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FORMAT OF MEDICAL CASE SHEET
CHIEF COMPLAINTS AND THEIR INTERROGATION
Symptomatology:
1. General:
i) Fever: Duration.
Onset Sudden or insidious
H/O chills and rigors
Diurnal variation
H/O sweating
Type of fever
ii) Oedema: Duration.
Unilateral/ Bilateral
Where did it appear first
Progress
Painful/ Painless
Diurnal variation
Any other
NB:
Bedridden patients may not complain of pedal edema
iii) Pain: Duration
Onset
Radiation
Aggravating factors
Relieving factors
Associated symptoms
Any other
2. Symptoms suggestive of cardio-respiratory disease:
i) Cough: Duration
Onset sudden or insidious
Diurnal variation
Postural variation
With or without expectoration
Any special character (if any) eg.
Whopping, Bovine, Brassy etc.
Any other
Sputum: Quantity /24 hours
Quality
Colour
Odour
(H/O haemoptysis) Delete from here and make
separate
Any other
ii) Breathlessness: Duration
Onset Sudden or Insidious
Severity at the night
Progress. If exertional, grade the
breathlessness.
Type
-
Orthopnea
-
PND attacks
-
Other unusual eg. Platypnea, trepopnea
Wheezing
iii) Hemoptysis: Duration
Frequency
Character: Rusty sputum/ Streaky sputum/
Frothy sputum/
Frank blood
Amount within 24/hr or each bout
Associated symptom
iv)
Palpitation: Duration
Onset
Progress
Regular or irregular
How does it subside?
Associated symptoms
H/O drugs intake/ aggravating factors
Any other
v) Chest
pain: As in (1:iii)
NB: Pleuritic chest pain is superficial well localized and worsens
on deep breathing, coughing or sneezing. Anginal chest pain is deep, poorly
localized and worsen on exertion.
vi)
Fainting attacks: Duration
Frequency
Position at onset
Premonitory symptoms
3) Symptoms suggestive of GIT disease
i)
Vomiting: Duration
Frequency/ 24 hours
Preceeding nausea/ abdominal pain present/
absent
Contents of vomitus
Blood in vomitus, appearance – fresh or
altered
Colour of vomitus
Projectile/ non-projective
Associated symptoms
Any other
ii) Loose
motions: Duration
Frequency 24 hours
Type of stool Rice water, watery, semisolid
etc.,
Contents: Worms, undigested food particles
etc.,
Colour
Presence of blood or mucus
Any other
iii)
Abdominal pain: As in (1:iii)
iv) Loss of
appetite: Duration
Is it for any special type of foods?
Associated symptoms
Any other
v) Bleeding
per rectum: Duration
Amount
Relation to defecation
H/O melena
vi)
Jaundice: Duration
How was it noticed?
H/O high coloured urine
H/O clay coloured stools or pruritus
H/O drug intake
4. Symptoms suggestive of urinary tract disease
i) Frequency of micturition Duration
ii) Pyuria Onset
iii)
Haematuria Associated
symptoms
iv) Burning
micturition Any other
v) Flank or
renal angle pain
5. Symptoms suggestive of Central Nervous System disease:
i) Loss of
power: Duration
Onset
Which are the limbs affected
Which muslce group - proximal/distal
Details of events
Progress
H/O stiffness
H/O thinning of affected limb (wasting)
H/O fasiculations or flexor spasms
Associated symptoms
Any other
ii)
Sensory: Complaints like: Tingling, numbness, pins and needle burning
of sole and palm etc.
Duration
Onset
Progress: Where did it begin and how did it
progress to other
parts
Can patient (appreciate hot or cold water
while bathing)?
Associated symptoms
Any other
iii)
Involuntary movements like tremor, chorea, athetosis hemiballismus
etc.,
Duration
Onset
Part of body involved
Aggravating factors
Associated symptoms
Any other
iv) Retention of urine Duration
Precipitancy: Onset
Hesitancy: Associated
symptoms
Incontinence:
Automatic micturition:
Autonomous micturition:
Any other
v) Symptoms
like: Tinnitus, giddiness, vertigo, black outs, syncope, drop,
attack etc.,
Duration
Onset
Frequency
Associated symptoms
Any other
vi) H/O
seizures or fits
Duration
Frequency
Description of typical attack
Focal or general
H/O tongue bite, injury, incontinence etc.,
Any relation to alcohol, television, menses
etc.,
vii) H/O
unconsciousness: Details
viii) H/O
difficulty in speaking
ix) History
suggestive of cranial nerve dysfunction, like visual
disturbance, diplopia, dysphoria
deviation of angle of mouth etc.,
x) H/O
headache (details as in pain)
6. Consumption of poision:
Time and
date
Name and
nature of poison and quantity consumed
Symptoms
developed after consumption of poison
Time
elapsed between consumption of poison and reaching hospital
(stomach wash)
Purpose of
consumption
Any other
7. Joint pains: Duration
Joints
involved in order
Morning
stiffness
Associated
complaints like swelling of joints, restriction of movements
etc.,
PAST HISTORY
1.
Any history of similar complaints in the past.
2.
Any other major illness like diabetes,
hypertension, jaundice, etc.
3.
Previous hospitalization.
4.
Any major operation and/or accidents.
5.
H/O blood transfusions.
6.
Any other
If answer is ‘yes’ give all the details.
PERSONAL HISTORY
Diet.
Appetite.
Sleep.
Micturition.
Bowels.
Habits:
Smoking Quantity
Alcohol Quantity
Drugs Duration
FAMILY HISTORY
1.
Married or not: If married.
a.
Number of issues: Number alive: H/O abortions,
pedigree chart
b.
If unmarried: No. of brothers/sisters/health of
parents etc.,
2.
H/O heriditary familial disease or infectious
disease like Diabetes, hypertension and tuberculosis etc.,
SEXUAL HISTORY
H/O
multiple partner
H/O
visiting commercial sex worker
Homosexual/Heterosexual/Bisexual
H/O penile
ulcer either present or past
H/O
inguinal swelling, urethral discharge, etc.,
SOCIOECONOMIC HISTORY:
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