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Temperature : B/P : RR : Pulse :

Personal History
Name
Sex
Residency Special Habits Occupation Menstrual History Age Smoking Alcohol intake Menarche: Marital Status Date of admission
Sexual Behaviour Others

Children

Common Disease Menopause:

Current cond. :

Complaints + Negative Data Pain


Swelling Disturbance of Function
Site : Characters : Radiation : Onset : Site : Size : Other Swelling : Onset : Dyspnea Dysphagia Horseness of voice Dizziness
Nervous Palpitation Heat Intolerance Exopthalmus Menstrual Problem Osteoporosis

Pressure manifestation

Course: Duration: Association: Increase@ decrease : Course: Duration: Apparent cause: Increase@ decrease : Ear Pain Horners Syndrome Others
Diarrhea Polyuria Sweaty skin Myopathy Fine Tremors Others

Toxic Manifestation

Past History
(Similar attack, common disease, drug allergy @intake, Previous operation and radiotherapy to neck)

Similar attack : Common Disease : Drug allergy @ intake : Previous Operation @ radiotherapy of Neck :

Family History

Examination
General Examination Inspection Eyes Inspection swelling
Swelling Skin Overlying Special signs
Exopthalmous Lid lag Jaundice Site : Size : Shape : Skin Overlying :
Failure of convergence Others Move up w deglutition w Protrussion of tongue Pulsation Others

Palpation
Swelling Carotid Artery Lymph Nodes Trachea Percussion Auscultation
Warmth: Tenderness : Surface edge : Consistency : Mobility :

Investigation
Ultrasound Thyroid Function Test Radiological Investigation Other Lab investigation
(Hb%, urine and stools analysis , blood sugar and urea)

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