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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]

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General Examination [401] I. 0BGeneral condition

1. 9BMental state

2. 10BBody built

3. 11BPosture

a) 15BIn bed-Decubitus

b) 16BOn standing and walk-gait

4. 12BFacial expression

5. 13BComplexion [pallor Jaundice - Cyanosis]

6. 14BVital sign`s [Pulse - Blood pressure - Respiratory rate - Temperature]

II. 1BHead

III. 2BNeck

IV. 3BUpper Limb`s

V. 4BLower Limb`s

VI. 5BLymphatic system

VII. 6BBreast

VIII. 7BSkin

IX. 8BGenitalia

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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

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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

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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

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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

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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

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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

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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

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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

concordPatient sheet General Examination [401] General condition Head Examination Neck Examination Upper Limb Examination Lower Limb Examination Breast Examination Lymph node examination skin examination