LONG CASES Particulars of the patient : NameAgeSexReligionOccupationAddress Date of admission Dare of examination

History The history proper : The history proper : Chief or presenting complaints History of (H/O) present illness Past history Personal history

Family history Family history Treatment history Treatment history Psychological history Psychological history Menstrual and obstetric history in females. Menstrual and obstetric history in females. Systems reveiw Systems reveiw

Physical examination : General examination- General examination- Level of consciousness: whether alert, oriented and co-operative. Level of consciousness: whether alert, oriented and co-operative. Appearance - Down’s syndrome, thalassaemia and in few endocrine disorders the patients look younger: and in progeria, the patient looks over than his/ her chronological age. Appearance - Down’s syndrome, thalassaemia and in few endocrine disorders the patients look younger: and in progeria, the patient looks over than his/ her chronological age.

Decubitus (position of the patient in bed) Build (skeletal frameworks)- Average/ dwarf/ tall stature. Build (skeletal frameworks)- Average/ dwarf/ tall stature. Co operation. Co operation.

Nutrition (nourishment of the body)- average/ undernutrition/ obese. Nutrition (nourishment of the body)- average/ undernutrition/ obese. Facies (facial appearance) Anaemia (mild, moderate, severe)- Probably `pallor’ is a better terminology. Jaundice (mild, moderate, severe) Jaundice (mild, moderate, severe) Cyanosis (central or peripheral) type) Cyanosis (central or peripheral) type)

Clubbing Koilonychia. Koilonychia. leuconychia leuconychia Neck vein (jugular veins) Neck vein (jugular veins) Lymph nodes( all over the body) Lymph nodes( all over the body) Thyroid gland.

Oedema Oedema Pulse (with all the points) Pulse (with all the points) Respiration (rate, rhythm, type and depth) Respiration (rate, rhythm, type and depth) Temperature (oral) Temperature (oral) Blood pressure (compulsory in all patients) Blood pressure (compulsory in all patients)

Systemic Examination 1) Cardiovascular system (CVS) 2) Respiratory system 3) Gastrointestinal system (G.I. system) 4) Nervous system 5) Genitourinary system 6) Lymphoreticular system 7) Locomotor system (optional)

(D) Salient features(Summary of the case) (E) Provisional diagnosis (F) Differential diagnosis (G) Relevant investigations