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. 1st
2nd Acuity Colour vision Field
3:4:6: Eyemovements Squint Diplopi Nystagmus
Pupil: Size Shape Light Reflex
Accommodation Reflex
5th Cornial
Reflex
Conjuntival Reflex
Sensation
over face
Muscles of
mastigation
7th Motor
Taste
8th Rennes
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
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
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
3rd & 4th 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.
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