Case Proforma

Name Age Sex

Address Religion

Occupation

Past History

-- any previous medical or surgical treatments

-- any medication that the person may be continuing to take at present date
-- h/o major accidents or injuries
if answer is yes to any of the above, give details

Personal History

Diet
Appetite
Sleep
Micturition
Bowels
Habits smoking duration/frequency/quantity/
-- alcohol duration /frequency/quantity

Occupational History

Family history

-- married/single
-- if married duration
-- no. of issues/no. alive/abortions
-- if unmarried no. of brothers/sisters/their health and health of
parents
-- h/o hereditary/familial disease
-- h/o complaints/tb/hypertension/diabetes/infections
Examination
General physical examination
1.Build/nourishment/consciousness/co-operation/orientation
to time, place and person
2.vital signs:
pulse rate/rhythm/volume/force/tension/character of
vessel wall/any special character of pulse/radio-radial
or radio-femoral delay/peripheral pulsations
blood pressure
respiration rate/type/rhythm
temperature
3.height
4.weight
5. a)body mass index weight(kg)/height(m)26.scalp
6.eyes palpebral conjunctiva
upper part of sclera
sclera on either side of the cornea
cornea
pupils
7.nose skin
Nasal septum
8.oral cavity lips
teeth and gums
tongue
oropharynx
10.ears external pinna
external acoustic canal

11.facial appearance
12.neck thyroid
lymph nodes
jugular venous pressure
13.upper limbs nails clubbing/cyanosis/pallor
oedema
pigmentations
axillary lymphadenopathy
14.Chest symmetrical expansion on respiration

Breath sounds whether clear or not

Heart sounds whether clear or not

Any murmurs

15.Abdomen --Normal abdomen is soft and flat

Any bowel sounds

Any tenderness

16.Lower Limbs -- Oedems

Pigmentations

Popliteal and inguinal lymphadenopathy

17 Joints swelling / erythema / deformity / effusion / tenderness

18 Muscles -- tone / atrophy / fasciculations

19 Cranial nerves -- whether intact or are there any deficits

systemic examination:
respiratory system

Cough if present whether dry or productive

Dyspnoea

whether there is dyspnoea on doing physical activities

Upper respiratory tract:

a) Oral cavity
b) Nose
c) Pharynx

Lower respiratory tract

1 Position of Trachea

2 Position of Apex beat

3 Symmetry --lie of ribs (Is there any crowding )

--shoulder drooping

--spine any spinal defects like kyphosis or scoliosis

4 Shape of Chest

5 Movement of Chest

Type of respiration

Respiratory Rate

B Palpation

Confirm the inspection findings

Position of mediastinum / trachea /apical impulse

Any tenderness ( present / absent )

Tactile Vocal Fremitus

C) Percussion

areas of percussion on both sides supraclavicular, clavicular, infraclavicular, mammary,

axillary, infraaxillary, suprascapular, upper interscapular,
lower interscapular, infrascapular

upper border of liver dullness

superficial cardiac dullness (present/obliterated)

D) Auscultation

Areas of Auscultation

Anterior : from an area above the clavicle down to the 6th rib

Axilla: area upto 8th rib

Posterior: above the level of the spine of the scapula down to the 11th rib

Breath sounds
type of breath sounds vesicular
-- bronchial
adventitious sounds wheeze
-- crepitations

vocal resonance