PERSONAL DATA DDx = Trauma # Infection # Neoplasm # Congenital # Autoimmune # Metabolism # Blood # Endocrine # Drugs PCs & HPCs

PCs & HPCs (Cont.)

1. Bed + MRN Hernia
2. Full Name Hx Taking Guidelines Surgery Ver. 3 1. Location
3. Gender & Race 2. Direct/Indirect?
4. DOB 3. Simple / Obstructed /
5. Ht/Wt/BMI Strangulate?
6. Date/Time Admit 4. Complete/ Incomplete
7. Date/Time Clerk (What level?)
8. Husband/Wife 5. Reducible ?
(Name/Age/Occp) 6. Assoc. Symptom
9. Total Income 7. Hx of straining (heavy
10. Address/House Type lifting, cough,
constipation,
micturation problems)
PCs & HPCs
Pain
1. Site SYSTEMIC REVIEW
2. Onset RESPI - runny nose, cough,
3. Characteristic wheeze, SOB, activity
(burn,throb,stab,constrict,c limitation
olicky,aching) ENT – throat infections,
4. Radiation snoring, noisy breathing
5. Associated Sympt CVS - sweating, cyanosis,
6. Time/Duration pallor, SOB, exercise
7. Exacerbating/Relieving tolerance, murmur
8. Severity/Score GIT - appetite, diet,
9. Progression/Ending vomiting, pain, abdominal
distention, bowel habit,
Lumps/Ulcer stools,
1. When & how noticed? MSK - gait, limb pain, joint
2. Changes/Development pain @ swelling,
3. Symptoms CNS - headaches, fits,
4. At other sites on the hearing, vision
body? GnUr - pain, colour,
5. Idea what cause it? frequency, training
Fever H&L - anemia, bleeding
1. Type (Cont./Remit/ tendency or clotting
Intmint./Relapse) tendency.
2. Character
3. Duration
(sudden/gradual) Systemic Review Gynae
4. Nocturnal Variation 1. Menstrual Hx
5. Chills/Rigor? a. LMP
6. Rashes/Joint Pain b. Lenght/Delay
7. Frequency/Recurrent c. Volume
8. Temperature d. 1st Period (Age)
9. Medication e. Irregular bleed?
10. Hx Contact 2. Discharge
11. Hx Travel a. Colour
12. Fits b. Amount (# pads)
c. Duration
Vomitting d. Pain/Itch/Rash
1. Frequency 3. Obstetric
2. Characteristics a. # of pregnancy
3. Volume b. # of miscarriages
4. Projectile/NonProjctle c. Complications?
5. Hematemesis (colour) 4. Contraception
6. Duration a. Type/Name
7. Exacerbating/Relieving b. For how long?
8. Timing 5. Menopause
9. Nausea a. When
Diarrhea b. Bleeding?
1. Character/Consistency c. HRT?
2. Colour
3. Frequency PAST Med Hx
4. Amount 6. Pass Illnesses
5. Blood/Mucous 7. Hospitalizations
6. Pain 8. Surgery
7. Abd. Distension 9. Medications
8. Flutulance 10. Allergies
Constipation
1. Onset Family Hx
2. Time 1. Parents
3. Bleeding 2. Siblings
4. Straining/Prolapse 3. Partner (if releveant)
5. Tenesmus
Loss of Weight
1. How much? Social Hx
2. Period of time? 1. Smoking/Drink/Drugs
3. Diet (type & intake) 2. Diet
3. Occupation
Cough 4. Income
1. Duration 5. Education
2. Sound 6. House type &
3. SOB? environment
4. Cyanosis
5. Type (Productive?)
6. Sputum Character
7. PostTussive (Condition)
8. Runny nose
9. Frequency
10. Exacerbating/Relieving
11. Medication Please add on if theres anything missing and improve this guideline
 General Examination CVS Examination CNS Examination CNS Examination
Bed 45° Stand @ Right Hand Side of Pt
1. Appearence, Alertness, General CVS Higher Function Test Motor Function Test
Activity(movements) 1. Pallor Sweating Cyanosis 1. Alertness, attention & Inspection
2. Is the patient in pain? SOB Palpitations Edema activity 1. Hypertrophy
3. Hydrational/Nutritional Status 2. Dysmorphic features 2. Speech & Language 2. Wasting
Sunken orbits 3. Vital Signs (fluency, comprehension, 3. Tremor
Dry buccal mucosa (HR,RR,BP,Ht,Wt, Head naming, repetition, 4. Chorea
Skin turgor Circumfrence) writing) Palpate
Capillary refill Inspection 3. Sleep 5. Bulk, Tone & Power
Anterior fontanelle 4. Nails (clubbing, splinter 4. Memory Fingers
4. Attachment/Equipment hemorrhages, cyanosis) Past Events Wrist
5. Temperature 5. Capillary refill time Present Events Elbow
6. Respiratory Distress 6. Eyes (pallor, scleral 5. Orientation Shoulder
Rate icterus, xanthomata, Name & Time (day, Hip
Nasal flaring senile arcus) month) Knee
Accesory Muscle Use 7. Mouth (central cyanosis, Place (hospital, country, Foot
7. BP & Pulses (Rt/Ry/Vol) hydration) city) 6. Relfex
Radial 8. JVP 6. Intelligence Biceps
Brachial 9. Chest (shape, precordial Brachioradialis
bulge, pectus carinatum/ Cranial Nerve Test
Femoral Triceps
excavatum, scars, visible 1. CN 1 (Olfactory)
Popletial Finger
impulse) Odor test (seperate
Dorsalis Pedis Knee jerk
P Peripheral Palpation nostrils)
Posterior Tibial Posterior tibialis
10. Pulses brachial & femoral, 2. CN 2 (Optic)
8. Colour Ankle jerk
Brachial femoral delay Acuity
Pink Babinski sign
Precordium Palpation Colour Vision
Blue/Cyanose Crossed adduction
11. Apex beat & all 4 Visual Fields
Yellow/Jaundice
auscultatory areas Retinal Examination
Pale Sensory Test
12. Thrills 3. CN 3 (Occulomotor)
9. Skin 1. Modalities
13. Liver CN 4 (Trochlear)
Rash Touch
14. Spleen CN 6 (Abducens)
Bruises Pain
15. Edema Eyelid & Pupil
Scratch Marks/Scars Temperature
Auscultation Light Reflex (Direct &
Eczema Vibration
16. Heart sounds/Murmurs at Consensual)
10. Hands Proprioception
4 Areas Accommodation (Near &
Nails shape & colour - Aortic (2nd R ICS) 2. Areas
Far object)
(clubbing,splinter H) - Pulmonic (2nd L ICS) Perineal
Extraocular Movement
Temperature - Tricuspid (Low L Strnl (H test) Sole of Foot
Moisture Bordr) Nystagmus Dorsum of foot
Colour - Mitral (Apex) Convergance Medial ankle and shin
11. Edema *Diaphragm (high 4. CN 5 (Trigeminal) Anterior mid thigh
12. Neck pitch:rubs, S1,S2) & Bell Motor – clenching muscle Lateral thigh
Trachea (low pitch: gallop, S2 spilit) (Palpate temporal & Medial arm
JVP 17. Lungs (pulm congestion) masseter muscle) 3. Stereognosis
Thyroid Asses pain, temperature 4. Tactile Discrimination
Lymph Nodes and light touch of 3 5. Graphesthesia
Respiratory Examination
 Cervical trigeminal areas
 Occipital Corneal reflex Cerebellar Function Test
General Respiratory
 Axillary 5. CN 7 (Facial) 1. Cerebellar System
1. Respiratory Rate, depth,
 Inguinal ease and rhythm of Symetrical movement of Finger to Nose
respiration face Heel – Knee – Shin
Inspection Smile, Frown, Show teeth, Rapid thumb index finger
Abdominal Examination Puff cheeks tapping
2. Thorax – Anterior &
Posterior Close eyes tightly and try rapid hand tapping againts
General Abdominal to open againts force examiner
(symmetry,retractions,
1. Activity 6. CN 8 (VestibularCochlear) screw light bulb action
accessory muscles, shape,
Lie still – appndcts/pritonits Whisper/Finger Rub test rapid alternate
vertebral column)
Moving – acute cholangitis movements (dorsum palm
3. Nose (nasal flaring) Rinne’s (f 512)
Inspection tapping)
4. Lips/Mucus membrane Webber’s
(Supine + Hips Flexed) 2. Balance & Gait
(cyanosis) 7. CN 9 (Glossopharyngeal)
2. Contour, peripheral vascular Romberg Test (stand feet
5. Oropharynx (Inflamed?) CN 10 (Vagus)
irregularities, skin markings together open/closed
6. Nail bed (peripheral Gag Reflex
3. Skin (dermatitis eyes)
cyanosis, clubbing) “Ahhhh” look at elevated
herperiformis, erytherma 3. Gait
P Palpation soft palate
nodosum, palmar Posture
7. Trachea at supra sternal 8. CN 11 (Accessory)
eryhterma, spider angioma, Blance
caput madusae) notch (mobility and SCM Muscle test (turn
deviation) head againts force) Arm swing
4. Abdomen (distention,
8. Lymph nodes (head & 9. CN 12 (Hypoglossal) Leg movement
schaphoid abdomen,
neck) Protrusion of tounge Tandem Walking – (Heel
peristaltic waves, scars,
9. Anterior & Posterior to toe walk)
protrusions in hernia)
Tactile Fermitus (99 test) Meningeal Irritation Test Heel walking
Palpate (superficial > deep)
10. Pulsus Paradoxus 1. Nuchal Rigidity Toe walking
5. Tenderness, liver, spleen,
(decrese in systolic BP 2. Spinal Rigidity Hop in place
kidney, detect masses
during inspiration) 3. Kernig’s Sign (resistance in Stand one leg and knee
6. Groin adenopathy, inguinal
11. Apex Beat knee extension) bend
hernias
Percussion Percussion 4. Brudizinski’s Sign (neck
7. Hepatomegaly, 12. Chest (dull, flexion – involuntary hip
hyperresonant,flat) flexion) Describing Ulcer
Spleenomegaly, 1. Base
Acites (shifting dullness, Auscultation
13. For each lobes (compare a. Solid brown/grey
fluid thrill) b. Yellow grey
P Auscultate R&L)
Describing Lumps c. Bluish
8. Abdominal sounds (active, - Air Entry
1. Site + Size + Surface d. Underlying structures bare
decreased, absent) - Breath Sound
2. Colour + Contour(Shape) + Consistency 2. Edge
Bruit - Additional Sounds
3. Tender? + Temperature + Transilluminable a. Sloping
- Vocal Resonance
4. Fluid filled + Fixed? + Fields (of lymph b. Punched out
drainage) c. Undermined
5. Pulsatile? d. Rolled
6. Expansible? e. Everted
7. Reducible 3. Discharge
4. Relations