Chest Diagnosis Sheet

History
Personal Name: …………………. Occupation: ……………………….

History Age: …………................ Martial Status: ……………………

Sex: …………………… Habits: …………………………….
Address: …………......... Menstrual History: ……………….
Floor No: ……………... ……………………………

Chief Cause of admission to hospital / Clinic (No medical terms)

Complaint ……………………………………………………………….
……………………………………………………………….
Present Use medical terms Duration of Disease: …….....

History Onset: …………………………. State of Disease: ……………

Course of disease: …………….. ……………………………….
………………………………….
Past Past diseases: ……………….. ……………………………..

History ……………………………….. ……………………………..

Family Similar Disease in the family

History Yes No
………………………………………………………………
 Examination
General
Examination
Mental Status Alert: ………………………. Mood & Memory: …..…..
Conscious: ……………….... …………………………….
……………………………… Well oriented to time &
Cooperate: ………………… place: ……………………..
……………………………… …………………………….
Built of the Body Over-weight: ……………………………………………………
Under-weight: ………………………………………………….

Decubitus ………………………………………………………………….
………………………………………………………………….
Overview Face: …………………………... Neck: ……………….
…………………………............. U&L Limb: Temp: ……...
Eyes: ………………………….. …………………………….
………………………….............. Nails: …………………….
Lips: …………………………... ……………….……………
………………………….............. Edema: …………………..
……………………………

Local
Examination
Inspection Shape: …………………………. Litten’s Sign : …………….
…………………………………. ………………………..........
Movement: ….………………… Hoover’s Sign: ….………...
 Trill’s Sign: …………………… ……………………….........
……………………….................. …………………………….
Palpation Tracheal Shift: ………………. Middle: …………………...
………………….……………... Lower: ……………………
Lung Expansion: Posterior: ………………...
Apical: ………………………. …………………………….
Upper: ……………………….. TVF: …………………..….

Percussion …………………………………….............................................
…………………………………………………………….........
Auscultation Bronchial: Normal: …………. Vesicular: Normal: ……..
…………………………………. ……………………………
Abnormal: …………………..... Abnormal: ………………
……………………………….… ……………………………
Bronchovesicular: Normal: …. Additional: ………….......
………………………………… ……………………………
Abnormal: …………………… ……………………………
………………………………… ……………………………

Diagnosis …………………………………………………..

X
A h m e d S a m ir