Case sheet proforma for History taking and Examination of Breast Lump.

Name: 

Age/Sex: 

Occupation: 

Socioeconomic Status:

Presenting Complaints

• Lump in the right/left breast for last………….. months/years.

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History of Presenting Illness

• H/O Lump

• Site

• Duration

• Onset

• Progress of the swelling:

• Associated

• H/O Pain

• Site

• Duration

• Onset

• Character: Usually dull-aching

• Radiation

• Relieving factors 

• Aggravating factors

• H/O Ulcer

• Site

• Duration

• Onset

• Progress of the ulcer

• Associated

10/24/2020 03:49:00 PM

Thyroid Case

Name:

Age/Sex:

Occupation:

Residence:

Presenting Complaints

Swelling in front of Neck   Duration

  

History of Presenting Illness

• H/O Swelling

• Site
• Duration
• Onset
• Progress of the swelling:
• Associated

• H/O Pain

• Site
• Duration
• Onset
• Character: Usually dull-aching
• Radiation
• Relieving factors
• Aggravating factors

R/O Pressure Symptoms

• H/O Difficulty in Swallowing: Solid or liquid  
• H/O Difficulty in breathing  
• H/O Hoarseness of Voice
• H/O Drooping of the upper eyelid (ptosis), Absence of sweating of the face (anhidrosis)

R/O Hyperthyroidism

  

Primary Hyperthyroidism (Mainly CNS Symptoms)

• H/O Tremors
• H/O Irritability on slight provocation
• H/O Insomnia
• H/O Muscle Weakness

Primary Hyperthyroidism (Eye Symptoms)

• H/O Bulging of eyes

• Duration
• Progress
• History of redness of eye and watering
• History of double vision
• Loss of vision

Secondary Hyperthyroidism (Mainly Cardiovascular Symptoms)

• H/O Palpitations
• H/O Ectopic Beats
• H/O Chest pain
• H/O Breathlessness on exertion

Hyperthyroidism (Sympathetic Hyperstimulation)

• H/O Increased sweating
• H/O Heat intolerance  

Hyperthyroidism (Increased BMI)

• H/O Increased Appetite
• H/O Weight Loss

Hyperthyroidism (GI)

• H/O Increased frequency of passing stools

6/02/2017 02:11:00 AM