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Case sheet for examination

Systems
RESPIRATORY SYSTEM:
Upper Resp. tract

Inspection:

Palpation:

Percussion:
Area

Septum
Oral cavity

Discharge
Tonsils

Sinuses
Pharynx

Shape of chest
Trachea
Spine
Hollowing;Bulging;Flattening;Retraction
Drooping of shoulder
Chest movement
Expansion
Accessory muscles
Scars;Pulsations;Dilated veins
Tenderness
Trachea
Apex
Chest movement
Expansion
Tactile vocal fremitus
Note
Rt

Auscultarion:
Rt
Area
Breath sounds
Lt
Area
Breath sounds

Lt

VR

Added 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
Orientation
Hallucination
Memory

Speech

Intelligence

Delusion

Release reflexes
Cr.N.
1st
2nd Acuity
Colour vision
Field
3:4:6:
Eyemovements
Squint
Diplopi
Pupil: Size
Shape
Light Reflex
Accommodation Reflex
5th
Cornial Reflex
Conjuntival Reflex
Sensation over face

Nystagmus

Muscles of mastigation
Motor
Taste
8th
Rennes
Weber
9;10;1 1: Gag
Palatal Reflex
7th

Vertigo

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
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 06) 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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