COMPREHENSIVE CASE SHEET FOR ALL SYSTEM DISORDERS

SECTION 1: IDENTIFICATION DATA

□ Name

□ Age

□ Sex

□ Hospital Registration Number

□ IP / OP Number

□ Date and Time of Registration

□ Date and Time of Admission

□ Referred From

□ Department

□ Consultant in Charge

□ Unit

□ Address

□ Contact Details

□ Occupation

□ Education Level

□ Socioeconomic Status

□ Marital Status

□ Insurance Details

□ Informant Name

□ Relationship to Patient

□ Reliability of Informant: □ Good □ Fair □ Poor

SECTION 2: CHIEF COMPLAINTS

Document in patient’s own words with duration.

□ Fever – duration

□ Pain – site – duration

□ Swelling – site – duration

□ Breathlessness – duration

□ Chest pain – duration

□ Cough – duration

□ Palpitations – duration

□ Syncope – duration

□ Vomiting – duration

□ Abdominal pain – duration

□ Altered bowel habits – duration

□ Burning micturition – duration

□ Reduced urine output – duration

□ Limb weakness – duration

□ Seizures – duration

□ Headache – duration

□ Joint pain – duration

□ Skin rash – duration

□ Weight loss – duration

□ Weight gain – duration

□ Fatigue – duration

□ Any other complaint

For each complaint clarify:

Onset

□ Sudden

□ Acute

□ Subacute

□ Insidious

Course

□ Progressive

□ Static

□ Relapsing

□ Episodic

□ Seasonal

Severity

□ Mild

□ Moderate

□ Severe

□ Disabling

□ ICU requiring

Aggravating factors

□ Exertion

□ Food

□ Posture

□ Stress

□ Cold exposure

□ Drugs

□ Infection

Relieving factors

□ Rest

□ Medications

□ Position change

□ Food

Diurnal variation

□ Morning

□ Evening

□ Night predominance

□ None

SECTION 3: HISTORY OF PRESENTING ILLNESS

Chronological detailed narrative

Initial symptom

Progression pattern

Functional limitation

Associated symptoms

Red flag events

Previous consultations

Investigations done

Treatment taken and response

Hospital admissions

ICU admissions

Procedures done

SECTION 4: SYSTEM-WISE SYMPTOM 

CARDIOVASCULAR

□ Chest pain – character – radiation – duration

□ Dyspnea – NYHA grading

□ Orthopnea

□ Paroxysmal nocturnal dyspnea

□ Palpitations

□ Syncope

□ Pedal edema

□ Claudication

□ Cyanosis

RESPIRATORY

□ Cough – dry / productive

□ Sputum – color – quantity

□ Hemoptysis

□ Wheeze

□ Dyspnea

□ Pleuritic pain

□ Tuberculosis contact

□ Occupational exposure

□ Smoking history

GASTROINTESTINAL

□ Dysphagia

□ Odynophagia

□ Reflux

□ Abdominal pain – site – relation to food

□ Vomiting

□ Hematemesis

□ Melena

□ Jaundice

□ Pruritus

□ Altered bowel habits

□ Tenesmus

□ Weight loss

GENITOURINARY

□ Dysuria

□ Frequency

□ Urgency

□ Nocturia

□ Hematuria

□ Flank pain

□ Reduced urine output

□ Frothy urine

□ Incontinence

NERVOUS SYSTEM

□ Headache

□ Seizures

□ Loss of consciousness

□ Limb weakness

□ Numbness

□ Speech difficulty

□ Visual disturbance

□ Memory impairment

□ Tremors

□ Gait imbalance

ENDOCRINE

□ Weight gain

□ Weight loss

□ Heat intolerance

□ Cold intolerance

□ Polyuria

□ Polydipsia

□ Polyphagia

□ Skin pigmentation

□ Striae

□ Voice change

□ Menstrual irregularities

MUSCULOSKELETAL

□ Joint pain

□ Morning stiffness – duration

□ Joint swelling

□ Redness

□ Deformity

□ Back pain

□ Muscle weakness

□ Muscle pain

HEMATOLOGICAL

□ Pallor

□ Easy bruising

□ Bleeding gums

□ Petechiae

□ Lymph node swelling

□ Recurrent infections

DERMATOLOGICAL

□ Rash

□ Photosensitivity

□ Oral ulcers

□ Alopecia

□ Skin tightening

□ Nodules

□ Ulcers

SECTION 5: PAST HISTORY

□ Hypertension – duration – control

□ Diabetes – duration – control

□ Coronary artery disease

□ Stroke

□ Chronic kidney disease

□ Chronic liver disease

□ Asthma

□ Tuberculosis

□ Thyroid disorder

□ Autoimmune disease

□ Malignancy

□ Surgery

□ Blood transfusion

□ ICU admission

SECTION 6: DRUG HISTORY

□ Antihypertensives

□ Antidiabetics

□ Antiplatelets

□ Anticoagulants

□ Steroids

□ Immunosuppressants

□ Statins

□ Hormonal therapy

□ Antiepileptics

□ Alternative medicine

Compliance

□ Regular

□ Irregular

□ Poor

Adverse drug reactions

□ Yes

□ No

SECTION 7: FAMILY HISTORY

□ Hypertension

□ Diabetes

□ Stroke

□ Sudden cardiac death

□ Genetic disorders

□ Autoimmune disease

□ Malignancy

□ Consanguinity

SECTION 8: PERSONAL HISTORY

Diet

□ Vegetarian

□ Mixed

□ High salt

□ High fat

Appetite

□ Normal

□ Reduced

□ Increased

Sleep

□ Adequate

□ Disturbed

Bowel

□ Regular

□ Constipation

□ Diarrhea

Bladder

□ Normal

□ Abnormal

Addictions

□ Smoking – pack years

□ Alcohol – quantity – duration

□ Tobacco

□ Substance abuse

Physical activity

□ Sedentary

□ Moderate

□ Heavy

Occupational hazards

SECTION 9: GENERAL EXAMINATION

Built

□ Well built

□ Moderately built

□ Poorly built

Nourishment

□ Good

□ Moderate

□ Poor

□ Obese

□ Cachectic

Hydration

□ Adequate

□ Mild dehydration

□ Moderate dehydration

□ Severe dehydration

Pallor

□ Absent

□ Present – mild

□ Moderate

□ Severe

Location

□ Conjunctiva

□ Nail beds

□ Palmar creases

Icterus

□ Absent

□ Present

Location

□ Sclera

□ Skin

□ Hard palate

Cyanosis

□ Absent

□ Central

□ Peripheral

Location

□ Lips

□ Tongue

□ Nail beds

Grade

□ Mild

□ Moderate

□ Severe

Clubbing

□ Absent

□ Grade I

□ Grade II

□ Grade III

□ Grade IV

Lymphadenopathy

□ Absent

□ Present

Site

□ Cervical

□ Axillary

□ Inguinal

□ Generalized

Size

□ <1 cm

□ 1–2 cm

□ >2 cm

Tenderness

□ Present

□ Absent

Consistency

□ Soft

□ Firm

□ Hard

Mobility

□ Mobile

□ Fixed

Edema

□ Absent

□ Present

Type

□ Pitting

□ Non pitting

Grade

□ 1+

□ 2+

□ 3+

□ 4+

Location

□ Feet

□ Ankles

□ Legs

□ Sacral

□ Periorbital

□ Generalized

Vital Signs

Pulse – rate – rhythm – volume – character

Blood pressure – right arm – left arm – supine – standing

Respiratory rate

Temperature

SpO2

BMI

SECTION 10: SYSTEMIC EXAMINATION

Cardiovascular

Inspection

Palpation

Percussion

Auscultation

Peripheral pulses

Respiratory

Inspection

Palpation

Percussion

Auscultation

Abdominal

Inspection

Palpation

Percussion

Auscultation

Neurological

Higher mental functions

Cranial nerves

Motor system – bulk – tone – power

Reflexes

Sensory system

Cerebellar signs

Gait

Musculoskeletal

Inspection

Palpation

Range of motion

Deformities

SECTION 11: FUNCTIONAL ASSESSMENT

□ NYHA

□ Glasgow Coma Scale

□ Modified Rankin

□ Child Pugh

□ MMSE

□ ECOG

□ DAS28

SECTION 12: INVESTIGATIONS

Laboratory

□ Complete blood count

□ ESR

□ CRP

□ Liver function

□ Renal function

□ Electrolytes

□ Blood sugar

□ HbA1c

□ Lipid profile

□ Thyroid profile

Imaging

□ X ray

□ Ultrasound

□ CT

□ MRI

□ Echocardiography

□ ECG

Special tests as per system

□ Autoimmune markers

□ Tumor markers

□ CSF analysis

□ Biopsy

□ Genetic testing

SECTION 13: PROVISIONAL DIAGNOSIS

SECTION 14: DIFFERENTIAL DIAGNOSIS

1

2

3

SECTION 15: FINAL DIAGNOSIS WITH STAGING

SECTION 16: MANAGEMENT PLAN

□ Medical management

□ Surgical management

□ Interventional

□ ICU care

□ Rehabilitation

□ Lifestyle modification

□ Follow up schedule

SECTION 17: PROGNOSIS

□ Favorable

□ Guarded

□ Poor