Professional Documents
Culture Documents
Age
Sex
OPD/IPD No:
Religion
Bed No
Education
: P/M/HS/GR/PG
DOA/DOD :
: ML/HW/ST/SO/A
Page 1
Adult Illnesses
: Medical/Surgical/Ob-gyn/Psychiatric/etc.
Health Maintenance
: Veg/Nonveg/Mixed!?
Agni/ Appetite
: Manda/Vishama/Teekshana/Sama
Koshta
: Mrudu/Madhyama/Kroora
Nidra
: Alpa/Ati/Sama/Diwaswapna/Ratrijagarana/None
Vyasana/Habits/ Addictions
: Tea/Coffee/Alcohol/Tobacco/None/Others
: Regular/constipated.
Page 2
: Standing /Sitting/Walking/Stooping
Nature of work
Medical
Surgical
Others -
Page 3
h) Ammenorrhea
11 .OBSTRETICAL HISTORY:
a) Gravida
b) Para
c) Abortion
d) Miscarriage
e) Still birth
f) Number of deliveries
g) Nature of delivery
Page 4
PHYSICAL EXAMINATION
(Includes -- I. General Survey & II. Systemic Examination)
I. General Survey
1. SAMANYA PAREEKSHA/ GENERAL EXAMINATION:
Vital data/Vital Signs:
Pulse:
Respiratory rate:
B P: Measured on left arm supine position.
Temperature:
General look/ Appearance: Healthy/Ill look/Depressed/Cheerful/Any other
Weight:
Height:
Built/Build : Well-built/Poorly built/Giant/Dwarf/Tall stature
Decubitus: Position of patient on bed.
Nourishment/Nutrition: Average/ under nutrition/obese
Cyanosis:
Pallor/Anaemia : Mild/Moderate/severe
Jaundice/Icterus:
Neck vein/Jugular venous-engorgement, pulsation, pressure: Raised/Not raised
Neck Artery/carotid arteries:
Edema:
Lymph nodes/Lymphadenopathy: Number, Site, Shape/Size-matted or discrete, Surface,
Tenderness, Temperature, Consistency, Mobility, Discharge.
Page 5
2. Mala
/min
Atisara
Pravahik
Grahini
Any other:
3. Mootra
: Prakrita / Vikrita
Frequency: Day:
Night:
Colour :
Other associated complaints:
4. Jihva
Anushna :
Ruksha:
khara :
7. Drik
8. Akrita
: Sthula /madhyama/heena
Mrudhu :
3. DASHAVIDHA PAREEKSHA
1.
Prakruti
2.
Vikruti
3.
Sara
4.
Samhanana
5.
Pramana
Page 6
Satmya
7.
Satva
8.
Ahara Shakti
9.
Vyayam Shakti
10.
Vaya
4. VISHESHA PAREEKSHA
SROTO PAREEKSHA:
Srotas
1.
2.
Pranavaha srotas
Annavaha srotas
3.
Udakavaha srotas
Lakshanas
Kupita abhikshana/ sashabha shoola ucchvasa.
Anannabhilasha/ arochaka/ avipaka/ chardi
Jihwashosha / talushosha/ oshtashosha/ kanta shosha/klomashosha/ Ati
pravridha pipasa
4.
Rasavaha srotas
5.
Raktavaha srotas
/ kota /asramandala/
Pidaka / Pradara /
Mamsavaha srotas
Sandivedana/
Rukshata/
Dhamanishitily/
Toda
Grivashuskata/
Page 7
Medovaha srotas
8.
Asthivaha srotas
9.
Majjavaha srotas
10 Sukravaha srotas
Klaibhya/Aharshana
11 Mootravaha
Kupitam/sashoola/bhahalam mootrayanti
12 Pureeshvaha
13 Swedavaha srotas
Page 8
o Miscellaneous:
Clubbing
Cynossis
Anaemia
B. Central CVS
Inspection
o Chest wall:
Shape of chest / Shape of precordium: Look tangentially whether there is bulge or
not.
Page 9
Palpation
o Apex beat (5th inter costal space inch medial to mid clavicular line)
Site Detected in supine position of patient.
Character-Described in left lateral position. Abnormal characters are
Heaving,Forcible,Tapping.
o Locate the tender areas
o Pulsations in other area- Palpate pulmonary area,palpate aortic area ,palpate left
parasternal area (Preferably by ulnar border). In normal Condition pulsations are not
felt in these areas pulmonary,aortic and parasternal areas.
o Thrills(Palpable murmers)-Systolic(Felt between first and second sound) ,
Diastolic(Felt after second sound),over mitral,pulmonary,aortic,tricuspid ares.
Percussion
o It is rarely done.
o Normally there will be dull note that means superficial cardiac dullness.
o Stony dull note over precordium due to pericardial effusion.
o Dullness in pulmonary area due to dilatation of pulmonary artery.
o Dullness in the aortic area and upper sternum due to aneurysm of aorta.
o Dullness over lower part of the sternum due to hypertrophied right ventricle.
o Dullness lateral to right sternal border due to gross cardiomegaly and its due to
shifting of right cardiac border to right lateral sternal border.
Page 10
Listen the First and second Heart sounds (S1 and S2 ) in all four auscultatory areas
Pericardial rub: Sound resembling pleural rub heard over the precordium which is
not releted to respiration. But related to cardiac cycle(Heard with each systole and diastole).
Page 11
Respiratory System
INSPECTION:
Chest:
o Movement /Type of breathing Abdomino thoracic in Male and Thoracco abdomen in
Female
o Shape Elliptical, Flat, Emphysematous(barrel shaped), Rachitic Chest, Rickety rosary
(costochondral beading),Harrisons sulcus, Pectus excavatum (funnel chest), Pectus
carinatum (Pigeon chest),Kyphosis, Scoliosis,
o Skin Lesions and Discoloration
Pursed-lip breathing:
PALPATION:
As you palpate the chest, focus on areas of tenderness and abnormalities in the overlying skin,
respiratory expansion, and fremitus.
sides/Diminished.
Respiratory expansion:
Page 12
Resonant-Normal
Liver dullness-Normal
AUSCULTATION:
Breath Sounds Vesicular breath sounds,
Bronchovesicular,
Bronchial breathing sounds-Tubular ,Cavernous ,Amphoric.
Intensity of breathing sound- Normal /High / Diminished.
Added Sounds/Adventitious sound (Inspiration/Expiration, Polyphonic/Monophonic)
1. Wet-Crepitations-coarce,medium,fine
2. Dry- Rhonchi, Pleural rub, Crackles, Wheezes.
Vocal resonance/ whispering pectoriloquy: Normal/High/Diminished
Succession splash/Hippocratic succession:
Coin test: Hydropneumothorax (This test is combination of percussion and auscultation)
Page 13
Posterior chest
Anterior chest
Anterior
Mammary
Bases of the lungsthe lowermost portions
Upper, middle, and lower lung fields
Suprascapular
Infrascapularbelow the scapula
Interscapularbetween the scapulae
Posterior
Infrascapular-Upper/Lower
Axillary
Infraxillary
Page 14
Per Abdomen
Inspection:
o Shape of abdomen
o Umbilicus Inverted / Everted
o Movement with respiration
o Pulsation
o Visible blood vessels- Engorged veins in abdomen which are better appreciated
with patient either sitting or standing than lying down position.
o Visible swelling & erythema.
o Scar/brand marks/ulcers/hypo/hyper pigmented areas describe their site size
number etc.
o Striae
o Hernia orifices
Palpation
o Tenderness
Bimanual Kidney.
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 15
Ballottement-
o Swelling :
o Rebound tenderness :
Percussion:
o Tympanic
o Dull note.
Normally percussion note is tympanic all over the abdomen. But over left hypochondrium and
epigastric area may be resonant due to presence of air.
Auscultation :
Hepatic rub
Splenic rub
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 16
Memory:
Personal identity:
Mathematical ability:
General behavior:
Hallucinations(False impressions from sense organs) and delusions(false belief and idea):
Speech: Dysarthria/Dysphasia
Gait:
Gait problems are common. Basically, it's either musculoskeletal or neurological (UMN, LMN,
Cerebellar syndrome, Extrapyramidal syndrome, Sensory ataxia). There are many patterns and
types of gaits.
The following patterns are recognized:
Antalgic gait/Ataxic gait / Cerebellar gait / Festinating gait /Frontal(apraxic) gait /Hemiplagic
gait/Helicopod gait / Hip extensor gait /High-stepping / Myopathic gait/ Paraplegic spastic gait/
Parkinsonian gait/Quadriceps gait/Scissor gait /Spastic gait /Sensory Ataxic /stiff-legged gait /
Steppage gait / Stuttering gait/ Tabetic gait /Vestibular gait/ Waddling gait myopathic gait/etc
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 17
The Glasgow Coma Scale (GCS) / Glasgow Coma Score. It defines the degree of altered
consciousness as an ordinal score between 3 and 15 - note that the lowest possible score is 3,
not zero. Non-quantitative descriptions should be avoided.
Eye-opening
Spontaneous
Oriented
Obeys commands
To speech
Confused
Localizes pain
To pain
Inappropriate
Normal withdrawal
None
Incomprehensible
Abnormal flexion
None
Abnormal extension
None
Cranial nerve I/Olfactory: Parosmia (altered sense of smell) or Anosmia (loss of smell).
Cranial nerve II/Optic : Visual disturbances (Snellen chart), Visual fields , Colour
disturbances
Cranial nerve VII/Facial: Symmetry in smile, Nasal fold, Blowing of Mouth , Facial
Expression
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 18
Cranial nerve IX, X/Glosssopheryngeal ,vagus,: Sensation of Taste, Nasal twang to speech,
Nasal regurgitation of food, Gag Reflex.
Cranial nerve XI/Spinal accessory: Difficulty while turning the Head & Shrugging Shoulder
Full strength
Reflexes/Jerks:
Primitive reflexes:
Glabellar Tap
Superficial reflex:
Corneal and conjunctival reflex
Palatal
Pharyngeal
Abdominal reflex-Upper, Middle ,Lower.
Cremasteric reflex
Plantar Reflex: Babinskis sign
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 19
Sensory system:
SuperficialTouch
Pain
Temperature
Deep
Crude touch
Vibration
Joint sense
Sense of position
Sense of pressure
Cortical
Tactile localization
Tactile discrimination
Tactile extinction
Astereognosis
Graphaesthesia
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 20
Neck stiffness
Kernigs sign
Brudzunskis sign
Meningeal signs:
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 21
JOINT DISEASE:
A combination of pain and stiffness, leading to loss of function, is a classic feature of joint
disease.
Usually one component predominates, as with stiffness in inflammation, and pain in
mechanical joint problems.
Therefore, specific questions will establish whether symptoms are mechanical (e.g.
degenerative joint disease or meniscal tear) or inflammatory (e.g. rheumatoid arthritis or
gout).
Cutaneous nodules
Lymphadenopathy Oedema
Enlarged bursae
Ocular inflammation
Diarrhoea
Urethritis
Oro-genital ulcer
Rheumatoid nodules
Xanthomataus deposition(hypercholesterolaemia)
Inspection:
Inflammation is often associated with redness of the joint, and with tenderness and warmth.
Look also for swelling or deformity of the joint. Note whether the distribution is symmetrical.
1. Spine deformities Kyphosis, Scoliosis, Lordosis
2. Range of Movements according to the Joint:(Inspection and palpation)
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 23
Palpation:
On palpation of a joint check first for tenderness and crepitus.
Assessment of joint tenderness:
Grade 1: The patient says the joint is tender
Grade 2: The patient winces
Grade 3: The patient winces and withdraws the affected part
Grade 4: The patient will not allow the joint to be touched
Local rise of temperature: Present/Absent
CREPITUS:
Tendon sheath crepitus: This is a grating or creaking sensation defined by palpating the tendon while
the patient is asked to contract the muscle tendon complex involved. It is particularly common in the
hand and is seen in rheumatoid arthritis and systemic sclerosis
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 24
1.
2.
SLR/Lassegues Test
Braggard's Test
Flip Test
Gaenslen's test
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 25
Skin
Morphology: Inspection and palpation(Use disposable gloves)
Elasticity of skin.
Symmetrical/asymmetrical
Cetripetal/centrifugal
Flexar/extensore
Macule
Bulla
13
Ecchymosis
Papule
Postule
14
Hemotoma
Plaque
Wheal
15
Poikiloderma
Nodule
10
Telangictasia
16
Erythema
Papilloma
11
Petechiae
17
Burrow
Vesicle
12
Purpura
18
Comedo
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 26
Scale
Ulcer
Crust
Sinus
Excoriation
Scar
Lichenification
10
Keloid
Fissure
11
Atrophy
Erosion
12
Stria
Kobners sign
Auspitz sign
Nicoles sign
Nail
Lesion:
Nail Fold:
Hair
Color:
Texture:
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 27
Relevant investigation:
Differential diagnosis:
Provisional diagnosis:
IMPORTANT:
Its just only the schematic outline on case taking, for further detailed
reading please refer authentic and recent edition of clinical examinations/clinical
methods books.
@Mcleod's Clinical Examination.
@Hutchison's Clinical Methods.
@Bate's guide to physical examination.
@Golwalla`s Physical Diagnosis.
Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. Private Circulation Only Page 28