A. CASE SHEET FORMAT
HISTORY TAKING
Name:
Age:
Sex:
Residence:
Occupation:
Chief Complaints
________ × days
________ × days
________ × days
History of Presenting Illness
Abdominal distention:
Duration
Onset
Progression
Aggravating factors
Relieving factors
Associated symptoms
Is it preceded by pedal edema or followed by it?
Pedal edema:
Duration
Onset
Progression
Aggravating factors
Relieving factors
Is it preceded by facial puffiness or followed by it?
Abdominal pain:
Onset
Site
Type of pain
Radiation
Aggravating factors
Relieving factors
Associated symptoms
Nausea and vomiting:
Episodes
Contents
Blood tinged or not
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How many hours after consumption of food associated with pain abdomen?
Conditions with nausea and vomiting but not associated with pain abdomen:
Metabolic
Neurologic
Drug induced
Psychogenic
Other symptoms:
Heart burn, flatulence, and waterbrash
Hematemesis and melena
Dysphagia
Constipation and diarrhea
Altered bowel habit:
Stool color
Stool odor
Stool frequency
Blood tinged or melena
Jaundice—itching and high colored urine
Fever
Weight loss
Pain in oral cavity
Halitosis
Hiccups
Other relevant history
Past history:
Asthma
Chronic obstructive airway disease
Tuberculosis
History of contact with tuberculosis
Diabetes mellitus (DM)
Hypertension (HTN)
Ischemic heart disease (IHD)
Seizure disorder
Family history:
Draw a three generations pedigree chart
Personal history:
Bowel habits
Bladder habits
Appetite
Loss of weight
Occupational exposure
Sleep
Dietary habits and taboo
Food allergies
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Smoking index or pack years
Alcohol history
Menstrual and obstetric history
G__P__L__A__
Age of menarche __
Menopause at __
Flow—ameno/oligo/menorrhagia
Summarize:
Differential diagnosis:
GENERAL EXAMINATION
Patient
Conscious
Coherent
Cooperative
Obeying commands
Body Mass Index (BMI)
Weight (kg)/Height2
(meters)
Grading according to WHO for Southeast Asian countries
Vitals
Pulse
Rate:
Rhythm:
Volume:
Character:
Vessel wall thickening:
Radio-radial delay and radio-femoral delay:
Peripheral pulses:
Blood pressure
Right arm:
Left arm:
Right leg
Left leg
Respiratory rate
Regular/irregular
Abdominothoracic/thoracoabdominal
Usage of accessory muscles:
Jugular venous pressure
__ cm of blood above sternal angle (+ 5 cm water from right atrium)
Jugular venous pulse
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Waveform (describe waves)
On Physical Examination
Pallor:
Icterus:
Cyanosis:
Clubbing:
Lymphadenopathy:
Edema:
Other Head to Toe Signs of Chronic Liver Cell Failure
Alopecia
Fetor hepaticus
Jaundice
Parotid swelling
Gynecomastia
Testicular atrophy
Loss of secondary sexual characters
Spider nevi
Palmar erythema
Dupuytren’s contracture
Asterixis
Xanthelasma
Signs of chronic cholestasis (scratch marks due to pruritus).
SYSTEMIC EXAMINATION
The order of examination of abdomen is preferably done—
Inspection→Auscultation→Palpation→Percussion (as the auscultatory findings might change post
palpation and percussion).
Inspection:
Spine
Shape/distention (localized/generalized) and flanks (free/full)
Skin over the abdomen
Symmetry
Umbilicus
Movement of corresponding quadrants with respiration
Dilated veins
Visible mass
Visible pulsations
Visible peristalsis
Scars or sinuses
Divarication of recti
Palpation:
Superficial palpation
Warmth
Tenderness
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