Medicine case proforma
Asking for Preferences
Here is a complete Medicine Case Proforma for medical student clinical posting:
MEDICINE CASE PROFORMA
SECTION 1 - PATIENT IDENTIFICATION
| Field | Details |
|---|---|
| Name | |
| Age | |
| Sex | M / F / Other |
| IP/OP No. | |
| Ward / Bed No. | |
| Date of Admission | |
| Date of Examination | |
| Informant & Reliability | |
| Occupation | |
| Address |
SECTION 2 - CHIEF COMPLAINTS
(List in chronological order with duration)
SECTION 3 - HISTORY OF PRESENT ILLNESS
(Elaborate each complaint - onset, duration, progression, character, severity, associated symptoms, relieving/aggravating factors)
Complaint 1:
Complaint 2:
Complaint 3:
Relevant Negative History (Pertinent negatives):
SECTION 4 - PAST HISTORY
- Diabetes Mellitus: Yes / No - Since: ______
- Hypertension: Yes / No - Since: ______
- Tuberculosis: Yes / No - Treated: ______
- Asthma / COPD: Yes / No
- Cardiac disease: Yes / No
- Epilepsy: Yes / No
- Jaundice / Hepatitis: Yes / No
- Thyroid disorders: Yes / No
- Renal disease: Yes / No
- Previous surgeries / hospitalizations: Yes / No - Details: ______
- Any other illness: ______
SECTION 5 - FAMILY HISTORY
- Similar illness in family: Yes / No - Details: ______
- Diabetes: Yes / No
- Hypertension: Yes / No
- Tuberculosis: Yes / No
- Malignancy: Yes / No
- Hereditary / Genetic conditions: ______
SECTION 6 - PERSONAL HISTORY
| Parameter | Details |
|---|---|
| Diet | Veg / Non-veg / Mixed |
| Appetite | Normal / Decreased / Increased |
| Bowel habits | Regular / Constipation / Diarrhea |
| Bladder habits | Normal / Frequency / Nocturia |
| Sleep | Normal / Disturbed |
| Menstrual history | Regular / Irregular / LMP: _____ |
| Marital status | Married / Unmarried |
| Addiction | Smoking (pack-years ___) / Alcohol (units/day ___) / Tobacco / Nil |
| Occupational exposure | Dust / Chemicals / Others / Nil |
SECTION 7 - DRUG HISTORY
- Current medications: (Name, dose, duration)
- Known drug allergies: Yes / No - Drug: ______
- Herbal / OTC / supplements: Yes / No - Details: ______
SECTION 8 - SOCIOECONOMIC HISTORY
- Socioeconomic status (Kuppuswamy / BG Prasad scale): ______
- Housing: Pucca / Semi-pucca / Kutcha
- Drinking water: Tap / Well / Borewell / Purified
- Sanitation: Adequate / Inadequate
SECTION 9 - GENERAL PHYSICAL EXAMINATION (GPE)
Vital Signs
| Parameter | Finding | Normal |
|---|---|---|
| Pulse | Rate: /min Rhythm: Vol: | 60-100/min |
| Blood Pressure | mmHg (arm: R/L, position: ) | <120/80 |
| Respiratory Rate | /min | 12-20/min |
| Temperature | °F / °C | 98.6°F |
| SpO2 | % (room air / O2) | >95% |
| Height | cm | |
| Weight | kg | |
| BMI | kg/m² | 18.5-24.9 |
General Appearance
- Built & Nourishment: Well built & well nourished / Moderately nourished / Poorly nourished
- Consciousness: Conscious / Drowsy / Stuporous / Comatose (GCS: E_ V_ M_ = ___)
- Orientation: Oriented to time / place / person
- Cooperation: Cooperative / Uncooperative
- Distress: In distress / Not in distress
Signs to Elicit
| Sign | Present / Absent | Details |
|---|---|---|
| Pallor | Conjunctival / Palmar / Mucosal | |
| Icterus / Jaundice | Scleral / Mucosal | |
| Cyanosis | Central / Peripheral | |
| Clubbing | Grade I / II / III / IV | |
| Koilonychia | ||
| Leukonychia | ||
| Lymphadenopathy | Site / Size / Consistency / Tender | |
| Edema | Site / Pitting / Non-pitting / Grade | |
| Dehydration | ||
| JVP | Raised / Normal / cm H2O |
SECTION 10 - SYSTEMIC EXAMINATION
10A - Cardiovascular System (CVS)
Inspection:
- Precordium: Normal / Bulging / Pulsations visible
- Apex beat: Visible at ______
Palpation:
- Apex beat: Located at ______ (ICS / MCL)
- Character: Normal / Heaving / Thrusting / Tapping / Diffuse
- Thrills: Present / Absent - Site: ______
- Parasternal heave: Present / Absent
Percussion:
- Cardiac borders:
- Right border: ______
- Left border: ______
- Upper border: ______
Auscultation:
- Heart rate: /min | Rhythm: Regular / Irregular
- S1: Normal / Loud / Soft / Absent
- S2: Normal / Loud / Soft / Split (physiological / paradoxical / fixed)
- S3: Present / Absent
- S4: Present / Absent
- Murmurs: Present / Absent - Area: ______ Grade: ______ Character: ______ Radiation: ______
- Pericardial rub: Present / Absent
10B - Respiratory System (RS)
Inspection:
- Shape of chest: Normal elliptical / Barrel / Pigeon / Funnel / Kyphoscoliosis
- Respiratory movements: Equal / Unequal bilateral
- Type of breathing: Abdomino-thoracic / Thoraco-abdominal / Paradoxical
- Use of accessory muscles: Yes / No
- Intercostal recession: Present / Absent
- Tracheal position: Central / Deviated (Right / Left)
Palpation:
- Tracheal position: Central / Deviated
- Chest expansion: Equal / Reduced on (R/L)
- Vocal fremitus: Normal / Increased / Decreased / Absent
Percussion:
- Right side: ______
- Left side: ______
- (Resonant / Dull / Stony dull / Hyperresonant)
Auscultation:
- Breath sounds: Vesicular / Bronchial / Absent / Reduced
- Added sounds:
- Crackles: Fine / Coarse - Site: ______
- Wheeze: Inspiratory / Expiratory
- Pleural rub: Present / Absent
- Vocal resonance: Normal / Increased / Decreased
10C - Per Abdomen (PA)
Inspection:
- Shape: Flat / Scaphoid / Distended / Globular
- Umbilicus: Central / Everted / Inverted / Transverse
- Skin: Scars / Striae / Dilated veins / Visible peristalsis
- Hernia sites: Visible / Not visible
- Movements with respiration: Present / Absent
Palpation:
Superficial:
- Tenderness: Present / Absent - Site: ______
- Rigidity / Guarding: Present / Absent
- Skin temperature: Normal / Increased
Deep:
- Hepatomegaly: Present / Absent - Size: ____ cm below right costal margin - Surface: Smooth / Nodular - Tender: Y/N - Edge: Sharp / Rounded
- Splenomegaly: Present / Absent - Schuffner grade: _____ - Notch: Felt / Not felt
- Kidneys: Palpable / Not palpable - Ballotable: Y/N
- Any mass: Present / Absent - Site / Size / Shape / Surface / Margins / Consistency / Mobility / Tenderness
- Urinary bladder: Palpable / Not palpable
Percussion:
- Liver dullness: Present - span: ____ cm
- Spleen dullness: Present / Absent
- Ascites: Shifting dullness - Present / Absent | Fluid thrill - Present / Absent
- Traube's space: Tympanitic / Dull
Auscultation:
- Bowel sounds: Present / Absent / Increased / Decreased
- Bruit: Present / Absent - Site: ______
10D - Central Nervous System (CNS)
Higher Functions:
- Consciousness: Alert / Drowsy / Stuporous / Comatose
- Orientation: Time / Place / Person
- Speech: Normal / Dysarthria / Aphasia (Broca's / Wernicke's / Global)
- Memory: Immediate / Recent / Remote - Intact / Impaired
- Cognitive function (mini mental status if needed): ______
Cranial Nerves:
| Nerve | Right | Left |
|---|---|---|
| CN I (Olfactory) | Intact / Impaired | Intact / Impaired |
| CN II (Optic) | VA: / VF: / Fundus: | VA: / VF: / Fundus: |
| CN III, IV, VI (Oculomotor) | PERRLA / Ptosis / Diplopia | |
| CN V (Trigeminal) | Sensation intact / Corneal reflex | |
| CN VII (Facial) | UMN / LMN pattern / Normal | |
| CN VIII (Vestibulocochlear) | Hearing / Rinne / Weber | |
| CN IX, X (Glossopharyngeal, Vagus) | Palate movement / Gag reflex | |
| CN XI (Accessory) | Sternomastoid / Trapezius | |
| CN XII (Hypoglossal) | Tongue deviation |
Motor System:
- Bulk: Normal / Wasted - Site: ______
- Tone: Normal / Hypotonic / Hypertonic (spastic / rigid)
- Power: (/5) - UL: R____ L____ LL: R____ L____
- Coordination: Finger-nose / Heel-shin - Normal / Dysdysmetria
- Involuntary movements: Present / Absent
Sensory System:
- Touch: Intact / Impaired
- Pain: Intact / Impaired
- Temperature: Intact / Impaired
- Vibration: Intact / Impaired
- Joint position sense (Proprioception): Intact / Impaired
Reflexes:
| Reflex | Right | Left |
|---|---|---|
| Biceps (C5,6) | ||
| Triceps (C7,8) | ||
| Supinator (C5,6) | ||
| Knee (L3,4) | ||
| Ankle (S1,2) | ||
| Plantar | Flexor / Extensor (Babinski) | Flexor / Extensor |
| Abdominal | Present / Absent | Present / Absent |
(Grade: 0 = absent, 1+ = diminished, 2+ = normal, 3+ = brisk, 4+ = clonus)
Signs:
- Meningeal: Neck stiffness / Kernig's / Brudzinski's - Present / Absent
- Cerebellar: Romberg's / Tandem gait / Nystagmus
10E - Musculoskeletal System (if relevant)
- Joints: Swelling / Tenderness / Warmth / Deformity
- Gait: Normal / Antalgic / Trendelenburg / Scissors / Hemiplegic
- Spine: Normal / Scoliosis / Kyphosis / Lordosis
SECTION 11 - PROVISIONAL DIAGNOSIS
Diagnosis: ______________________
Basis for Diagnosis:
1.
2.
3.
SECTION 12 - DIFFERENTIAL DIAGNOSES
SECTION 13 - INVESTIGATIONS
Routine
| Investigation | Ordered | Result | Normal Range |
|---|---|---|---|
| Hemoglobin | 12-17 g/dL | ||
| TLC | 4000-11000/mm³ | ||
| DLC | |||
| Platelets | 1.5-4.5 lakh/mm³ | ||
| ESR | |||
| Blood glucose (F/PP/Random) | |||
| Blood urea | 10-45 mg/dL | ||
| Serum creatinine | 0.6-1.2 mg/dL | ||
| Serum Na+ | 135-145 mEq/L | ||
| Serum K+ | 3.5-5.0 mEq/L | ||
| LFT (Bil/AST/ALT/ALP/Alb) | |||
| Urine R/E & M/E | |||
| Chest X-ray | |||
| ECG |
Special / Relevant Investigations
| Investigation | Ordered | Result | Interpretation |
|---|---|---|---|
SECTION 14 - FINAL DIAGNOSIS
Primary Diagnosis: ______________________
Secondary / Comorbid Diagnoses:
1.
2.
SECTION 15 - MANAGEMENT
Non-Pharmacological
- Diet:
- Activity:
- Patient education:
Pharmacological
| Drug | Dose | Route | Frequency | Duration |
|---|---|---|---|---|
Monitoring Parameters
- Clinical:
- Laboratory:
Referrals
- Speciality / Reason:
SECTION 16 - PROGNOSIS
- Short term:
- Long term:
- Complications anticipated:
SECTION 17 - STUDENT DETAILS
| Field | Details |
|---|---|
| Student Name | |
| Roll No. | |
| Year / Batch | |
| Posting Date | |
| Faculty Signature |
This proforma covers all standard components expected in a medicine clinical posting - from history to examination to management. You can print it directly or copy it into a Word document. Let me know if you want it tailored for a specific case type (e.g., cardiac, respiratory, diabetic) or want a downloadable
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