Division: __________ Ward: __________ Bed: _________ Case No. ___________
Chest wall: 1.normal 2.barrel chest 3.prominence or retraction:
( left________right_________Precordial prominence__________)
Percussion pain over sternum 1.No 2.Yes
Breast: 1.Normal 2.abnormal _______________________________________ Lung: Inspection: respiratory movement 1.normal 2.abnormal_____________ Palpation: vocal tactile fremitus:1.normal 2.abnormal _______________
pleural rubbing sensation:1.no 2.yes______________________
Subcutaneous crepitus sensation:1.no 2.yes________________ Percussion:1. resonance 2. Hyperresonance &location_____________
3 Flatness&location_________________________________
4. dullness & location:_______________________________ 5.tympany &location:_______________________________ lower border of lung: (detailed percussion in respiratory disease)
midclavicular line : R:_____intercostae L:_____intercostae midaxillary line: R:______intercostae L:_____intercostae scapular line: R:______intercostae L:_____intercostae movement of lower borders:R:_______cmL:__________cm
Auscultation: Breathing sound : 1.normal 2.abnormal _______________ Rales:1.no 2.yes__________________________________ Heart: Inspection:Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuse
Subxiphoid pulsation: 1.no 2.yes
Location of apex beat: 1.normal 2.shift (______ intercosta,
distance away from left MCL______cm)
Palpation:
Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsation
Thrill:1.no 2.yes(location:___________ phase:_________________) Percussion: relative dullness border: 1.normal 2.abnormal Right(cm) Anterior midline Left(cm) II III IV V (Distance between Anterior Medline and left MCL _______cm) Auscultation: Heart rate:___bpm Rhythm:1.regular 2.irregular_______ Heart sound: 1.normal 2.abnormal________________________ Extra sound: 1.no 2.S3 3.S4 4. opening snap
P2_________ A2_________Pericardial friction sound:1.no 2.yes
Murmur: 1.no 2.yes (location____________phase_____________
quality______intensity________ transmission___________
effects of position_________________________________
effects of respiration______________________________
Peripheral vascular signs:
VI
Division: __________ Ward: __________ Bed: _________ Case No. ___________
1.None 2.paradoxical pulse 3.pulsus alternans 4. Water hammer pulse
5.capillary pulsation 6.pulse deficit 7.Pistol shot sound 8.Duroziez sign
Abdomen:
Inspection: Shape: 1.normal 2.protuberance 3.scaphoid 4.frog-belly Gastric pattern 1.no 2.yes Intestinal pattern 1.no 2.yes Abdominal vein varicosis 1.no 2.yes(direction:______________ ) Operation scar1.no 2.yes ________________________________ Palpation: 1.soft 2. tensive (location:____________________________)
Tenderness: 1.no 2.yes(location:_______________________) Rebound tenderness:1.no 2.yes(location:________________) Fluctuation: 1.present 2.abscent Succussion splash: 1.negative 2.positive
Liver:_______________________________________________ Gallbladder: __________________Murphy sign:____________ Spleen:______________________________________________ Kidneys:____________________________________________ Abdominal mass:______________________________________ Others:______________________________________________
Percussion: Liver dullness border: 1.normal 2.decreased 3.absent
Upper hepatic border:Right Midclavicular Line ________Intercosta Shift dullness:1.negative 2.positive Ascites:_____________degree Pain on percussion in costovertebral area: 1.negative 2.positve ____
Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis
4.absence Gurgling sound:1.no 2.yes
Vascular bruit 1.no 2.yes (location_____________________)
Genital organ: 1.unexamined 2.normal 3.abnormal Anus and rectum: 1.unexamined 2.normal 3.abnormal Spine and extremities:
Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis 3.scoliosis)
3.Tenderness(location______________________________) Extremities: 1.normal 2.arthremia & arthrocele (location_________________) 3.Ankylosis (location__________) 4.Aropachy: 1.no 2.yes
5.Muscular atrophy (location_______________________)
Neurological system:1.normal 2.abnormal_______________________________
_____________________________________________________________________
Important examination results before hospitalized
VII
Division: __________ Ward: __________ Bed: _________ Case No. ___________
___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Summary of the history:______________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Initial diagnosis:_____________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Recorder: Corrector:
VIII