Medical History & Examination Format
By 2027-Group B 😀
1. Patient Demographics
● Full Name:
● Age:
● Gender:
● Residence: (City/Village; some diseases are region-specific)
● Marital Status:
● Children:
● Occupation:
● Education Level:
2. Chief Complaint (CC) / Presenting Complaint
● Primary reason for visit (e.g., fever, pain, cough, etc.)
● Additional complaints (Ask: "Koi aur masla to nahi?")
● Chronological order (oldest to newest e.g cough for 2 days and throat pain for 1
day)
3. History of Presenting Complaint (HOPC)
(Use ODPARA framework for each complaint)
● Onset: When did the symptom start?
● Duration: How long has it lasted?
● Progression: Getting better, worse, or stable?
● Associated Symptoms: Any other related issues?
● Relieving Factors: What makes it better?
● Aggravating Factors: What worsens it?
For pain: Use SOCRATES
● Site: Where is the pain?
● Onset: Sudden or gradual?
● Character: Sharp, dull, burning?
● Radiation: Spreads to other areas?
● Associated Symptoms: Fever, nausea, etc.?
● Timing: Continuous or intermittent?
● Exacerbating/Relieving Factors
● Severity: Scale of 1–10
1 2 3 4 6 7 8 9 10
4. Systemic Review
General Symptoms:
● Diet
● weight changes
● Appetite
● Sleep
● Mood
● Lumps & bumps
● Fever
Respiratory System:
● Cough
● shortness of breath
● Wheezing
● Chest tightness
Cardiovascular System:
● Chest pain
● Palpitations
● Swelling of legs
● Dizziness
Gastrointestinal (GIT):
● Nausea
● Vomiting
● Diarrhea
● Constipation
● Jaundice
● Abdominal pain
Genitourinary (GUR):
● Urinary frequency ( din ma kitni dafa ata ha, subah ziada ata h ya raat m, neend to
kharab nahi hoti)
● Pain & blood during urination
● Incontinence ( Mushkil to nahi hoti)
Endocrine System:
● Thyroid issues (gilhar ka msla to nahi)
● Diabetes
● Adrenal disorders ( hormones ka masla to nahi )
● Hypertension
Neurological (CNS):
● Headaches
● Dizziness
● Weakness
● Numbness
● Seizures
Rheumatology: (auto-immune)
● Joint pain (joron ka dard to nahi)
● Swelling
● Stiffness
● Morning stiffness
Skin & Integumentary System:
● Rashes
● Pigmentation
● Infections on skin
● Hair loss
Eye & ENT:
● Vision problems
● Hearing loss
● Nasal congestion
● Sore throat
Gynecological History (if applicable):
● Menstrual cycle (regular/irregular) & time interval
● Pregnancies
● Menopause
Psychological:
● "Zindagi se mutmaeen hain?"
● Depression
● Anxiety
● mood swings
5. Past Medical & Surgical History
● Previous illnesses (treated one) (e.g.,tuberculosis, hepatitis)
● Previous hospitalizations
● Past surgeries and procedures
● Road Accidents ( or any trauma)
6. Drug & Allergy History
● Current Medications: (Only those taken before admission)
● Previous medications
● Drug allergies
● Vaccination
● Blood transfusions
7. Family History
● Number of siblings and family members in the household
● Congenital/ Hereditary /genetic diseases (Diabetes, Hypertension, Cancer, etc.)
● Chronic illnesses in family members
8. Personal & Social History
● Lifestyle habits:
1. Smoking
2. Alcohol
3. Drug use
● Daily routine & hobbies
● Socioeconomic status:
○ Family support system (Kaun kamaata hai?)
○ Household environment (Aapas ka rishta kaisa hai?)
○ Impact of illness on family role (Agar ghar ka kamanay wala bimaar ho jaye
to kya hoga?)
9. Psychological Assessment
● Mental health status:
1. Feeling stressed
2. Anxious
3. Depressed
● Coping mechanisms & support system
● Need for psychiatric referral? ( baat cheet ka doctor)
Examination
10. General Physical Examination (GPE)
● General Appearance:
Well
unwell
conscious,
alert/oriented
● Pallor:
Present
Absent
● Jaundice:
Present
Absent
● Cyanosis:
Present
Absent
● Clubbing:
Present
Absent
● Lymphadenopathy:
Present
Absent
● Edema:
Present
Absent
Pitting
non-pitting
● Dehydration:
Mild
Moderate
Severe
11. Cardiovascular System (CVS) Examination
● Pulse:
1. Rate
2. Rhythm
3. Volume
4. Character
● Blood Pressure (BP):
● Heart Sounds:
Normal
murmurs
● Jugular Venous Pressure (JVP):
Raised
Normal
● Peripheral Pulses:
Palpable
Weak
12. Respiratory System Examination
● Inspection:
1. Chest symmetry
2. use of accessory muscles
● Palpation:
1. Tracheal deviation
2. chest expansion
● Percussion:
Normal
Dull
hyper-resonant
● Auscultation:
1. Breath sounds (normal/reduced/absent)
2. Crepitations
3. Wheezes
13. Central Nervous System (CNS) Examination
● Consciousness Level: GCS Score
● Cranial Nerve Examination: I–XII intact/impaired
● Reflexes: Hyperreflexia/Hyporeflexia
● Cerebellar Function: Coordination tests (finger-nose test, Romberg’s
test,dysdiadokinasia)
14. Motor & Sensory Examination
Motor Examination:
● Tone:
Normal
Increased
Decreased
● Power: (0-5 scale for each limb)
1. Right
2. Left
● Reflexes:
Hyper
Hyporeflexia
● Gait:
Normal
Abnormal
Sensory Examination:
1. Light touch
2. Pain
3. Temperature
4. Vibration
5. proprioception
15. Gastrointestinal (GIT) Examination
● Inspection: Distension, scars, visible peristalsis
● Palpation: Tenderness, hepatosplenomegaly, masses
● Percussion: Liver span, shifting dullness
● Auscultation: Bowel sounds (normal/hyper/hypoactive)
16. Provisional Diagnosis & Plan
● Possible Differential Diagnoses
By GROUP-B (2027) 🎉
M.S
Additional informations:
Glasgow Coma Scale (GCS) for Consciousness Evaluation
The GCS Score is used to assess the depth of unconsciousness based on Eye, Verbal, and
Motor responses.
🔹 Eye Opening Response (E) [Score: 4]
● 4 – Opens eyes spontaneously
● 3 – Opens eyes to verbal command
● 2 – Opens eyes to pain
● 1 – No eye opening
🔹 Verbal Response (V) [Score: 5]
● 5 – Oriented (Knows name, place, time)
● 4 – Confused conversation but can talk
● 3 – Inappropriate words (random words, no sentences)
● 2 – Incomprehensible sounds (moaning, groaning)
● 1 – No verbal response
🔹 Motor Response (M) [Score: 6]
● 6 – Obeys commands (moves on request)
● 5 – Localizes pain (tries to remove painful stimulus)
● 4 – Withdraws from pain
● 3 – Abnormal flexion (Decorticate posture)
● 2 – Abnormal extension (Decerebrate posture)
● 1 – No motor response
3. Clinical Interpretation of GCS Score
● GCS 13 – 15 → Mild Consciousness Impairment (Fully conscious or slightly drowsy)
🆘
● GCS 9 – 12 → Moderate Consciousness Impairment
● GCS ≤ 8 → Severe Consciousness Impairment (Coma)
💡 GCS ≤ 8 requires airway protection (intubation) and urgent medical intervention.
🚑
This evaluation is crucial in neurology, trauma cases, stroke assessment, and ICU
monitoring.
