Cardiovascular System Examination

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I. Preparation & General Inspection

1. Wash hands
→ Maintain hygiene and infection control.

2. Introduce yourself and obtain consent

3. Position the patient
→ Supine at 45° with chest exposed appropriately.

4. General observation from end of bed:

• Cyanosis (bluish discoloration — indicates hypoxia)
• Pallor (pale skin — suggests anemia)
• Dyspnea (difficulty breathing — seen in heart failure)
• Use of accessory muscles (suggests respiratory distress often due to left heart failure)
• Edema (swelling — usually pedal; suggestive of right heart failure)
• Cachexia (wasting — occurs in chronic heart failure)

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II. Hands and Arms

1. Look at the hands:

• Clubbing (bulbous fingers — seen in infective endocarditis, congenital heart disease)
• Splinter hemorrhages (linear bleeding under nails — seen in infective endocarditis)
• Osler’s nodes (tender nodules on fingers — due to immune complex in infective endocarditis)
• Janeway lesions (painless red macules on palms/soles — septic emboli from endocarditis)
• Palmar crease pallor (suggests anemia)

2. Capillary Refill Time (CRT)
→ Press the fingernail bed for 5 seconds and release.
→ Refill time >2 seconds = poor perfusion.
(CRT: delayed refill shows reduced cardiac output or shock)

3. Assess the pulse

• Rate (Normal: 60–100 bpm)
• Rhythm
  • Regular
  • Irregularly irregular (Atrial fibrillation — no consistent rhythm)
  • Regularly irregular (e.g., sinus arrhythmia — natural variation with breathing)
• Character
  • Bounding pulse (strong, forceful — seen in aortic regurgitation)
  • Collapsing pulse (sharp upstroke, rapid fall — "water hammer pulse", in aortic regurgitation)
  • Pulsus parvus et tardus (slow rising, weak — typical of aortic stenosis)

4. Blood Pressure

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III. Face and Neck

1. Face:

• Malar flush (rosy cheeks — seen in mitral stenosis)
• Conjunctival pallor (anemia)
• Xanthelasma (lipid plaques near eyes — seen in hyperlipidemia)

2. Eyes:

• Arcus senilis (white ring — hypercholesterolemia in young)
• Roth spots (retinal hemorrhages — infective endocarditis)

3. Mouth:

• Central cyanosis (bluish tongue)
• High-arched palate (Marfan syndrome — predisposes to aortic dissection, MVP)

4. Neck:

• Jugular Venous Pressure (JVP)
  • Raise head to 45°, observe internal jugular vein pulsations.
  • Use right side.
  • Measure from sternal angle — normal <4 cm.
  • Raised JVP → seen in right heart failure, fluid overload, constrictive pericarditis.
  • Prominent 'v' wave → tricuspid regurgitation.
    (JVP reflects right atrial pressure; unlike carotid pulse, it is non-palpable)

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IV. Precordium (Chest) Examination

1. Inspection:

• Scars (CABG, pacemaker)
• Visible pulsations
• Chest wall deformities
• Apex beat — visible in thin individuals

2. Palpation:

• Apex Beat Location:

  • Normally at 5th intercostal space, mid-clavicular line
  • Thrusting apex (forceful & sustained — volume overload as in aortic regurgitation)
  • Heaving apex (sustained, forceful — pressure overload like aortic stenosis)
  • Displaced apex (seen in cardiomegaly/heart failure)

• Parasternal Heave (sustained lift felt along left sternal edge — indicates right ventricular hypertrophy)

• Thrills (palpable murmurs — turbulent blood flow as in severe valvular disease)

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V. Auscultation

Valves:

1. Aortic — 2nd Right ICS
2. Pulmonary — 2nd Left ICS
3. Tricuspid — 4th Left ICS
4. Mitral — 5th Left ICS MCL (Apex)

Murmurs:

• Pan-systolic murmur (murmur throughout systole — seen in mitral regurgitation, tricuspid regurgitation, VSD)
• Ejection systolic murmur (crescendo-decrescendo — seen in aortic or pulmonary stenosis)
• Mid-diastolic murmur (seen in mitral stenosis — due to turbulent filling)

Manoeuvres:

• Valsalva maneuver (forced expiration against closed glottis — reduces venous return)
  → Helps identify murmurs like HOCM and MVP
• Squatting and standing → Used to differentiate murmurs by affecting venous return and afterload

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VI. Back, Abdomen, Legs

Back:

• Listen for basal crackles (pulmonary edema — left heart failure)
• Sacral edema (seen in right heart failure or immobile patients)

Abdomen:

• Hepatomegaly (congestive hepatomegaly — right heart failure)
• Ascites (fluid accumulation — right heart failure)
• Abdominal aortic aneurysm (AAA) — palpate above umbilicus

Legs:

• Pedal edema (pitting swelling — right-sided heart failure)
• Calf tenderness (DVT — risk of embolism)

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VII. Special Conditions & Their CVS Findings

Condition	Key Signs
Heart Failure	Raised JVP, displaced apex, pedal edema, crackles
Mitral Stenosis	Malar flush, tapping apex beat, mid-diastolic murmur
Infective Endocarditis	Fever, murmur, Osler’s nodes, Janeway lesions, splinter hemorrhages
HOCM (Hypertrophic Obstructive Cardiomyopathy)	Ejection murmur ↑ with Valsalva
MVP (Mitral Valve Prolapse)	Mid-systolic click, murmur ↑ on standing
Aortic Dissection	Sudden chest pain, pulse deficit, unequal BP
Coarctation of Aorta	Radiofemoral delay, HTN in upper limbs, weak lower limb pulse
Atrial Fibrillation	Irregularly irregular pulse, loss of 'a' wave in JVP
Sinus Arrhythmia	Pulse varies with respiration (normal in youth)
Bounding Pulse	Wide pulse pressure — aortic regurgitation
Collapsing Pulse	Water-hammer pulse — aortic regurgitation
Pulsus Parvus et Tardus	Weak & slow — aortic stenosis

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Technical Terms - Cardiovascular System Examination

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❤️‍🩹 Cardiovascular System Examination — Terminology .

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🪞 1. Inspection – Look

Term	Explanation
Precordium	The area on the front of the chest overlying the heart (left chest wall)
Pulsations	Visible throbbing movements — may be normal at the apex but abnormal elsewhere
Apical impulse	Visible or palpable heartbeat in the 5th intercostal space, midclavicular line — normally mild and focused
Heaving impulse	Strong and forceful apical beat — suggests left ventricular hypertrophy (LVH)
Parasternal heave	Outward thrust felt at the left sternal border — suggests right ventricular hypertrophy (RVH)
Jugular venous pulsation (JVP)	Visible wave-like movement in the neck veins caused by blood returning to the right atrium
Cyanosis	Bluish discoloration of lips, tongue, or extremities — indicates low oxygen levels
Clubbing	Bulbous enlargement of fingertips — may occur in congenital heart disease or infective endocarditis
Edema	Swelling, especially in legs — suggests fluid retention, often from heart failure

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✋ 2. Palpation – Feel

Term	Explanation
Apex beat	The point where the heart’s contraction is felt most strongly — normally in the 5th intercostal space, midclavicular line
Displaced apex beat	Apex felt more lateral or inferior — indicates enlarged heart (cardiomegaly)
Heaving apex	Sustained and forceful — suggests pressure overload (like in aortic stenosis)
Thrusting apex	Hyperdynamic, tapping, or bounding — seen in volume overload (like mitral regurgitation)
Thrill	A palpable vibration — felt over turbulent blood flow, e.g., over a murmur-producing valve
Parasternal heave	A forceful lifting of the chest wall — indicates right ventricular enlargement
Peripheral pulses	Pulses felt at wrist (radial), neck (carotid), feet (dorsalis pedis/posterior tibial) to assess rhythm, rate, and volume
Pulse deficit	Difference between apical and peripheral pulse rate — seen in atrial fibrillation
Capillary refill time (CRT)	Time taken for color to return after pressing nail bed — normal <2 seconds; delayed in shock

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🫳 3. Percussion – Tap

Term	Explanation
Cardiac dullness	Dull sound heard when tapping over the heart — helps estimate heart size (now rarely done due to imaging)
Percussion note	Sound generated when tapping — resonant over lungs, dull over the heart

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🎧 4. Auscultation – Listen

Term	Explanation
Heart sounds	Sounds produced by closing of valves
S1 (First Heart Sound)	"Lub" — Closure of mitral and tricuspid valves — marks start of systole
S2 (Second Heart Sound)	"Dub" — Closure of aortic and pulmonary valves — marks end of systole/start of diastole
S3	Extra sound in early diastole — normal in children/athletes; pathological in heart failure
S4	Extra sound in late diastole — indicates stiff ventricle (e.g., hypertension, aortic stenosis)
Murmur	Abnormal, prolonged heart sound due to turbulent flow — can be systolic or diastolic
Ejection click	High-pitched sound just after S1 — heard in aortic or pulmonary stenosis
Opening snap	Sharp sound in early diastole — heard in mitral stenosis
Pericardial rub	Scratching/grating sound — due to inflamed pericardium (pericarditis)
Gallop rhythm	Presence of S3 or S4 — sounds like a horse’s gallop; sign of heart failure

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🩺 Auscultation Areas (Valvular Points)

Valve	Location for auscultation
Aortic valve	2nd right intercostal space, just next to sternum
Pulmonary valve	2nd left intercostal space, next to sternum
Tricuspid valve	4th or 5th left intercostal space, close to sternum
Mitral valve	5th left intercostal space, midclavicular line (apex area)

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🫀 Pulse Characteristics

Term	Explanation
Bounding pulse	Strong, forceful pulse — in high output states (fever, anemia)
Thready pulse	Weak, thin pulse — seen in shock
Irregularly irregular pulse	No pattern at all — classic in atrial fibrillation
Pulsus paradoxus	Drop in systolic BP during inspiration >10 mmHg — seen in cardiac tamponade
Pulsus alternans	Alternating strong and weak pulse beats — in severe left ventricular failure
Radio-femoral delay	Radial and femoral pulse not felt together — seen in coarctation of the aorta

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🧠 Common Pathological Terms in CVS

Term	Explanation
Mitral stenosis	Narrowing of mitral valve — leads to obstructed blood flow from left atrium to left ventricle
Aortic regurgitation	Aortic valve leaks blood back into the left ventricle
Heart failure	Heart’s inability to pump blood effectively
Cardiomyopathy	Disease of the heart muscle affecting function
Pericarditis	Inflammation of the membrane around the heart
Endocarditis	Infection of the inner lining/valves of the heart
Myocardial infarction	Heart attack — damage due to blocked coronary arteries
Congenital heart disease	Heart defect present from birth (e.g., ASD, VSD, TOF)

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📚 Summary Tip:

• S1 = AV valves close, S2 = semilunar valves close
• Systolic murmur between S1–S2 (e.g., aortic stenosis)
• Diastolic murmur after S2 (e.g., mitral stenosis)

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Technical Terms - Respiratory Examination

 

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Technical Terms - Respiratory Examination

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🪞 Inspection Terms

Term	Explanation
Tachypnea	Breathing faster than normal (adult >20 breaths/min)
Bradypnea	Breathing slower than normal (adult <12 breaths/min)
Dyspnea	Difficulty in breathing; patient may feel breathless
Orthopnea	Difficulty breathing when lying flat (common in heart failure)
Accessory muscles	Muscles not normally used in breathing (e.g., neck muscles) — used when breathing becomes difficult
Nasal flaring	Widening of the nostrils while breathing — sign of respiratory distress
Barrel-shaped chest	Rounded, bulging chest seen in long-term COPD
Pectus carinatum	Outward protrusion of the chest (pigeon chest)
Pectus excavatum	Sunken chest (funnel chest)
Scoliosis	Sideways curvature of the spine
Kyphosis	Forward hunching of the upper back

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✋ Palpation Terms

Term	Explanation
Tracheal deviation	Displacement of the trachea from the midline — suggests lung pathology
Apex beat	The point of maximal impulse (PMI) of the heart, felt in the 5th intercostal space
Chest expansion	The movement of the chest wall during deep breathing; decreased movement may indicate lung disease
Vocal fremitus	Vibrations felt on the chest wall when the patient speaks — reduced in fluid/air-filled lungs

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🫳 Percussion Terms

Term	Explanation
Percussion	Tapping the chest with fingers to assess underlying structures
Pleximeter	The finger placed on the patient’s chest while percussing
Plexor	The finger used to tap on the pleximeter
Resonant note	Normal sound heard over air-filled lungs — low-pitched and hollow
Dull note	Thud-like sound over fluid or solid structures (e.g., consolidation or effusion)
Hyperresonant note	Louder, lower-pitched sound heard over extra air (e.g., pneumothorax)
Stony dullness	Extremely dull sound, like tapping on a wall — seen in pleural effusion

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🎧 Auscultation Terms

Term	Explanation
Stethoscope diaphragm	The flat side of the stethoscope used to listen to high-pitched sounds like breath sounds
Vesicular breath sound	Normal soft rustling sound heard during breathing over healthy lung tissue
Bronchial breath sound	Loud, harsh, hollow sound — normally heard over the trachea but abnormal if heard over lung fields (suggests consolidation)
Crackles (rales)	Popping or bubbling sounds, like Velcro — indicates fluid in lungs (e.g., pneumonia, fibrosis)
Fine crackles	Short, high-pitched crackles (pulmonary fibrosis)
Coarse crackles	Longer, low-pitched crackles (bronchiectasis)
Wheeze	High-pitched, musical sound due to narrowed airways (e.g., asthma)
Rhonchi	Low-pitched, snoring sounds due to mucus in large airways (e.g., COPD)
Pleural rub	Creaking or grating sound — like walking on snow — caused by inflamed pleura rubbing against each other
Vocal resonance	Sound of spoken words heard through a stethoscope — increased in solid lung (e.g., consolidation), decreased in fluid or air-filled lung (e.g., effusion, pneumothorax)

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🫁 Common Pathological Conditions

Term	Explanation
Consolidation	Lung tissue filled with fluid or pus — common in pneumonia
Pleural effusion	Accumulation of fluid in the pleural space between the lungs and chest wall
Pneumothorax	Air in the pleural space causing lung collapse
Fibrosis	Thickening or scarring of lung tissue — reduces elasticity
COPD	Chronic Obstructive Pulmonary Disease — long-term lung damage (e.g., chronic bronchitis, emphysema)
Bronchiectasis	Permanent dilation and damage to the airways due to infection/inflammation

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Symptoms

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🧠 Nervous System

✅	Symptom	Definition	Why It Happens (Pathogenesis)
☐	Headache	Pain in the head or scalp	Due to tension (muscle contraction), increased intracranial pressure, migraine (vasodilation + neurogenic inflammation), or inflammation of meninges
☐	Dizziness	Lightheadedness or feeling faint	Decreased cerebral perfusion, anemia, hypotension, vestibular imbalance
☐	Vertigo	Illusion of movement or spinning	Disturbance in vestibular system – inner ear, vestibular nerve, or cerebellum
☐	Seizure	Sudden, uncontrolled brain activity	Abnormal neuronal firing due to electrolyte imbalance, tumor, trauma, infection, or epilepsy
☐	Syncope	Temporary loss of consciousness	Global cerebral hypoperfusion caused by cardiac, neurogenic, or orthostatic causes
☐	Paresthesia	Tingling, prickling sensation	Due to nerve injury, ischemia, or peripheral neuropathy (e.g., diabetes)
☐	Weakness	Loss of muscle strength	May be due to stroke (UMN lesion), neuropathy, myopathy, or NMJ disorders
☐	Ataxia	Loss of coordination	Damage to cerebellum or dorsal columns
☐	Aphasia	Inability to speak or comprehend language	Lesions in dominant hemisphere (Broca’s, Wernicke’s areas)

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❤️ Cardiovascular System

✅	Symptom	Definition	Why It Happens (Pathogenesis)
☐	Chest Pain	Discomfort in chest	Due to ischemia (angina, MI), pericarditis, aortic dissection
☐	Palpitations	Awareness of heartbeat	Arrhythmia, anxiety, caffeine, thyrotoxicosis
☐	Dyspnea	Shortness of breath	Pulmonary congestion, LV failure, low cardiac output
☐	Orthopnea	Breathlessness on lying down	Pulmonary venous return increases → fluid backs up into lungs
☐	PND	Sudden night-time breathlessness	Reabsorption of interstitial fluid in lungs during sleep
☐	Pedal Edema	Swelling of legs/feet	Right heart failure, hypoalbuminemia, renal causes
☐	Cyanosis	Bluish discoloration of skin	Due to deoxygenated hemoglobin > 5 g/dL in capillaries
☐	Syncope	Sudden loss of consciousness	Drop in cerebral perfusion due to arrhythmias, valve disease

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🫁 Respiratory System

✅	Symptom	Definition	Why It Happens (Pathogenesis)
☐	Cough	Sudden forceful expulsion of air	Irritation of airways from infection, allergens, or secretions
☐	Sputum	Expectoration  of mucus from lungs	Produced in response to inflammation/infection
☐	Hemoptysis	Coughing up blood	Bronchial vessel rupture due to TB, cancer, bronchiectasis
☐	Wheeze	High-pitched breath sound	Bronchial narrowing in asthma or COPD
☐	Stridor	Harsh inspiratory sound	Upper airway obstruction (e.g., foreign body, croup)
☐	Dyspnea	Difficulty breathing	Reduced oxygen exchange or airflow obstruction
☐	Pleuritic chest pain	Sharp pain on deep breathing	Inflammation of pleura (pleuritis, PE)

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🍽️ Gastrointestinal System

✅	Symptom	Definition	Why It Happens (Pathogenesis)
☐	Nausea/Vomiting	Urge or act of expelling gastric contents	Stimulated by vomiting center (toxins, GI irritation, ICP)
☐	Anorexia	Loss of appetite	Cytokine response in infection, malignancy, or GI irritation
☐	Abdominal Pain	Pain in the abdomen	Stretch, inflammation, or ischemia of viscera
☐	Diarrhea	Frequent, loose stools	Increased intestinal motility, secretions (infection, IBS)
☐	Constipation	Infrequent, hard stools	↓ Motility, dehydration, hypothyroidism, obstruction
☐	Dysphagia	Difficulty in swallowing	Obstruction, neurological lesion, esophageal motility disorder
☐	Heartburn	Burning chest pain	Acid reflux irritating esophagus (GERD)
☐	GI bleeding	Blood in vomit or stool	Ulcers, varices, carcinoma, hemorrhoids

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🧬 Renal / Genitourinary System

✅	Symptom	Definition	Why It Happens (Pathogenesis)
☐	Dysuria	Pain during urination	UTI, urethritis, inflammation of mucosa
☐	Frequency	Increased urge to urinate	Bladder irritation or reduced capacity
☐	Urgency	Sudden strong urge to urinate	Detrusor instability, cystitis
☐	Hematuria	Blood in urine	Glomerular damage, stones, cancer
☐	Oliguria	<400 mL/day urine output	AKI, dehydration, obstruction
☐	Incontinence	Involuntary urine leakage	Stress, overflow, neurogenic bladder
☐	Flank pain	Pain in loin area	Stone, pyelonephritis, trauma

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🧠 Endocrine System

✅	Symptom	Definition	Why It Happens (Pathogenesis)
☐	Weight Loss	Unintended loss of weight	↑ Metabolism (hyperthyroid), malignancy, DM
☐	Weight Gain	Unintended gain	Hypothyroidism, Cushing’s syndrome
☐	Polyuria	Excess urination	Osmotic diuresis in DM, ↓ ADH in DI
☐	Polydipsia	Excess thirst	Dehydration due to polyuria
☐	Fatigue	Lack of energy	Hypothyroid, Addison’s, anemia
☐	Cold Intolerance	Sensitivity to cold	↓ Basal metabolic rate in hypothyroid
☐	Heat Intolerance	Overheating	↑ BMR in hyperthyroid

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🦴 Musculoskeletal System

✅	Symptom	Definition	Why It Happens (Pathogenesis)
☐	Joint Pain (Arthralgia)	Pain in joints	Inflammation (RA), cartilage wear (OA)
☐	Morning stiffness	Stiffness after waking	RA, spondyloarthritis (inflammatory)
☐	Muscle Cramps	Painful spasm of muscle	Electrolyte imbalance (low Ca/K), overuse
☐	Back Pain	Pain in lumbar region	Disc herniation, strain, spinal stenosis

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🧠 Psychiatric Symptoms

✅	Symptom	Definition	Why It Happens (Pathogenesis)
☐	Insomnia	Inability to sleep	Anxiety, depression, stress, stimulant use
☐	Depression	Persistent low mood and energy	Neurotransmitter imbalance (low serotonin)
☐	Anxiety	Excessive worry or fear	Overactive sympathetic system; GABA imbalance
☐	Delusions	False belief not based on reality	Psychotic disorders like schizophrenia
☐	Hallucinations	Perception without stimulus	Dopamine excess (schizophrenia, drugs)

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PATIENT HISTORY TAKING TEMPLATE

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🏥 PATIENT HISTORY TAKING TEMPLATE

(✅ Tick all that apply. ⬜ Leave blank if not applicable.)

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👤 IDENTIFICATION DATA

Name	_______________________
Age	______ yrs
Sex	⬜ Male ⬜ Female ⬜ Other
Marital Status	⬜ Single ⬜ Married ⬜ Widow ⬜ Divorced
Address	_______________________
Occupation	_______________________
Date of Admission	________________
Date of Examination	________________
IP/OP No.	________________
Informant	⬜ Patient ⬜ Relative ⬜ Friend ⬜ Attendant ⬜ Other: ___________
Reliability of Informant	⬜ Good ⬜ Fair ⬜ Poor

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🗣️ CHIEF COMPLAINT(S)

Symptom	Duration	Tick if present
⬜ Fever	____ days/weeks	⬜
⬜ Cough	____ days/weeks	⬜
⬜ Breathlessness	____ days/weeks	⬜
⬜ Chest Pain	____ days/weeks	⬜
⬜ Abdominal Pain	____ days/weeks	⬜
⬜ Vomiting	____ days/weeks	⬜
⬜ Headache	____ days/weeks	⬜
⬜ Weakness	____ days/weeks	⬜
⬜ Back Pain	____ days/weeks	⬜
⬜ Swelling	Site: ____________	⬜
⬜ Others (Specify)	__________________	⬜

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📜 HISTORY OF PRESENTING ILLNESS

• ⬜ Onset: ⬜ Sudden ⬜ Gradual
• ⬜ Duration: ____________
• ⬜ Progression: ⬜ Increasing ⬜ Decreasing ⬜ Static
• ⬜ Associated symptoms:
  ⬜ Nausea ⬜ Diarrhoea ⬜ Loss of appetite ⬜ Weight loss ⬜ Sweating
  ⬜ Radiation of pain: ______________
  ⬜ Aggravating Factors: ____________
  ⬜ Relieving Factors: ____________
• ⬜ Treatment taken: ⬜ Yes ⬜ No
  If yes, specify: ________________________
• ⬜ Similar complaints in the past: ⬜ Yes ⬜ No

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🕰️ PAST MEDICAL HISTORY

Condition	Present	Duration	Treatment
⬜ Hypertension	⬜	______	__________
⬜ Diabetes Mellitus	⬜	______	__________
⬜ Tuberculosis	⬜	______	__________
⬜ Asthma/COPD	⬜	______	__________
⬜ Seizures	⬜	______	__________
⬜ Jaundice	⬜	______	__________
⬜ Surgery (Specify): ________	⬜	______	__________
⬜ Hospitalizations	⬜	______	__________
⬜ Others: _____________	⬜	______	__________

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🧬 FAMILY HISTORY

Disease	Present	Relationship
⬜ Hypertension	⬜	__________
⬜ Diabetes Mellitus	⬜	__________
⬜ Heart Disease	⬜	__________
⬜ Stroke	⬜	__________
⬜ Cancer	⬜	__________
⬜ Genetic Disorders	⬜	__________
⬜ TB	⬜	__________
⬜ Others: _______________	⬜	__________

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🧠 PERSONAL HISTORY

Item	Details
Diet	⬜ Veg ⬜ Non-Veg ⬜ Mixed
Appetite	⬜ Normal ⬜ Reduced ⬜ Increased
Bowel Habits	⬜ Normal ⬜ Constipation ⬜ Diarrhea
Bladder Habits	⬜ Normal ⬜ Frequency ⬜ Dysuria
Sleep	⬜ Normal ⬜ Disturbed ⬜ Insomnia
Addiction	⬜ Smoking ⬜ Alcohol ⬜ Tobacco ⬜ Drug abuse
Sexual History	⬜ Normal ⬜ Issues (Specify): __________
Occupation-related Exposure	⬜ Yes ⬜ No (If yes, specify): _________

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♀️ OBSTETRIC & GYNAECOLOGICAL HISTORY (If applicable)

Parameter	Details
Menarche Age	______ yrs
Cycle	⬜ Regular ⬜ Irregular
LMP	__________
Contraception	⬜ Yes ⬜ No (Type: ________)
Gravida	G:___ P:___ L:___ A:___
Obstetric Complications	⬜ Yes ⬜ No
Menopause	⬜ Pre ⬜ Post (Age: ____ yrs)

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💉 IMMUNIZATION HISTORY (if child or relevant)

Vaccine	Received	Age
⬜ BCG	⬜	___
⬜ OPV/DPT	⬜	___
⬜ MMR	⬜	___
⬜ Hepatitis B	⬜	___
⬜ COVID-19	⬜	___
⬜ Others: ____________	⬜	___

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⚠️ DRUG HISTORY

Drug Name	Indication	Duration	Side Effects
__________	__________	______	____________
⬜ Known Drug Allergies: __________________

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🏠 SOCIOECONOMIC HISTORY

Parameter	Detail
Socioeconomic status	⬜ Low ⬜ Middle ⬜ High
Living conditions	⬜ Pucca ⬜ Kutcha ⬜ Crowded
Water source	⬜ Tap ⬜ Borewell ⬜ Open
Toilet facility	⬜ Present ⬜ Absent
Education	⬜ Illiterate ⬜ School ⬜ Graduate
Monthly Income	₹ __________

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🧍‍♂️ GENERAL PHYSICAL EXAMINATION

Parameter	Value	Abnormalities
Built	⬜ Normal ⬜ Thin ⬜ Obese
Nourishment	⬜ Adequate ⬜ Inadequate
Pallor	⬜ Yes ⬜ No
Icterus	⬜ Yes ⬜ No
Cyanosis	⬜ Yes ⬜ No
Clubbing	⬜ Yes ⬜ No
Lymphadenopathy	⬜ Yes ⬜ No
Edema	⬜ Yes ⬜ No
Height	______ cm
Weight	______ kg
BMI	______ kg/m²

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🔍 VITAL SIGNS

Vital	Value
Temperature	______ °C
Pulse	______ /min, ⬜ Regular ⬜ Irregular
Respiratory Rate	______ /min
BP	______ mmHg
SpO₂	______ % on ⬜ Room air ⬜ Oxygen
RBS	______ mg/dL

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🔎 SYSTEMIC EXAMINATION

1. CVS (Cardiovascular System)

Finding	Present
⬜ Apex beat visible/palpable	⬜
⬜ Thrill	⬜
⬜ S1/S2 Normal	⬜
⬜ Murmur (Specify)	⬜

2. RS (Respiratory System)

Finding	Present
⬜ Trachea central/deviated	⬜
⬜ Breath sounds: ⬜ Vesicular ⬜ Bronchial
⬜ Added sounds: ⬜ Crepitations ⬜ Rhonchi

3. GI (Abdominal)

Finding	Present
⬜ Shape: ⬜ Flat ⬜ Distended
⬜ Tenderness	⬜
⬜ Guarding/Rigidity	⬜
⬜ Organomegaly: ⬜ Liver ⬜ Spleen
⬜ Bowel sounds present	⬜

4. CNS (Central Nervous System)

Finding	Status
Higher functions	⬜ Normal ⬜ Abnormal
Cranial Nerves	⬜ Normal ⬜ Abnormal
Motor	⬜ Normal ⬜ Weakness
Sensory	⬜ Intact ⬜ Loss
Reflexes	⬜ Normal ⬜ Exaggerated
Gait	⬜ Normal ⬜ Ataxic ⬜ Hemiplegic

5. Musculoskeletal

Finding	Present
⬜ Joint swelling	⬜
⬜ Tenderness	⬜
⬜ Deformities	⬜
⬜ Range of motion	⬜ Full ⬜ Restricted

6. Skin

Finding	Present
⬜ Rash	⬜
⬜ Ulcers	⬜
⬜ Pigmentation	⬜
⬜ Itching	⬜

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🧪 PROVISIONAL DIAGNOSIS

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📋 DIFFERENTIAL DIAGNOSIS

Dx	Features Supporting	Features Against
1.
2.

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📌 PLAN OF MANAGEMENT

Aspect	Plan
Investigations	__________________________
Initial Management	__________________________
Medications	__________________________
Referral (if any)	__________________________

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