Case Sheet

Case sheet for examination

Systems

RESPIRATORY  SYSTEM:

        Upper Resp.  tract          Septum                  Discharge               Sinuses

                                              Oral cavity             Tonsils                 Pharynx

                                              

             Inspection:          Shape of chest                 Trachea           Spine

                                        Hollowing;Bulging;Flattening;Retraction

                                        Drooping of shoulder

                                        Chest movement                   Expansion

                                         Accessory muscles

                                         Scars;Pulsations;Dilated veins

           Palpation:             Tenderness                         Trachea          Apex

                                        Chest movement                   Expansion

                                        Tactile vocal fremitus

         Percussion:                                                Note

               Area                          Rt                                                            Lt

       Auscultarion:               Rt

             Area           Breath sounds                     VR                      Added sounds

                                            Lt

            Area           Breath sounds                     VR                      Added sounds

GASTROINTESTINAL  SYSTEM:

     

              Oral  cavity                 

     Inspection:          Shape of abdomen                            Swellings                Pulsation

                                Peristalsis                 Veins                 Hernial orifices          Umbilicus

                                 External genitalia              

     Palpation:         Tenderness                Liver                 Spleen              Other organs 

    Percussion:     Shifting dullness                   Fluid thrill 

   Auscultation:      Bowel sounds                              Bruit

CENTRAL  NERVOUS  SYSTEM: 

     Higher functions:    Behaviour                     Speech              Intelligence

                                     Orientation

                                     Hallucination         Delusion

                                      Memory

   Release reflexes

  Cr.N.           1^st

                      2^nd   Acuity                      Colour  vision                         Field

                      3:4:6:          Eyemovements              Squint         Diplopi             Nystagmus

                                         Pupil:   Size          Shape        Light Reflex

                                                        Accommodation  Reflex                 

                        5^th        Cornial   Reflex                 Conjuntival   Reflex

                                    Sensation over face

                                     Muscles of mastigation

                        7^th       Motor

                                    Taste

                        8^th            Rennes               Weber              Vertigo

                         9;10;1 1: Gag                Palatal  Reflex

                                                                                  

                           12th

       Motor system          

           Bulk

           Tone

           Power

           Involuntary movt.                                                                                                                                                                      

           Reflexes   Deep    

                          Superfical

          Clonus

       Co-ordination

      Sensory system

    Posterior column 

  Cerebellum

    Cortical  sensation

    Meningeal  iritation

   Autonomic functions

CARDIOVASCULAR SYSTEM

Inspection

poor physical development

squatting

dyspnea

tachypnea

central cyanosis

edema

finger clubbing

distention of superficial veins.

precordial bulging and abnormal pulsation

increased pulsation in the central and superior parts of the precordium

pulsation and visible lifting of the apical precordium.

Bulge is due to RV dilatation

LPH (left parasternal heave) is due to RVH.

The position of the apex beat displaced down and out means LV dilatation

Jugular venous pressure (increased if above the level of the manubrium sterni

Palpation

Applying the palm of the hand to the chest

Thrills

increased precordial pulsation (apical in left ventricular hypertrophy and basal and right sided in right ventricular hypertrophy)

diastolic shock (in the pulmonary area in pulmonary hypertension)

The apex beat, normally in the fourth or fifth intercostal space within the mid-clavicular line

pulse wrist (radial) or inguinal region (femoral).

Sinus arrhythmia (increase in rate on inspiration with decrease on expiration)

bounding pulse

weak pulse

collapsing (

femoral pulses may be absent, or delayed

Percussion

right cardiac border does not extend beyond the right sternal edge

the upper border is at the level of the second intercostal space

determine cardiac size

Diminished or absent cardiac dullness is found in emphysema and pneumothorax.

Auscultaition

The ranges for heart rate in infancy and childhood are:

Newborn        70/120 

Infant             80/160             

Preschool child 75/120           

School child 70/110

Auscultate areas -

Mitral

Tricuspid

Pulmonary

Aortic

3^rd & 4^th left intercostal spaces,below left clavicle.

Auscultatory assessment

cardiac rhythm

heart sounds

murmurs.

Third heart sound

ejection click

intensity of heart sounds

Description of murmurs should include

1)  site,

2)  intensity (graded 0—6) with point of maximum intensity,

3)  timing (systolic: pan, early or late; or diastolic: early diastolic, mid-diastolic or presystolic,

4)  propagation (mitral systolic murmurs radiate to the left axilla, aortic systolic to the neck, aortic regurgitant down the left sternal edge) and

5)  variation with position. Coarctation of the aorta may produce a murmur audible over the back.

6)  Variation with respiration

venous hum

pericardial friction rub

to his ear.

other systems, e.g. by hepatic enlargement in cardiac failure.