Name:
Age:
Sex: male
/female:
Religion:
Occupation:
Marital
status:
Present
address:
Permanent
address:
Unit: Ward :
Bed no:
Date of
admission:
Date of
examination:
Source of
history : patients/relatives/others.
Chief complaints / presenting complaints:
History of present illness:
Elaboration of the chief complaints,
(mode of onset, progression , etc)
Systemic inquiry ,drug
history during this illness,
(long term medicine
anti-hypertensive, Anti- diabetic,anti-thyroid,bronchilal
asthma , etc)
History of past illness:
Illness
relevant to the present illness ,H/O Hospitalization,
H/O Operation,
Social & Occupational History:
Ø Socio-economic status:
Ø Education:
Ø Monthly income:
Ø Family members:
Ø Housing:
Ø Sanitation:
Ø Water supply:
Ø Occupational exposure:
Family History: (TB,HTN,DM,IHD,relevant to the chief complaints).
Personal History:
Ø Habits:smoking,addiction.
Ø Personal hygiene:
Ø H/O exposure to venereal disease.
Menstural & Obstetric History (in female patient)
Ø Menstural period
Ø Menstrual cycle
Ø LMP (last day of menstrual period)
Ø Para(no of child birth)
Ø Gravid(if pregnant)
Ø Menarche
Ø Menopause
Immunization & Overseas Travels:
H/O EPI vaccination, Hepatitis B
vaccination. Etc.
General Examination:
A.
Appearance:
B.
Body-built:
C.
Co-operation:
D.
Decubitus :
E.
Nutritional status:
1.
Anaemia
2.
Jaundice
3.
Cyanosis
4.
Clubbing
5.
Dehydration
6.
Oedema
7.
Koilonychias
8.
Leukonychia.
9.
Thyroid gland
10.
Engorged neck vein
11.
Pulse:
a)
Rate
b)
rhythm,
c)
volume,
d)
character,
e)
condition of the vessel wall
f)
radio-femoral delay:
g)
symmetry.
12.
Blood pressure
13.
Respiratory rate : (12-18 per minute
normally)
14.
Temperature
15.
Lymph node:
Ø Groups
of involved
Ø Number
Ø Size
Ø Consistency
Ø Matting/discrete
Ø Tenderness
Ø Mobility
16.
Overlying skin local temperature , discharging sinus.
Ø Skin
condition:
Ø Hair
distribution
Ø Pigmentation
Ø Skin
eruption
Ø spider
naïve
17.
bony tenderness:
18.
gynaecomastia:
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