ____________________________ Temperature ___________________________

Growth ____________ Anaemia ______________ Respiration ________________________

Nutrition ___________ Jaundice ______________ Pulse _____________________________

Built _______________ Cyanosis ______________ Blood Pressure _____________________

Height _____________ Neck: Lymph Gland

Weight ____________ Pulsation ___________________________________

Thyroid ____________________________________

Other swellings ______________________________

Glandular Enlargement ________________________________

Clubbing ____________________________________________

Edema ______________________________________________

Pigmentation ________________________________________

Joints ______________________________________________

Herneal sites ________________________________________

LOCAL EXAMINATION
 (3)

Systemic Respiratory system:

Inspection -Form and shape of Chest
Movement of the Chest
Apex beat
Palpation -Movement of the Chest
Trachea
Apex beat
Vocal fremitus
Percussion -
Auscultation - Breath sounds
Adventitious sounds
Vocal resonance

Cardiovascular System:
Inspection - Apex beat
Shape Precordial
Precordial Pulsation
Palpation - Apex beat
Thrill
Auscultation - Rate
Heat Rhythm
Sound 1st sound
Adventitious Sound – Murmur
Pericardial Rub
Lungs bases

Gastro Intestinal System:

Inspection - Form and shape of Abdomen
Umbilicus
Surface of Abdomen
Epigastric Pulsation
Movements
Visible Peristalsis
Any Localised swelling
Palpation - General
Local - Liver
Spleen
Kidney
Percussion - Fluid Thrill
Shifting dullness
Auscultation –
Nervous System:
Higher and intellectual function
Speech
Handedness
 (4)

Cranial Nerves
I Olfactory
II Optic – Acuity of vision
Field of vision
Colour of vision
III IV & VI Occulomotor
Pupil - Size
Mobility – reaction to light
Reaction to accommodation
Ciliospinal reflex
V Trigeminal – Motor
Sensory
Jaw jerk
Tectile sensation
VII Facial
VIII Audotpry
IX Glossopharyngeal
X Vagus
XI Accessory Spinal
XII Hypoglossal
Motor function left Right
Upper Extremity
Power
Nutrition
Tone
Co-ordination
Abnormal movements
Lower Extremity
Power
Nutrition
Tone
Co-ordination
Abnormal movements
Reflexes:
Superficial – Abdominal
Plantar
Cremasteric reflex
Deep (jerks) – Biceps
Triceps
Radial
Knee
Ankle
Clonus – Knee
Ankle
Organic Bladder
Bowel
 (5)

Sensory Functions
Touch Superficial
Deep
Pain
Temperature
Sense Position
Joint senses
Sense of vibration
Stereognosis
Topognosis
Tactile discrimination

Trophic disturbances
Gait
Skull
Spine
Movement of Neck
Carotid

Special Clinical Tests

Romberg Tests
Kernigs Test

Loco motor system

(1) Bone
(2) Joints
(3) Muscles

Summary

Provisional Diagnosis
 (6)

Differential Diagnosis

INVESTIGATION
BLOOD X-ray and special investigations

STOOL

URINE

SPUTUM

Final Diagnosis -

Management and follow up –

Pre-operative –

Operation Note –
 (7)

Post Operative

Complication & Treatment

Autopsy