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PROTOCOL FOR HISTORY AND CLINICAL EXAMINATION

CHRISTIAN MEDICAL COLLEGE, LUDHIANA

Name……………………..Sex……………Age………….Occupation…….Address…………
……
Date of Admission…………….Date of Examination……..
Identification mark…………Married/Single………Widow/Widower………..Insurance
status……

INFORMANT: NAME / RELATION

THE HISTORY: Chief complaints:- Relate symptoms to your time of examination, (a)
reason for coming to the hospital in patient’s own words, (2) duration of these complaints
– to be presented in chronological order.
HISTORY OF PRESENT ILLNESS:- Elaborate on each chief complaint describing the
symptoms in full and giving associated symptoms. Indicate onset and progression or
regression of symptoms and new symptoms if any..
SYSTEM REVIEW (TEMPORAL PROFILE): Describe the current status
Ask the patient specific relevant positive and negative symptoms of each system in
relation to the above chief complaints. Start with the system affected followed by other
systems.
The following points of systemic history will serve as guidelines for the history and for
eliciting details of chief complaints.
General:- Fever, chills, rigors, type of fever, diurnal variation, associated features
1. Cardiovascular:-
(a) Breathlessness:– (on heavy exertion, moderate exertion, exertion on
accustomed work at rest), progression, paroxysmal nocturnal dyspnoea (PND),
orthopnoea, swelling of feet or face, or around the eyes; sacrum or of any other part of
the body .
(b) Anginal pain:– on how much exertion, duration, frequency of attacks, duration of
each
attack, whether relieved by rest and/or drugs. Any worsening of angina in the recent
past. Any history of previous myocardial infarction or embolic phenomena.
(c) Palpitation:– whether sudden in onset or gradual in onset, in attacks, at rest or
on
exertion, frequency
2. Respiratory:- Cough – whether dry or moist, sputum type, whether mucoid,
purulent, frothy and pink, quantity, and diurnal or postural variation, chest pain–type,
site, radiation, relationship to breathing and posture. Breathlessness, wheezing,
hemoptysis – frequency, quantity, weight loss, night sweats
3. Gastrointestinal:- Appetite, weight loss, abdominal pain – site, type, radiation,
aggrevating or relieving factors relation to meals, any abdominal mass, any change in
bowel habits.
Vomiting – number, quantity, content of vomitus, preceded bynausea, projectile or not.
Abdominal distension, flatulence, intolerance to certain types of food, heart burn.
Dysphagia for solids, semisolids or liquids, progression, Hematemesis – frequency ,
amount of blood, any abdominal pain or any drug taken before the episode, malena –
qualtity, frequency
Jaundice – progression, fluctuating, colour of urine and stool, any itching.
Diarrhoea – frequency, any blood or mucus, any abdominal cramps, tenesmus, piles,
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fresh bleeding rectum, undigested food particles in stools.

4. Urinary:- Colour of urine frothing or urine, frequency of micturition, amount of
urine whether normal, oliguria or polyuria or anuria, hematuria, nocturia, loin pain, fever
with chills, burning on micturition any history of retention or incontinence of urine, pyuria,
passing of gravel in urine, renal colic, oedema feet or puffiness of face
5. Central Nervous System symptoms relating to higher functions:-
Headache-type, site, continuous throbbing or non-throbbing, any diurnal/posturnal
variations, whether associated with nausea or vomiting.
Any alteration in sensorium – sudden or gradual – seizures – focal or generalized or
focal becoming generalized – duration, any aura, any post-ictal paresis. Any impairment
of memory or fall in intellectual functions, demential, speech disturbances, aphasia. Any
delusions, hallucinations.

Cranial nerves:- Any history of parosmia, anosmia, diplopia, squint or drooping of eye
lids. Numbness of face, difficulty in chewing or biting Any facial deviation. Inability to
close the eyes, tinnitus, deafness, Dysphagia, dysarthria, nasal regurgitation, impaired
tongue movements, wasting, fasciculations of tongue.
Motor system:- Any wasting, abnormal movements, weakness of upper limb – proximal
weakness, difficulty in lifting hands above shoulder, difficulty in combing hair, tying
turbans etc. distal weakness, difficulty in putting buttons etc. Lower limbs – difficulty in
climbing stairs – getting up from squatting position, buckling of knees, tripping of toes,
unsteadiness of gait, co-ordination – whether worse at night or with eye closure (sensory
vs cerebellar ataxia)
Sensory system:- Loss of pain, temperature, numbness, paraesthesia, hyperalgesia,
root pain.
Autonomic nervous system:- Any bladder/bowel disturbances, postural giddiness,
change in sweating, impotence.
6. Endocrine:- Excessive weight gain or loss, tremors, polyuria, increase in
appetite, libido, impotence, menstrual disturbance, asthenia, pigmentation, goiter,
palpitation, eye prominence, hypersomnia, change in voice, bowel habits, delayed
wound healing furuncles / carbuncles
7. Locomotor:- Weakness, swelling, pain in joints, skin rash, morning stiffness.
8. Any history of bleeding disorder:- Bleeding from gums, petechial or purpuric
spots, ecchymoses, easy bruising, bleeding from multiple sites, prolonged bleeding from
trivial wounds.
9. Etiological history:- The questionnaire in this category will depend upon the
major etiological diagnosis considered based on chief complaints and history of present
illness. A few examples are given below.
CVS:- History suggestive of rheumatic fever i.e. fever, joint pain any subcutaneous
nodules etc. in valvular heart disease
RS:- History suggestive of tuberculosis – weight loss, evening rise of temperature, night
sweats, occupation, history of exposure to organic dusts in pneumoconiosis
CNS:- History of ear discharge, head injury in pyogenic meningitis. History of intrathecal
injections or ingestion of kesari dal, trauma etc., in myelopathies.
Others:- History of suggestive of any underlying malignancies (make your own list in
each system for syndromes).
10. Past History:- (i) Injuries and any past history (ii) allergy venereal exposure,
history of drug allergy particularly antibiotics, NSAIDs etc. must always be sought e.g.
Penicilline, Sulfonamide etc. (iii) Previous medical history – including immunization
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status e.g. Tetanus, Hepatitis, thyroid etc. (iv) operations, accidents (v) previous
hospitalizations and (vi) blood transfusions.
11. Menstrual history:- Amenorrhoea, oligomenorrhoea, metrorrhagia,
menorrhagia, and post menopausal bleeding
12. Obstetrical History:- Complications during pregnancies if any (mention in
chronological order with dates), pregnancies, dates, deliveries.
13. Family History:- Diabetes mellitus, Hypertension, ischaemic heart disease,
bleeding disorders, tuberculosis.
14. Social – personal:- Occupation, Economic status, number in family, location of
home, education. Use of drugs, alcohol, tobacco, etc. Previous residence in other parts
of India or abroad, recent trvel
15. Dietary history:- If adequate of not

GENERAL EXAMINATION: Does the patient appear well or ill ?

Consciousness (fully conscious, drowsy, stuporose, comatose, delirious) asterixis if any,
Build and nutrition (look for signs or nutritional deficiency)
Evidence of recent weight loss and/or dehydration
Pallor (anemia), clubbing, koilonychias, cyanosis (peripheral, central), jaundice (mild,
moderate, severe), lymphadenopathy (mention details), oedema (pitting, non-pitting and
distribution of edema)
Vital signs – pulse rate, respiratory rate and blood pressure and temperature
Skin – Rash, pigmentation, purpura, nodules, café-au-lait spots deformities (obvious and
relevant ones)

A. CARDIOVASCULAR SYSTEM:- Radial pulse rate, rhythm, force, character,

state of arterial wall. Check for pulse asynchrony, if any, Compare pulses on both sides.
Examine finger nails and lips for capillary pulsations. BP-jugular venous pressure,
carotid pulsations, suprasternal pulsations (stick to this order)
Inspection:- Shape of chest, any bulging of precordium, position of apex beat, other
precordial pulsations, distended veins on the chest wall.
Palpation:- Localise apex beat precisely (in relation to Lt MCL) impulse, tapping,
heaving or hyperdynamic. Examine for thrills if present systolic or diastolic. Parasternal
heave, palpable pulmonary valve closure, pulmonary artery pulsations. Tracheal tug,
palpable S1 S2 S3 or S4.
Percussion:- Map out cardiac borders
Auscultation:- First sound – loud/normal/soft. Second – loud/normal/soft and splitting
abnormal sound (1) pericardial friction rub, position, character, relation to sounds (2)
murmurs, position or maximum intensity, character, position in cardiac cycle, if
conducted – direction, effect of posture and respiration, pitch grading 1-6 (3) gallop
rhythm (learn to depict palpatory and auscultatory findings diagrammatically).
B. RESPIRATORY SYSTEM:- Respiratory rate, character (thoracic,
abdominothoracic). Any special type of breathing (acidotic breathing, cheynestokes
breathing etc) measure chest expansion as taught
Inspection:- Shape of the chest, symmetry (note any curvature or the spine).
Respiratory movements compare the two sides. Any inspiratory recession. Any
prominent veins, scar marks over the chest wall. Note direction of blood flow in the
veins. Any paradoxical movement of the diaphragm
Palpation:- Confirm the findings of inspection, crowding of ribs, chest movement (total
lung expansion, differential lung expansion; position of trachea, apex beat; tactile vocal
fremitus, lower intercostals space tenderness, palpable rales, rhonchi, rub.
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Percussion:- Anteriorly (clavicular, intercostals space, liver/cardiac, tidal percussion,

shifting dullness. Posteriorly (suprascapular, inter scapular, infra scapular), axilla
(axillary, infra axillary). Define Traube’s space (hyper resonance is significant only to
localized and/or unilateral)
Ausculation:- Compare in (1) breath sounds (bronchial or vesicular) and their intensity
(2) vocal resonance – diminished or increased, bronchophony, whispering pectoriloquy
(3) adventitious crepitations, post tussive crepitations (occasionally one has to look for
post tussive suction and succusions splash).
C. ABDOMEN:- (Auscultate abdomen first in case of acute abdomen
Inspection:- Shape, describe any swelling, condition of skin, any dilated veins, scars,
state of umbilicus, movements with respirations, visible peristalsis. Fullness in flanks (in
male patients whenever possible examine the genitalia). Hernial orifices (liver = 12cms)
Palpation:- Superficial – for tenderness, guarding, rigidity and hyperaesthesia deep –
for tenderness and rebound tenderness, palpable systematically for liver, spleen,
kidneys, other masses, bladder etc. Look for fluid thrill.
Percussion:- Define extent of liver and splenic dullness, shifting dullness. Character of
note over a swelling. Determine vertical span of liver.
Auscultation:- Bowel sounds, gastric succusion splash, bruit, splenic friction rub.
Rectal examination and vaginal examination (in married women with their consent).
D. NERVOUS SYSTEM:- HIGHER FUNCTIONS
While taking history note patients intelligence, memory, attention, facial expression,
speech, any asymmetry of face etc. Also note handedness.
Higher functions:- (mention as clearly as possible)
Handedness
Consciousness
Memory
Calculation: Simple / complex
Abstract thinking; judgment
Mood
Insight
Speech

Learn applied anatomy of cranial nerves

I. Olfactory nerve : Perception of smell / identification of smell
Check one nostril at a time. Do not use strong and irritant substances
II. Optic nerve:- Visual acuity
Field of vision (confrontation method)
Colour vision
Pupils – size, shape
Fundus
III,IV & VI
Exophthalmos / enopthalmos / strabiosmus
Ptosis
Eye movements – Saccadic eye movements
Pursuit eye movements
Individual extraocular muscles
Reaction to light, accommodation
Nystagmus
V Sensation 1. Touch
2. Pinprick over face
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3. Temperature
Corneal reflex Direct
Consensual
Look for deviation of jaw on opening the mouth
Lateral movements of jaw
Masseters and Temporales – on opening the mouth
Jaw jerk
VII Corneal reflex (as above)
Eye closure
Forehead wrinkling
Angle of the mouth (any deviation)
Whistling and blowing
Taste ant. 1/3 of tongue (use sugar / salt)
VIII auditory acuity – to whispered voice – if there is diminished hearing
Do (Weber’s test / Rinne’s test), Ear discharge
IX & X Movements of soft palate on saying ‘Ah’
Swallowing
Phonation
Gag reflex
IX Trapezius
Strenocleido mastoid (atrophy, power)
XII Atrophy of tongue
Fasciculations of tongue
Deviations of tongue on protrusion of tongue
III. Motor system (learn about myotomes)
Test all groups of muscles (neck, upper limb, trunk and lower limb muscle)
Compare both sides
Look for abnormal position of limbs
Involuntary movements (including asterixis)
Wasting of muscles
Fasciculations (in a resting muscle)
Measure the muscle girth
Tone
Power (grade of power 0-5)
Co-ordination of movement
Gait

IV Reflexes (grading 0 = absent; 1 = normal’ 2 = brisk, normal but more than 1,

3 = very brisk (exaggerated), 4 – clonus
Deep tendon reflexes: Biceps (C5,6)
Triceps (C6,7)
Supinator (C5,6)
Knee jerk (L2,3,4)
Ankle jerk (S1,S2)
Look for clonus – Patellar / ankle
Note:- Clonus should be sustained
Superficial Reflexes: Abdominal (T7-12)
Cremasteric (L1,2)
Plantar (L5,S1)
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IV. Sensory system (Learn about dermatomes and variations patterns of sensory
loss)
a) Superficial sensations
Test – Face, Upper limbs, Trunk, Lower limbs - According to dermatomes
1. Light touch
2. Pain
3. Temperature
Test for hyperaesthesia / hyperalgesia
If radicular sensory loss, give or draw all areas affected with reference to dermatomes
Dissociated sensory loss
Trophic ulcers
Neuropathic joints
b) Deep sensations
1. Deep pressure (squeeze the calves) – Hyperalgesia / analgesia
2. Position sense, Romberg’s test
3. Joint sense
4. Vibration sense (with tuning fork)
c) Cortical sensations (to be tested only if primary sensations are intact and patient
is conscious)
1. Stereognosis
2. Barognosis
3. Figure writing
4. Sensory exinction (Inattention)
5. Apraxia
6. Two point discrimination
V. CEREBELLAR SYSTEM
Nystagmus – look for direction of fast component) – horizontal / vertical
Finger to finger
Finger nose test
Rapid alternating movements
Heel knee heel test
Walking tandem
Gait and stance
VII EXTRAPYRAMIDAL SYSTEM
Facies
Tremors
Rigidity
Other involuntary movements (describe rate / rhythm)
VIII Signs of meningeal irritation
Neck rigidity
Kerning’s sign
Brudzinski’s sign
VIIIA Neck movements
Bruit over head, spin / carotids
IX Autonomic Nervous System
Horner’s syndrome (cliospinal reflex)
Urinary bladder (percuss and palpate)
Anal sphincter tone
Sweating
Disturbance of temperature
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Postural hypotension
NERVOUS SYSTEM (short examination to be done when patient has no symptoms
referable to the nervous system.
Pupils – size, reaction to light, and accommodation, eye movements, observe other
cranial nerves VII, XII.
Reflexes – Biceps, supinator, triceps, abdominal, cremasteric, knee, ankle, plantar
(All students must constantly revise anatomy of cranial nerves sympathetic nervous
system, spinal cord, peripheral nerves. They must also learn all pathways, reflex arcs,
dermatomes and major muscle innervations and actions as well as methods of testing
various muscles)
1. Spine:- Kyphosis, scoliosis, tenderness, deformity, movements of spine,
paravertebral spasm and mass.
2. Thyroid:- Inspection, palpation and auscultation (refer K.Das)
3. Head and neck:- Examination of scalp, face, ears, periarticular swelling,
crepitus
4. Musculoskeletal system and joints:- Joint swelling warmth, tenderness, fluid,
movements, skeletal deformity (have an orderly approach)
5. Breasts:- (in female patients with consent) inspection and palpation (refer
K.Das)
Possible diagnosis:- (placing the most likely one first)
1. Syndrome diagnosis
2. Anatomical diagnosis
3. Etiopathological diagnosis
(All entries must be dated and time recorded)
LABORATORY DATA:-
Findings, including routine urine, stool, Hb, white count (familiarize yourself with other
tests), CXR, Ultrasound, Echocardiogram, ECG, CT Scan etc
Differential diagnosis:- (common ones – based on history, physical examination and Lab
tests)
FINAL DIAGNOSIS
Progress Notes:- i.e. changes in clinical state, fresh information, changes in treatment
Use ‘SOAP’ pattern S = Subjective
O = Objective
A = Assessment, and
P = Plan – Diagnostic and Therapeutic
Discussion of case:- Points leading to diagnosis, etiology, pathologic explanation of
symptoms and signs, comments on progress, and on treatment given.
N.B:_ Sign your full name whether you make a note in a chart
Basic Text Book:- Clinical Methods by Hutchison and Hunter (latest edition)
Reference Books
Clinical Diagnosis – MacLeod / Chamberiain
Examination of the Nervous System – Mayo Clinic
Clinical Neurology (Brain) edited by Bannister or Bieckerstaff
Text Book of Medicine – Kumar & Clark, Davidson or API (latest edition only)
*BUY A GOOD MEDICAL DICTIONARY

Medical examination kit

(a) Stethescope (b) Reflex hammer
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(c) Tape measure (g) Coins

(d) Tuning fork (h) Sugar / salt for checking taste
(e) Torch light (i) Clove oil / Asafoetida for smell
(f) Pins – cotton, dividers (j) Tongue depressor / swab sticks
Please bring this every time you come to medical wards
USE A SEPARATE CASE DIARY FOR WORKING UP PATIENTS
Stick to this standard format. Be regular in your work habits
Approach to an unconscious patient
1. Maintain a record of vital signs
2. Ensure an adequate and patent airway
3. note all external injuries, bruises, abrasions and fracture, if any – avoid painful
manoeuvres
4. Grade coma (drowsy, stuprose, comatose, delirious)
5. Movement of limbs – spontaneous or on command
6. Involuntary movements, convulsions, spasms, asterixis
7. Posture (decerebrate, decorticate, universal flexion or opisthotonic) – Conjugate
deviation of eyes
8. Pupils (size, shape, reaction in light)
9. Doll’s eye movements
10. Cold caloric test (ensure there is no perforation of the ear drum)
11. Note – paresis or paralysis of various parts of the body including face (on painful
stimuli) – this includes cranial nerve and motor system examination including reflexes
12. Optic fundi – signs of meningeal irritation
PROBLEM ORIENTED MEDICAL RECORD (POMR)
Principle – Individual solution of each definite clinical problem. Data Base – patient’s
history, physical examination and lab findings. Patient’s profile – summary of socio-
economic, health, education, family and bahavioural characteristics

COMPLETE PROBLEM LIST

Problem Active Inactive
1
2

Data Base Diagnosis Initial Outcome &

Patient and problems plan prognosis
Profile (new) if not recovered

Physical
findings

Lab data

NOTE FOR STUDENTS:

1. Should read Hutchison’s preferably a day before each lecture in Introductory
Course
2. Learn the meaning of all new terms

Dr.Mary John
Professor and Head
Department of Medicine. 7 /7/2014
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mj/sp