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Des:CONCORD 1 Page-

Patient sheet
Personal History

sex Full Name Age Residence Marital life Occupation
M F S M
child
Special Habit`s
1.
2.
3.
4.
5.
Smoking Alcohol

I.V. addiction Diet habits


Complain
Symptom`s [ as own patient word]
1. 2. 3. 4. 5.
Onset
Course
Duration






Past History

Surgery 1. T.B. Yes/No Hypertension Yes/No Medication`s 1.
2. Bilharsiasis Yes/No Diabetes
Mellitus
Yes/No 2.
3. 3.
4. Hepatitis Yes/No Blood
Transfusion
Yes/No 4.
5. 5.



Family History






Then doing:
General Examination
Local Examination [according complain]
Des:CONCORD 2 Page-

General Examination [401]
I. General condition
1. Mental state
2. Body built
3. Posture
a) In bed-Decubitus
b) On standing and walk-gait
4. Facial expression
5. Complexion [pallor Jaundice - Cyanosis]
6. Vital sign`s [Pulse - Blood pressure - Respiratory rate - Temperature]
II. Head
III. Neck
IV. Upper Limb`s
V. Lower Limb`s
VI. Lymphatic system
VII. Breast
VIII. Skin
IX. Genitalia




Des:CONCORD 3 Page-

General condition
1- Mental state
a- consciousness
b- Attention
c- Memory
d- Mood
e- Intelligence
f- Conception & Preception

2- Body Built
a- Weight
[ kg]
b- Height
[ m] Dwarfism - normal - Gigantism
c- Body Mass Index

=
2



W= weight Kg
H= height - m
Underweight < 18.5
Normal 18.5 - 24.9
Overweight 25 - 29.9
Obese 30 - 39.9
Morbid
obesity
40
d- Span Extend both hands outward (each arm abducted to
90)-Measure finger tip to Finger tip
e- Upper Segment &
Lower Segment
Upper S: Top of head to top of pubic symphysis
Lower S: Top of pubic symphysis to floor

3- Posture
[ position in bed ]
a- Restleness b- Plexim altiude
c- Lateral decubitus d- qaitundus
e- Orthopneic posture
f- Squatting position
g- Prayer posture

4- Facial Expression
See Head Examination

5- Complexion
a- Pallor
b- Bluish discoloration
1- Central Cyanosis
2- Peripheral Cyanosis
c- Yellow discoloration 1- Haemolytic jaundice
2- Hepatocellular jaundice
3- Obstructive jaundice

6- Vital Sing`s
a- Temperature
Oral
Rectal
Axillary
b- Blood Pressure
c- Respiratory Rate
d- Pulse
1-Rate
2-Rhythm
3-Volume
4-Special character
Water hammer pulse
Plateau pulse
Pulses bisferiens
Pulses alternans
Pulses paradoxes
Des:CONCORD 4 Page-

Head Examination
1. Cranium
a- Size Hydrocephalus - Microcephaly
b- Local abnormalities Local bulging Local depression

2. Face
a- Facial expression
Anxiety dull apathetic moon face
b- Color change
Malar flush discoid lupus
c- Asymmetry of face
As in Facial palsy

3. Eye
a- Eye brow Fall of outer third
b- Eye lid Puffiness yellowish plaques dropping
lid retraction lid lag
c- Eye ball Exophthalmos - enophthalmos
d- Conjunctiva Discolouration - haemorrhage
e- Sclera
Jaundice blue colouration
f- Cornea
Greenish gray white
g- Pupil
Size shape reaction to light
h- Lens
Cataract

4. Nose
a- Large
b- Saddle
c- Working alae nasi
d- Nasal discharge

5. Ear
a- Taphi
b- Yellowish white nodules
c- Low set ear
d- Ear discharge

6. Mouth
a- Lib
Color macrocheilia microcheilia
tremor
b- Breath odour

c- Teeth
Delay dentation loosing of teeth
wide spacing Hutchison teeth
d- Gums
Pyorrhea bleeding hypertrophy
pigmentation
e- Tongue
Color atrophic macroglossia
scrotal tongue furring strawberry
leukoplakia moisture tremor
f- Buccal mucosa
Pigmentation stomatitis koplik`s
spots
g- Palate
Deformities paralysis
h- Tonsils



Des:CONCORD 5 Page-

Neck Examination
1- Abnormalities of
position
a- torticollis
b- rigidity


2- Abnormal movements
a- Parkonisonism
b- Aortic incompetence = De Musset`s sign




3- Thyroid gland
Inspection Enlargement size shape
Palpation Size of the enlargement
Surface [diffuse or nodular]
Thrill
Lower border of the gland
Consistency
Pulsation
Fixed or mobile
Percusion Detect retrosternal goiter
Auscultation




4- Lymph node
Cervical L.N.
supraclavicular L.N.




5- Pulsation
Arterial pulsations Apparent pulsation in supresternal notch
Exaggerated carotid pulsation
Venous Pulsation a- Jagular venous pulse
b- Jagular venous pressure




6- Thrill



Des:CONCORD 6 Page-

Upper Limb Examination
1- Skin
a- Temperature
Warm hand
Cold hand
b- Sweating
c- Colour & Trophic changes
Palmer erythema
Xanthomatosis
Cutaneous haemorrhage
Raynaud`s phenomena
Hyperkeratosis
Gangrene & ulceration
Leprosy
Jane way macules
d- Nodules
Osler`s nodes
Heberden`s node
TOPHI
Subcutaneous nodules

2- Nails
clubbing
Pale
blue
Koilonychia
Leuconychia
Nail dystrophies
Splinter haemorrhage

3- MusculoSkeletal system
Muscles wasting
Involuntary movements
tremors
Fine of tremors
Coarse trmors
Static
Kinetic
Flapping
Familial
Hysterical tremors
Skeletal changes &
deformaities
Polydactyly
Syndactyly
Arachnodactyly
Spade hand
Spindle shaped hand
Obstetric hand
Sclerodermic hand
Dupuytren`s contracture



Des:CONCORD 7 Page-

Lower Limb Examination
1- Edema
a. Generalized
cardiac
Respairatory
rena
Liver
nutritional
b. Localized
Venous causes
Lymphatic causes
Inflammatory causes
Allergic causes





2- Clubbing of toes






3- Peripheral arterial system
a. Color changes
Paroxysmal
Persistent
b. Skin change
Atrophy ulcer - fungus
c. Temperature Ischemia lead to coldness
d. pulsation
dorsalis pedis artery
Anterior, posterior
tibial arteries
Popliteal artery
Femoral artery





4- Venous system
a. Deep venous thrombosis
b. Varicose veins





5- musculoskeletal
a. general appearance Pes cavus
b. joint's Arthritis
c. muscle's Atrophy

Des:CONCORD 8 Page-

Breast Examination
In female:
Breast should be palpated for any swelling
particularly when secondaries are suspected.
In male:
Enlargement of breast in males is know as
"gynaecomastia" = means hypertrophy of
the glandular tissues of male breast usually
with prominence of the nipple and the
breast is commonly tender.




1- physiological at puberty






2- neoplastic Feminizing testicular tumor
Bronchial carcinoma
Hodgkin`s disease
Adrenal tumours
hypernephroma






3- endocrinal
Thyrotoxicosis
Addison`s disease
Diabetes mellituse
Testicular atrophy
Acromegaly
Adrenogenital syndrome
hypothyroidism






4- metabolic
Sever malnutrition
Liver cell failure
Chronic renal failure
Wasting disorders
Des:CONCORD 9 Page-

Lymph node examination
using three middle fingers for palpation, the glands are rolled up and down, back and forward with
rotatroy motion

- size consistency matting tenderness number
- mobility in relation to deep structures
- overlying skin

1- cervical
Circle group
Submental submandibular tonsillar -
pre auricular post auricular - occipital
Vertical group
Upper & lower deep cervical lymph nodes which
lie under cover of the sternomastoid

2- supraclavicular Palpated in supraclavicular fossa

Virchow's gland
Scalene lymphe node

3- Axillary lymph node
Anterior group Behind pectoralis major
Posterior group On posterior wall of axilla
Lateral group Lies along the Axillary vessels
Medial group On chest wall in upper Axillary zone
Apical group High up in the apex of axilla

4- Supratrochlear
Flet little above medial epicondyle of the humerus

5- Inguinal
Superficial & deep femoral [these deep groups lie on the medial
side of the femoral vein



Des:CONCORD 10 Page-

skin examination
1- Pigmentation
General
pigmentation
Endocrinal disorder
Metabolic disorder
Drugs
Miscellaneous
localized
Senile pigmentation
Neurological pigmentation
Stria gravidarum cloasma linea nigra
Taenia versicolor lickenplanus
Post irradiation
Al-bright`s syndrome
As a result of friction and scratching

2- vitiligo White skin patches may be primary oe secondary

3- dryness
Dehydration
Myxoedema
Malnutrition
Old age

4- sweating
Nervous excitement
Thyrotoxicosis
Toxic conditions
Respairatory failure

5- elasticity
Tense or tight
Wrinkled or loose
Excessive elasticity

6- thickness
Generalized Acromegaly
myxoedema
localized Elephantiasis
Leprosy

7- atrophy
Old age
Wasting diseases
malnutrition
Over ischaemic areas

8- striae
Striae alba: pregnancy obesity
Striae rubrae: Cushing's syndrome
Striae tensea

9- hair
Fall of hair excessive growth over the face in female