This document contains a template for documenting a patient's case history and physical examination. It includes sections for collecting the patient's personal details and history, including presenting complaints, past medical history, treatment history, and family history. The physical examination section templates the systematic examination of major body systems, including general appearance, cardiovascular, respiratory, gastrointestinal, and neurological systems. Fields are provided to document findings from inspection, palpation, percussion, and auscultation of each relevant area.

1. CMMUNITY BASED MEDICAL COLLEGE,BANGLADESH DEPARTMENT OF MEDICINE DR.TOFAYEL UDDIN AHMED REGISTRAR MU-2

2. CASE HISTORY PARTICULARIS OF THE PATIENT HISTORY PHYSICAL EXAMINATION

3. A . PARTICULARIS OF THE PATIENT NAME AGE SEX RELIGION OCCUPATION MARITAL STATUS ADDRESS DATE OF ADMISSION DATE OF EXAMINATION

4. B. HISTORY PRESENTING COMPLAINTS HISTORY OF PRESENT ILLNESS HISTORY OF PAST ILLNESS TREATMENT HISTORY DRUG AND TRANSFUSION HISTORY FAMILY HISTORY SOCIOECONOMIC HISTORY / INCLUDING OCCUPATION PERSONAL HISTORY/ habit, hobby, diet, sleep, bowel, bladder etc HISTORY OF TRVELLING HISTORY OF IMMUNIZATION

5. C. PHYSICAL EXAMINATION GENERAL EXAMINATION SYSTEMIC EXAMINATION

6. GENERAL EXAMINATION APPEARANCE DECUBITUS Posture of patient in bed INTELLIGENCE Educational and occupational history COOPERATION BODY BUILD Heavy/average/small NUTRITION HEIGHT WEIGHT

7. GENERAL EXAMINATION ANAEMIA – type/site/eg JUNDICE CYANOSIS OEDEMA CLUBBING KOILONYCHIA SKIN AND BODY HAIR NECK VEINE LYMPHNODES PULSE BP TEMP DEHYDRATION

8. SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM GASTROINTESTINAL SYSTEM NERVOUS SYSTEM

9. CARDIOVASCULAR SYSTEM PULSE RATE Tachycardia >100bpm-fever,anaemia,thyrotoxicosisCCF,shock,drug-sulbitamol bradycardia<50/bpm-in.MI,myxoedema,hypothermia,obstructive jundice,drug-beta-blockers,amioderon,vrapamil RHYTHM

10. VOLUME SYMMETRY CHARACTER CONDITION OF VESSEL WALL RADIO-FEMORAL DELAY

11. CARDIOVASCULAR SYSTEM BP NECK VEINE OTHER PULSATION

12. INSPECTION SHAPE CARDIAC IMPULSE OTHER VISIBLE PULSATION ANY SWELLING OR SCAR MARK

13. PALPATION APEX BEAT THRILLS LEFT PARASTERNAL LIFT/HEAVE PALPABLE HEART SOUND OTHER PALPATION

14. PERCUSSION AREA OF SUPERFICIAL CARDIAC DULLNESS

15. AUSCULTATION - HEART SOUND - MURMUR - pericardil rub - other sound

16. RESPIRATORY SYSTEM SHAPE OF THE CHEST MOVEMENT OF THE CHEST SINGS OF RESPIRATORY DISTRESS VISIBLE PULSATION ANY SCAR MARK RATE AND RHYTHM OF RESPIRATION

17. PALPATION POSATION OF TRACHEA POSATION OF APEX BEAT EXPANTION OF THE CHEST WALL VOCAL FREMITUS LOCALISED TENDERNESS

18. PERCUSSION POSATION OF TRACHEA POSATION OF APEX BEAT EXPANSION OF THE CHEST WALL VOCAL FREMITUS LOCALISED TENDERNESS

19. PERCUSSION PERCUSSION NOTE ON - MID CLAICULAR LINE - MID AXILLARY LINE - INFACSCAPULAR LINE LIMITS OF CARDIAC DULLNESS UPPER BORDER OF LIVER DULLNESS

20. AUSCULTATION BREATH SOUND - INTENSITY - CHARACTER VOCAL RESONANCE ADDED SOUNDS - RHONCHI - CREPITATION - PLEURAL RUB

21. GASTROINTESTINAL SYSTEM MOUTH AND PHARYNX ABDOMAN PROPER INSPECTION - SIZE AND SHAPE - MOVEMENT - SKIN- SCAR,PROMINENT VEINE,SPIDER NAEVIA - POSATION AND SHAPE OF UMBILICUS - VISIBLE MASS - VISIBLE PERISTALSIS - EPIGASTRIC PULSATION - PUBIC HAIRS,GROIN,GENITALIA - HERNIAL ORIFICES : IMPULSE ON COUGHING

22. PALPATION SUPERFICIAL START IN THE LEFT ILIAC REGION AND THEN GO ANTICLOCKWISE TENDERNESS RIGIDITY HYPERASETHESIA RIGIDITY FLUID THRILL DEEP

23. PALPATION DEEP LEFT KIDENY SPLEEN RIGHT KIDENY LIVER URINARY BLADDER AORTA AND PARA-AORTIC GLAND AND COMMON FEMORAL VESSELS INGUINAL LYMPH GLANDS GENITALIA : PEINS/SCROTUMA/SPERMATIC CORD/VULVA PER RECTAL EXAMINATION

24. PERCUSSION SHIF TING DULLNESS PERCUSSION OVER ENLARGED ORGAN AND OTHER MASSES UPPER BORDER OF THE LIVER DULLNESS

25. AUSCULTATION BOWEL SOUND BRUITS

26. NERVOUS SYSTEM MENTAL FUNCTION CRANIAL NERVES MOTOR FUNCTION SENSORY FUNCTION

27. MENTAL FUNCTION APPEARANCE , BEHAVIOUR AND COMMUNICATION EMOTIONAL STATE ORINTATION IN PLACE AND TIME MEMORY SPEECH AND LANGUAGE SLEEP HALLUCINATION/DELUSION INTELLIGENCE

28. CRANIAL NERVES OLFECTORY OPTIC OCLOMOTOR, TROCHLEAR AND ABDUCENT TRIGEMINAL FACIAL NERVE VESTIBULOCOCHLERA GLOSSOPHARYNGEAL AND VAGUS ACCESSORY HYPOGLOSSAL

29. 1 OLFECTORY TEATING OF SMELL EG. EFFECT – ANOSMIA - PAROSMIA - OLFACTORY HALLUCINATION

30. 2 OPTIC VISUAL ACUITY – SNELLEN,S CHART IS USED – DISTANT VISION,NEAR VISION FIELD OF VISION – CONFRONTATION TEST

31. 2 OPTIC COLOR VISION OPTHALMOSCOPIC EXAMINATION PUPILLARY REFLEXES

32. 3,4,6 OCLOMOTOR, TROCHLEAR AND ABDUCENT Ocular movement Pupil - size - shape - light reflex - accommodation reflex

33. 5 TRIGEMINAL Sensory function - pain, touch, temp - Corneal reflex Motor function - muscle of mastication- clench Teeth, open mouth aginst pres. - jaw jerk

34. 7 FACIAL MOTOR Wrinkling of forehead – frontal belly of occipito – frontalis Close eye , don`t let me open – orbicularis occuli Ask to whistle – orbicularis oris Puff your cheek out – buccinator Show me your teeth and a smile -levator anguli oris and risorius

35. 7 FACIAL SENSORY TEST - ANTERIOR 2/3 OF TOUNG

36. 8 VESTIBULOCOCHLERA VESTIBULAR – VERTIGO,DIZZINESS COCHLEAR DIVISON – RUB FINGER RINNE`S TEST WEBER`S TEST

37. 9,10 GLOSSOPHARYNGEAL AND VAGUS OPEN MOUTH AND SAY AAA…. ASK THE PATIENT TO COUGH SEE THE PALATAL REFLEX SENSATION IN THE POSTERIOR 1/3 OF TOUNG

38. 11 ACCESSORY SHRUG YOUR SHOULDER AGAINST REGISTANCE TURN YOUR HEAD TO OTHER SIDE AGAINST RESISTANCE

39. 12 HYPOGLOSSAL LOOK AT THE TOUNG - WASTING - FASICULATION WAGGLE YOUR TOUNG FROM SIDE TO SIDE

40. MOTOR FUNCTION BULK OF MUSCLE TONE OF MUSCLE STRENGTH OF MUSCLES REFLEXS COORDINATION OF MOVEMENT INVOLUNTARY MOVEMENTS GAIT

41. EXAMINATION OF REFLEXES TENDON/DEEP REFLEX SUPERFICIAL REFLEXES

42. TENDON/DEEP REFLEXES KNEE JERK- L3,4 ANKLE JERK-S1,2 BICEPS JERK-C5,6 TRICEPS JERK-C6,7 SUPINATOR JERK-C5,6 JAW JERK- CLONUS :PATELLAR/ANKLE

43. CLONUS PATELLAR CLONUS – SHARPLY PUSH THE PATELLA TOWARDS THE FOOT ANKLE CLONUS – SUPPORT THE FLEXED KNEE WITH ONE HAND IN POPLITEAL FOSSA

44. SUPERFICIAL REFLEXES ABDOMINAL REFLEX CORNEAL REFLEX ANAL REFLEX PALATAL REFLEX CREMASTERIC REFLEX

45. COORDINATION OF MOVEMENT TEST FOR COORDINATION OF UPPER LIMB FINGER NOSE TEST RAPID ALTERNATING MOVEMENT TEST FOR COORDINATION OF LOWER LIMB - HEAL SHIN TEST

46. INVOLUNTARY MOVEMENT ABSENT IN NORMAL INDIVIDUALS - TREMOR – CHOREA – ATHETOSIS – DYSTONIA – MYOCLONUS – TICS – DYSKINESIA – HEMIBALLISMUS – EPILEPSY – TETANY - CRAMP

47. GAIT manner of walking Spastic gait Stamping gait Drunken gait Wadding gait High steping gait Fastinate gait Scissor gait Dancing gait Hemiplegic gait

48. SENSORY FUNCTION TACTILE SENSATION: LIGHT TOUCH,PRESSURE,TACTILE LOCALIZATION AND TACTILE DISCRIMINATION P0SITION SENSE RECOGNITION OF SIZE,SHAPE,WEIGHT AND FORM OF OBJECT APPRECIATION OF VIBRATION PAIN TEMPERATURE