CASE PROFILE
UIN NUMBER:
NAME:
AGE:
SEX:
ADDRESS:
PH.NUMBER:
OCCUPATION:
RELIGION:
MARITAL STATUS:
DATE OF CASE TAKING:
PRESENTING COMPLAINTS/ CHIEF COMPLAINTS:
HISTORY OF PRESENTING COMPLAINTS:
TREATMENT HISTORY:
1
PAST HISTORY (CHRONOLOGICAL ORDER):
(1) Major illness:
(2) Operation:
(3) Accident:
(4) Exposure to X-Rays (if yes, how many times):
(5) Allergies:
(6) Vaccination:
(7) Suppression:
FAMILY HISTORY:
(1) Father:
(2) Mother:
(3) Paternal Grandfather:
(4) Paternal Grandmother:
(5) Maternal Grandfather:
(6) Maternal Grandmother:
(7) Siblings:
PERSONAL HISTORY:
(1) Developmental Landmarks:
(2) Diet:
(3) Habits/Addictions:
(4) Environment at Home:
(5) Environment at Workplace:
GYNECOLOGICAL AND OBSTETRICS HISTORY:
GYNECOLOGICAL HISTORY
(1) Menarche:
(2) Duration:
(3) Cycle:
(4) Amount of flow:
2
(5) Character:
(6) Clots:
(7) Any complaints before or after menses:
(8) Any other discharges:
OBSTETRICS HISTORY
G P L A
PHYSICAL GENERALS:
(1) Thermal Reaction:
(2) Thirst:
(3) Appetite:
(4) Desires:
(5) Aversions:
(6) Craving:
(7) Perspiration:
(8) Stools:
(9) Urine:
(10) Sleep:
(11) Dreams:
MENTAL GENERALS:
3
GENERAL PHYSICAL EXAMINATION:
(1) Built:
(2) Attitude:
(3) Height:
(4) Weight:
(5) Gait:
(6) Decubitus:
(7) Temperature:
(8) Facies:
(9) Blood Pressure:
(10) Respiratory Rate:
(11) Pulse Rate:
(12) Pallor:
(13) Cyanosis:
(14) Icterus:
(15) Clubbing:
(16) Edema:
(17) Pigmentation:
(18) Tongue:
(19) Lymph Nodes:
(20) Skin Eruptions (if present and type):
SYSTEMIC EXAMINATION:
RESPIRATORY EXAMINATION
INSPECTION
(1) Shape of chest:
(2) Type of breathing:
(3) Respiratory Rate:
4
(4) Prominence of vein:
(5) Apex Beat:
PALPATION
(1) Position of trachea:
(2) Position of Apex Beat:
(3) Vocal fremitus:
PERCUSSION
AUSCULTATION
(1) Breath sounds:
(2) Added sounds:
(3) Vocal resonance:
CARDIOVASCULAR SYSTEM
INSPECTION
(1) Shape of Precordium:
(2) Apical Thrust:
(3) Prominent Veins:
PALPATION
(1) Apex Beat:
(2) Thrills:
(3) Tracheal Tug:
PERCUSSION
(1) Cardiac dullness:
5
AUSCULTATION
(1) Heart Sounds (HS1&HS2):
(2) Audible Murmur:
(3) Added Sounds:
GASTRO INTESTINAL SYSTEM
INSPECTION
(1) Shape of abdomen:
(2) State of Umbilicus:
(3) Visible Epigastric Pulsation:
(4) Visible Peristalsis:
(5) Movement of abdominal wall:
(6) Prominence of Veins:
(7) Colour of the skin:
PALPATION
(1) Superficial palpation:
(2) Deep palpation:
(3) Kidney:
(4) Spleen:
(5) Liver:
(6) Any palpable lump:
PERCUSSION
(1) Abdomen (Liver & Splenic Dullness):
(2) Fluid thrill:
(3) Shifting dullness:
(4) Horseshoe:
6
AUSCULTATION
(1) Sound of peristaltic movement:
CENTRAL NERVOUS SYSTEM
HIGHER FUNCTIONS
(1) Conscious:
(2) Memory:
(3) Intelligence:
(4) Orientation:
EXAMINATION OF CRANIAL NERVES
EXAMINATION OF MOTOR SYSTEM
(1) Gait:
(2) Bulk of muscles:
(3) Muscle tone:
(4) Muscular strength:
(5) Coordination of movements:
(6) Superficial and deep tendon reflex:
EXAMINATION OF REFLEXES
(1) Superficial Reflexes:
(2) Deep Reflexes:
EXAMINATION OF SENSORY SYSTEM
(1) Pain:
(2) Touch:
(3) Temperature:
7
JOINTS AND BONES
(1) Pain:
(2) Swelling:
(3) Redness:
(4) Tenderness:
PROVISIONAL DIAGNOSIS:
INVESTIGATIONS:
FINAL DIAGNOSIS:
REMEDY INDICATED:
JUSTIFICATION:
