General Medicine Clinical Case Proforma

For Ward Presentation — Department of General Medicine

| Date:

1. Identification & Presenter Details

Patient Name

Age / Sex

IPD / Bed No.

Occupation

Address

Date of Admission

Presenting Student & Roll No.

History given by

Patient Attendant

2. Chief Complaints

Tick all that apply (patients often present with more than one). Fill site, side and duration for each selected.

✓	Chief Complaint	Side	Site	Duration (since)
	Fever
	Cough
	Breathlessness
	Generalized weakness / fatigability
	Abdominal pain
	Chest pain
	Headache
	Loss of appetite / weight loss
	Nausea / vomiting
	Swelling of feet (pedal edema)
	Other:

3. History of Present Illness

Mode of Onset & Course

Acute onset Gradual / insidious onset Progressive course Episodic / recurrent Following a specific trigger (exertion, food, drug, infection) Static / non-progressive Other:

Character of Pain / Key Symptom — SOCRATES

To be filled whenever pain (chest, abdominal, headache, etc.) is a chief complaint.

S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)

4. Past, Personal, Family & Treatment History

5. General Physical Examination

Build

Nutrition

Consciousness

Sign	Absent	Present	Details (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema
Jugular venous pressure (JVP)
Thyroid swelling

Vitals

PR (/min)

BP (mmHg)

RR (/min)

Temp

SpO2 (%)

RBS

GCS

6. Systemic Examination

A. Cardiovascular System

Inspection / Palpation
Auscultation — S1/S2
Added sounds

B. Respiratory System

Inspection
Palpation / Percussion
Auscultation

C. Per Abdomen

Inspection
Palpation
Percussion / Auscultation

D. Central Nervous System

Higher mental functions
Cranial nerves
Motor system
Reflexes
Sensory system
Cerebellar signs / gait
Meningeal signs

7. Investigations

✓	Investigation	Findings
	Complete blood count (Hb/TLC/DLC/Platelet)
	ESR / CRP
	Renal function test
	Liver function test
	Blood sugar (F/PP) / HbA1c
	Serum electrolytes
	Urine routine & microscopy
	Chest X-ray
	ECG
	2D Echo
	Ultrasound abdomen
	Blood/urine culture
	Other:

8. Diagnosis

Provisional Diagnosis

Differential Diagnosis

9. Treatment Plan

Conservative management IV fluids / electrolyte correction Antibiotics Symptomatic management Specialist referral Further work-up planned Discharge planning / follow-up

10. Summary

Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.

Presenting Student's Signature

Countersigned by Faculty / Resident

General Medicine Clinical Case Proforma — for teaching purpose · not a legal medical record