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Classical medical history And Physical examination template.

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This template is designed to help medical student in generating questions during History taking and to assist Physical examination.

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Classical medical history And Physical examination template.

  1. 1. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. Date: ............................ Historian: .................................... Time:............................ Informant: .................................... Reliability: ..................% GENERAL DATA:  Name......................................  Age..........................................  Sex................................ ..........  Status......................................  DOB/POB................................  Occupn.....................................  Religion....................................  Nationality...............................  Address....................................  Times of Adm................  Adm. Date......................  Adm. Time................... CHIEF COMPLAINT: ........................................................................................................................................................... HPI (PRESENT ATTACK) :  Site: (where? diffuse/localized? maximal pain?)...................................................................................................  Onset – When? Sudden or gradual? Progressive/regressive? ...............................................................................  Character – how? What? (Sharp, dull, crushing, burning, tearing, throbbing, constant, intermittent)………………  Radiation – Does? ..................................................................................................................................................  Associations – other S & sx? ...................................................................................................................................  Time -how long (duration- Y/M/W/D/Hr/Min/S)................................................................................................... o Episodic (better/worse, frequency, duration).......................................................................................... o Continuous (any change in severity?)......................................................................................................  Exacerbating/Relieving factors – Circumstances (food, meds, posture, sleep).......................................................  Severity - How bad? pain scale O (min) – 10 (max) .................................................................................................  Previous Lab test (include Pertinent Negatives)...................................................................................................... PAST MEDICAL HISTORY:  Measles/ mumps /chicken pox /recurrent tonsillitis/ respiratory disease like pneumonia....................................  Major injuries- trauma /history of fall or operations (date, effects).....................................................................  Previous hospitalizations/ o Hospital date dx , stay duration attending remarks o Eg. hosp. X 10.25.2014 Diabetes 1 Week Dr. X -  Drug History o Name dose(route) frequency duration remarks (compliance) o EG. Aspirin 75mg once daily 2 month No allergy o o  Food & drug allergy .....................................................................................................................  History of asthma, diabetes, HPN, PTB.................................................................................................  History of similar complaint or present problem in the past (chronic/recurrent)...................................................  Surgical History (Procedures)  Tonsillectomy 1952 Hospital X  COPD since 1990 General practitioner PERSONAL AND SOCIAL HISTORY:  Educational attainment..........................................................................................................................................  Occupation (past & present)...................................................................................................................................  Hx. of travel.............................................................................................................................................................  Smoking/ Drinking  Age started...............................................................................................................................................  Consumption per day / pack year (No of pack per day X yr smoked)......................................................  Reason of stopping (financial or health)...................................................................................................  Drugs (tranquilizers, laxatives), other......................................................................................................................  Sleeping habits........................................................................................................................................................  Married  Duration and health of partner/ Compatibility.........................................................................................  No of living children/age/health............................................................................................................
  2. 2. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. FAMILY HISTORY:  Grandparents (if dead, age & COD).........................................................................................................................  Parents.....................................................................................................................................................................  Brothers /sisters......................................................................................................................................................  Heredo-familial disease  Asthma  Diabetes  HPN  CA  Psychiatric epilepsy  Migraine,  Allergy  Hematologic disease  other MENSTRUAL AND OBSTETRICAL HISTORY:  Menarche.............................................................  Duration...............................................................  Cycle (monthly or irregular)...............................  Menstrual flow (minimal/moderate/ profuse)....  Associated symptoms (dysmenorrhoea, flow, breast pains & headache).....................................  Date of last menstruation (LNMP)......................  Menopause (age last menstruated).....................  Vaginal bleeding/discharges................................  No. Of pregnancies.............................................  Route and No. Deliveries....................................  Complications (HPN, eclampsia, abortions)....... .............................................................................  Procedures (CS, BTL, hysterectomy -dates, surgeon).............................................................  Contraceptives Used............................................ REVIEW OF SYSTEMS: Double check of the HPI Skin :  Cyanosis  pallor  jaundice  moisture (cold)  eruption /lesion  distribution  pruritis,  bruishing  bleeding Hair :  loss /growth (bladness)  premature graying Nails :  cyanosis  Clubbing  brittleness Head :  headache o location o character o severity o radiation  Migraine  Hx of trauma,  vertigo  convulsive seizures Eyes:  visual loss  color blindness,  diplopia,  hemianopsia,  trauma,  inflammation,  photophobia,  pain  blurring,  abnormal lacrimation,  Abn discharges(desrice the color),  use of eyeglasses (date when started to use )  use of contact lens. Ears :  deafness (L/R)  tinnitus  vertigo  discharges (L/R , color )  Pain  Mastoiditis  previous operations (masoidectomy)  hx of infections (otitis) Nose :  coryza  rhinitis  sinusitis  discharges  epistaxis  No smell Mouth :  soreness of mouth /tongue  symptoms of teeth  bleeding /swelling of gums  taste ulcers ,  hx of recent tooth extraction  complications Throat :  hoarseness  sorethroat,  hx of recurrent tonsillitis,  pharyngitis,  voice charges Neck :  swelling  suppurative lesions (scrofula)  LN enlargement  Goiter,  stiffness,  limitation of movement.
  3. 3. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. Breast :  development,  lactation,  hx of trauma,  lumps,  pain  discharges from nipple(color),  changes in nipple  gynecomastia,  hx of surgical procedure (mastectomy/biopsy )  Results Respiratory system:  Pain  SOB o walking short distance o climbing stairs  Wheezing,  Dyspnea o Exertional o At rest  Nocturnal dyspnea  Orthopnea ( No of pillows used)  Cough o hard o paroxysmal o productive o non productive o occasional  Sputum o scanty o copious  Hemoptysis  Night sweats,  Afternoon or night fever,  Hx of pleurisy,  Bronchitis,  TB  Pneumonia,  Asthma,  Hx of X-ray  Result. Cardiovascular :  palpitation,  Irregularity of rhythm ,  Pain in the chest ,  Exertional dyspnea,  PND,  Orthopnea(how many pillows used),  Cough,  Cyanosis,  Edema,  Easy fatigability ,  Fainting spells,  Legs cramps,  Hx of HPN,  RHD  Rheumatic fever,  Angina pectoris,  MI,  Hx of EKG done,  Drugs (digitalis,nitroglycerin, diuretic ) GIT:  Appetite  increase or loss  changes in weight o Approx. Loss......... o Approx. Grain...... o highest wt............  Dysphagia  Nausea,  Vomiting o Episodes........... o Vomitus........... o Volume............  Flatulence  Abdominal pain o S o O o C o R o A o T o E o S  Hematemesis  Melena  Diarrhea o episodes o volume  Constipation o Duration o Laxatives use  Changes in color  Change calliber of stool  Change in bowel habits,  jaundice  Haemorrhoids,  Hx of operations( appendectomy)  Hx of procedures (GI series on BA- enema) GUT:  Color of urine.................................  volume of urine (per void) ............  polyuria  oliguria  nocturia(no.of voids)......................  frequency.....................................  dribbing  hematuria o initial o terminal o all thoughout  dysuria o initial o terminal o throughout  location of pain o hypogastric/ penis  incontinence  pain or colic (passage of stone )  hx of recurrent infection  history procedures like IVP,  hx of STD,  penile discharges  vaginal discharge Neuromuscular system:  Disturbances in smell  Disturbances in vision,  Parethesiaises,  Weakness,  Convulsions,  Paralysis,  anethesia,  loss of concoiusness,  Numbness,  Malaise ,  joint pain. Metabolic :  wt . loss  wt. Gain  fever Neuro psychiatric:  Hallucinations o Visual o Auditory  insomnia,  nervousness  memory loss
  4. 4. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. PHYSICAL EXAMINATION: (describe, give No diagnosis) Objective Examination using 4 basic maneuvers; inspection , percussion, palpation and auscultation. Gen survey:  Physical appearance  apparent age  Mental state  Distress  Ambulatory /non  Cooperative/non  Undernourished  state of consciousness o conscious o lethargic o stuporous o comatose  Smells  Ht/wt/WC.  febrile /afebrile  emotional state Vital signs:  BP  RR  PR,  Temp  wt.  BMI Skin :  complexion  color (don’t state normal)  texture  turgor(lost/ senile/ good)  pigmentation and location ,  lesions,  rashes/ eruptions o location o distribution  pallor  severity Head:  Shape:  normocephalic  Scars o size o location  fractures  asymmetry ,  abn. Movements ,  amount and texture of hair  facie  color changes of face. Eyes:  Eye lids edema ,  ptosis  lid lag  sclera jaundice  hge.  Conjunctiva pallor  severity,  petechiae, injection  corneal scars,  ulceration,  arcus senillis  corneal opacity,  corneal reflex  Pupils size/ shape,  equality reactive to light and accommodation  vision  acuity confrontation  convergence  xanthelasma,  strabismus,  nystagmus,  palpate for IOP  exopthalmos Ears :  ext. Ears-defect  ext. Ears- abnormalities  ext. Ears -lesions  hold pinna,  tophi,  discharges( L/R) ,color  foreign body ,  cerumen ,  mastoid tenderness  test for hearing. Nose:  shape ,  discharge (color)  congestion of turbinates,  polyps,  foreign body,  epistaxis,  palpable septal deviation  sinus tenderness.
  5. 5. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. Mouth and throat:  inspect from outside  lips symmetry,  color changes like cyanosis,  ulcerations,  swelling lesions  gums swelling ,  bleeding/ color  teeth caries  no. of dental repair  buccal / mucosal pallor,  ulcerations,  lesions like koplick spots in measles  tongue color,  ulceration,  deviation/tremor  palate deviation  tonsils  pharynx congestion,  enlargement,  presence of exudates ,  odor of breath Neck :  landmarks,  pulsation,  blood vessels engorgement  position (like 45 angle)  palpate thyroid gland  enlarged or not,  tracheal deviation,  palpate lump node  described size, location, tenderness, no.)  note presence of rigidity  auscultate for bruit,  palpate for cupitus. Breast :  symmetry ,  dimpling,  nipple discharges,  lymph node (axillary)  mass o location, o size, o mobility, o consistency , o tenderness , o borders , o no. CHEST AND LUNGS: Inspection  contour,  symmetry,  expansion ,  rate and rhythm of breathing  bony abnormalities. Palpation:  tactile or vocal fremitus o equal o increase/ decrease  note the location ,  tenderness in chest area/ sternum, Percussion :  changes in remnance/dullnss  note exact location eg. R basal lung field) Auscultation :  type of breath sounds, o bronchial o vesicular  abnormal sounds o rales, o rhonchi, o wheeze,  rub  exact location HEART: Inspection  symmetry PMI  (5th L- MCL)  heave  abn. Pulsation  lesion,  bony abnormality.
  6. 6. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. Palpation :  PMI  location,  thrill(location and timing),  pulse rate,  tenderness. Percussion :  cardiac dullness Auscultation:  heart sounds  distinct or faint  rate and rhythm,  friction rub  murmur(TLDIPCTQ) ABDOMEN: Inspection  contour  shape  scars (size/location)  state surgical procedure  engorged veins  spider nevi  visible masses  Striae  Pulsations  bulging like hernia. Auscultation:  bowel sounds (normo/ hypohyperactive / absent)  metallic sounds ,  bruit, venour hum,  fetal heart ( pregnant )  special maneuvers o puddle sign –ascites o Succession splash-obstruction Percussion :  Change in tympany  super liver dullness  fluid wave  shifting dullness  RUQ fist percussion  CVA tenderness. Palpation: (area of pain -last )  muscles guarding (voluntary or involuntary)  muscle spasticity  consistency (soft / rigid)  crepitations  tenderness (location, whether on light or deep palpation)  masses (location , size, shape, consistency, mobility, tenderness, borders)  engorgement of liver , spleen , spleen, kidney  bladder distention   fetal parts (female)  aortic pulsation,  rebound tenderness,  direct tenderness,  lmp nodes,  rovsings sign  Psoas sign  obturator sign BACK AND SPINE  Mobility  Curvature  vertebral tenderness  bony abnormality. EXTREMITIES: (specify whether upper/ lower, R/L)  Color/ cyanosis  moisture  clubbing  joint swelling /deformity  Mobility  Temperature  equality of pulses  Edema  Varicosity  Atrophy/ Hypertrophy  tenderness of muscles  abn. Movements  range of motion  signs of inflammation  congenital
  7. 7. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. NEUROLOGIC EXAM: 1.cerebral functions  level of consciousness  appearance  gen. Behaviour  emotional status  thought content  intellectual performance  recognize object (yes/no)  Communicate(yes/no)  carry out skills(yes/no) 2. cereblum functions  gait  posture.  Coordination (romberg’s test)  finger to nose  heel to shin  knee pat 3. motor system :  strength (weakness or paralysis) -ranges ( 0/5-5/5) Right Left UE (hand grip ) LE (resistance)  muscle tone ( spaticity, rigidity, flaccidity)  spontaneous movements (Tics, tremors, twitching, chorea, athetosis) 4. sensory system (both sides,eye closed)  Sensations of : o pain o touch o temp.  position sense/ vibrations  discrimatory sensation  sensory dysfunction 5. CRANIAL NERVES EXAMINATION: a. olfactory (check both side one at a time|)  smell  identify odor (by smelling) b. optic  visual acuity  confrontation test  color vision  visual field.  opthalmoscopic exam C. Oculomotor  Papillary light reflex  Near response (parasympathetic) o Convergence o accomodatio d. trochlear/abducents  EOM  diplopia e.Trigeminal  corneal rxn  ability to open mouth  pain sensation of face.
  8. 8. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. f. Facial  symmetry of face  wrinkle forehead ,  smile, frown, raise eyebrows  test for taste (ant 2/3)  chovstek sign . g. Acoustic  hearing o rhinne test (Air > bone conduction) o weber test (bone conduction)  equilibrium h. Glossopharyngeal/ vagus  symmetry of uvula with phonation  elicit gag reflex i. accessory  strength of trapezius/  shoulder shrug (strong or week )  Turn head (up- down, L/R)  Check w/ resistance j. hypoglossal  deviation of protruded tongue  tremors and strength  impaired swallowing 6. REFLEX: 1. DTR – result ranges from 0 - ++++ a. biceps b. triceps c.knee jerk d. Achilles or ankle joints 2.Superficial a. cremasteric male – whether (+) or (-) b. abdominal – whether (+) or (-) 3. Pathological a. ankle clonus + if abn L and R b. babinski + if abn L nd R c. karnigs + if abn d. brudzinski +if abn report : Right Left Biceps ++ ++ Triceps ++ ++ Knee ++ ++ Achilles ++ ++ Ankle clonus ++ ++ Babinski ++ ++
  9. 9. Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine. REFERENCES : -Bates physical diagnosis - Macleod's Clinical Examination Acknowledgement :  Dr. Louella Quijano  kalpana shah, Southwestern University For suggestions and comments : Deepakghimire101@gmail.com,

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