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    Medical Case Sheet

    Uploaded by

    Mary Caldwell
    The document provides a detailed outline for taking a history and performing a physical examination on a patient presenting with abdominal symptoms. It includes sections on gathering information on the patient's presenting complaints, relevant medical history including past illnesses and surgeries, family history, lifestyle factors, and previous treatments. The physical examination section lists assessments to perform for the general exam, liver, abdomen, and other organ systems, including palpation findings and percussion tests to check for fluid.

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    Download as ODT, PDF, TXT or read online from Scribd

    Medical Case Sheet

    Uploaded by

    Mary Caldwell
    2K views5 pages
    The document provides a detailed outline for taking a history and performing a physical examination on a patient presenting with abdominal symptoms. It includes sections on gathering information on the patient's presenting complaints, relevant medical history including past illnesses and surgeries, family history, lifestyle factors, and previous treatments. The physical examination section lists assessments to perform for the general exam, liver, abdomen, and other organ systems, including palpation findings and percussion tests to check for fluid.

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    A proforma to help history taking of the GI system

    Original Title

    Medical case sheet

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    © Attribution Non-Commercial (BY-NC)

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    The document provides a detailed outline for taking a history and performing a physical examination on a patient presenting with abdominal symptoms. It includes sections on gathering information on the patient's presenting complaints, relevant medical history including past illnesses and surgeries, family history, lifestyle factors, and previous treatments. The physical examination section lists assessments to perform for the general exam, liver, abdomen, and other organ systems, including palpation findings and percussion tests to check for fluid.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    2K views5 pages

    Medical Case Sheet

    Uploaded by

    Mary Caldwell
    The document provides a detailed outline for taking a history and performing a physical examination on a patient presenting with abdominal symptoms. It includes sections on gathering information on the patient's presenting complaints, relevant medical history including past illnesses and surgeries, family history, lifestyle factors, and previous treatments. The physical examination section lists assessments to perform for the general exam, liver, abdomen, and other organ systems, including palpation findings and percussion tests to check for fluid.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    of 5

    HISTORY TAKING IN ABDOMEN CASE Name/Age/Sex/Occupation/Place PRESENTING COMPLAINTS H/o PRESENTING COMPLAINTS: Abdominal pain Duration Site Nature

    ure (Continuous/ intermittent) Character (constant/colicky) Severity Radiation Aggravating/ Relieving factors Associated features (fever/ nausea/ vomiting/ defecation) Abdominal distension Duration Onset (insidious/ acute) Site (localized/ uniform) Progress RVF features Leg swelling Breathlessness Chest pain Liver features Loss of appetite Hematemesis/ Melena Constipation/ Obstipation Renal Oliguria Puffiness of face Frothy urine ( Nephrotic syndrome)

    Vomitting/ Blood in vomit No. of episodes Duration Projectile Associated with nausea/ headache/ blurring of vision Quantity Character (colour/ smell/ blood stricken) Associated with food intake Associated features (pain/ melena/ hematemesis/ loss of consciousness) H/o drug intake(NSAIDs, steroids) Jaundice Duration Itching

    Colour of urine/ stools Any fever with rigor Treatment taken Frequency Colour (dark/ tarry black/ pale) Consistency (solid/ liquid) Nature (sticky/ mucoid) Associated pain Blood streaks

    Stools

    Mass in abdomen Site Duration Progression Associated pain

    NEGATIVE HISTORY

    Fever

    Duration and time of occurrence Grade (high/ low) Nature (continuous/remittent) Associated with rigors/ sweating

    Upper GIT Dysphagia( solids/ liquids/ both) Heat burn Vomitting Urinary Tract Dysuria Pain/ burning micturition Oliguria Hematuria Frequency Fever with rigor H/o bleeding diathesis Epistaxis Bleeding gums Menorrhagia Prolonged bleeding after trauma H/o loss of appetite/ weight loss TB and malignancy H/o swelling of legs CVS

    H/o puffiness of face renal H/o pruritides, bleeding per rectum liver H/o altered sleep pattern

    PAST HISTORY H/o previous similar episodes H/o surgery/ drug intake Jaundice H/o tattooing H/o drug intake H/o blood transfusion H/o exposure to STDs H/o vaccination

    Ascites

    Previous abdomen surgeries(scar irritation) H/o TB, DM, IHD, HT H/o renal colic

    FAMILY HISTORY Any similar history (Cirrhosis/ Wilsons disease/ a-1-AT/ HepA /HepB/ HepE) PERSONAL HISTORY Smoking Alcohol Diet (appetite) Sexual history Menstrual history/ obstetric history TREATMENT HISTORY SUMMARY : Age/ Sex/ Name? Personal h/o? Family h/o? Presenting complaints? Other relevant positive features. EXAMINATION OF ABDOMEN CASE GENERAL EXAMINATION

    Conscious Cooperative Built Afebrile Cyanosis Anemia Jaundice Clubbing (Cirrhosis/ IBD/ Malabsorption syndrome) Significant lymphadenopathy Pedal edema

    Markers of LIVER CELL FAILURE Head Alopecia Eye Bitot Spots (Vit A) Sub conjunctival hemorrhage (Vit K) Colour (anemia pale/ Jaundice yellow) Metabolism (KF Ring Wilsons/ Xanthelasma Fat)

    Face

    Medial surpaciliary madarosis Sunken eyes, cheeks Loss of facial hair Parotid enlargement Bleeding gums Fetor hepaticus Spider nevi Gynaecomastia Atrophy of breast Loss of pectoral hair, axillary hair, Pectoral muscle atrophy Dilated veins

    Mouth

    Chest

    Hands Anemia Bounding pulse Clubbing Duputryens contracture Flapping tremor/ asterexis Erythema palmar Leuconychia Abdomen Distension Dilated veins ( Caput medusa) Testis Atrophy Pubic hairloss Tumor Lower limbs Pedal edema Chromic leg ulcers General Pruritis/ Spiderman appearance

    Markers of TB Markers of HIV

    PALPATION Superficial Palpation Warmth Tenderness Thrills Deep Palpation Liver A tender/ non tender swelling is palpable ______ cm below right costal margin in MCL extending from ________ (medial) to _____ (lateral) , with ______ (smooth/ nodular) surface and _____ (sharp/ rounded) margins, _____ (soft/ firm/ hard) in consistency. It _____ (moves, not) with respiration, not bimanually palpable, not able to insinuate fingers under the costal margin. Spleen Site Surface Tender Splenic abscess, IMV Extent Notch on medial border Consistency It moves with respiration, not bimanually palpable, not ballotable, upper border, cannot be felt, colonic band of resonance not felt. Kidney (Normally lower rt pole in thin individuals) It moves with respiration, bimanually palpable, ballotable, colonic band of resonance felt. Others Direction of blood flow Fluid thrill Abdominal girth measurement Inguinal/ Para Aortic/ Supraclavicular nodes

    PERCUSSION Fluid Shifting dullness Puddle sign

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