Historian: Section B Group 14

Patient’s name: Preceptor: Dr. E. Lim

Informant: Date of Interview:

Reliability: Date of Submission:

General Data

Initials, Age, Sex, Civil Status, Citizenship, Religion, Work, born on ________, at

_________, residing at ____________, admitted for the _th time at QCGH on ________, 2014.

Chief Complaint

(CC)

History of Present Illness

________ PTA, experienced __________

________ PTA, experienced __________

(What was the patient doing? Sitting? Standing? Playing?)

(Pain: characteristic, scale, location, time, radiation, aggravating factors, reducing factors,

*Medications, Continuous or not, Time, *Consultations)

(Dyspnea: Time, accompanied by pain? Aggravating factors, reducing factors, *meds, *consultation,

continuous? )

(Hypertensive: Highest BP, usual BP, lowest BP, *meds, *consultation, dizziness? Headache?

Associated pain? Visual acuity?)

(Meds*: Name, dose, prescribed by whom, for what condition, frequency, how many days therapy?)

(Consultation*: Where? Doctor? Meds prescribed? Diagnostic tests done? Results?)

Recent travel?

Any accompanying signs/symptoms?

____________ Due to the persistence of the ______, pt sought consult at QCGH for admission.

Past Medical History

Allergies? What happens during allergic reactions? Immunizations? When and where? Blood

transfusions? (ask for MMR, DTap, Varicella) Childhood illnesses? Adult illnesses? How often

contracting headache, colds, cough? Previous hospitalizations? Previous surgeries? (Cause, Time,

Result) Any history of DM, Hypertension, TB, Asthma? Medications previously taken. Medications

currently taking. Herbals taking.

Family History

Father illnesses, mother illnesses, siblings illnesses. (Ask for illness, age, what treatment, what

diagnostics, duration, why illness was become). No other family diseases reported such as

(hypertension, DM, Tuberculosis, Asthma, Cancer, Stroke, Rheuma, Liver diseases)

Personal and Social History

A _______ graduate, worked as a ________ in _________ on _____ until ______, then worked as a

_______ in _______ on _______ until_______. Does/not smoke cigarette. (If yes, pack years?) (If no,

second hand smoke) Does/not drink alcohol. (If yes, frequency, type of alcohol (beer? Hard drink?

Scotch?, volume) Has a/no history of substance abuse. (If yes, what substance? When? How much?

Why?) Does/not drink coffee/tea/milo/energy drink. (If yes, how much? What time? How frequently?

What type?) Pt’s interests, lifestyle are _________. Pt does/not exercise. (if yes, what type? How

frequently?) Pt sleeps an average of ___ hours a day from ___ to ____, interrupted/uninterrupted. (If

interrupted, why? How often? What manifestations?) Pt’s favorite dishes are _______. (Does he eat a

large amount of rice? Sugars? Chocolates? Canned/junk goods?) Pt lives in a _______ house, ___

sqm , w/ ___ famil/ies, _____ members, ___ rooms, ___ windows, ___ as ventilation, ____ bathrooms.

Bathroom toilet is ____. Water supply is ____. Drinking water supply is _____. Garbage is collected

____. House pests are ______. (Methods to control pests?)

OB-Gyne History

(refer to Exam Form)

Review of Systems

General: ( ) fever, ( ) headache, ( ) weight change

Integumentary: ( ) pigmentation, ( ) pruritus, ( ) lesions/sores

HEENT: ( ) headache, ( ) dizziness, ( ) syncope, ( ) blurring of vision, ( ) tinnitus, ( ) ear pain, ( )

hearing loss

Respiratory: ( ) cough, ( ) dyspnea, ( ) chest pain, ( ) tachypnea, ( ) orthopnea

Cardiovascular: ( ) chest pain, ( ) palpitations, ( ) SOB, ( ) easy fatiguability

GI: ( ) vomiting, ( ) hematemesis, Bowel elimination: ( ) regular, ( ) constipation, ( ) diarrhea

GUT: ( ) Dysuria, ( ) Oliguria, ( ) Hematuria

MS: ( ) muscle pain, ( ) joint pain, ( ) weakness, ( ) dislocation

Neuropsychiatric: ( ) syncope, ( ) seizures, ( ) tremors

Endocrine: ( ) heat/cold intolerance, ( ) polyphagia, ( ) polydipsia

Hematologic: ( ) easy bruisability, ( ) bleeding, ( ) pallor

Physical Examination

General Survey

Pt is found (position: sitting, lying supine, lying on side). Pt is (alert, conscious, coherent, lethargic,

obtunded, stuporous, comatose). Pt is (calm, apathetic, anxious, depressed, sedated, combative,

paranoid) Pt is non/cooperative and does/not respond to questions asked. (Good) eye contact. Pt’s

posture is _____. Pt’s gait is ______. Pt’s grooming is ______. Pt can move ____ extremities. Pt is

(body build). Pt is not/in cardiopulmonary distress. (No) gross deformities noted.

Vital signs: BP ____mmHg, PR/CR ___ bpm, regular/irregular, bounding, @ _____. RR _____ cpm

regular/irregular, Temp: _____ @____.

Skin is ____ in color, normal texture, no lesions noted except ________. Skin is warm/cold, moist/dry,

equally distributed hair. Skin turgor is ____. Nail beds have (no) ______. (Clubbing? Swelling?)

Capillary refill is ___ seconds.

HEENT

Head is normocephalic, (no) lumps or depressions or tenderness noted. Temporal artery is

(not) palpable, bilaterally, (not) bounding, (weak). Hair is color ____, ______ distributed, dry/oily,

with/out dandruffs. (No) scalp lesions noted.

Face is (color), symmetrical/nonsymmetrical, movement is symmetrical/nonsymmetrical,

lesions noted at ______. (No) abnormal facies, tremors, twitches noted.

Pupils equal/unequal, reactive/nonreactive to light, _mm bilaterally. Eyebrows are evenly

distributed. Color is ____. Eyelids are symmetrically open, (no) ptosis, swelling, lagging noted.

Eyelashes are scanty/many. Pointing up/downward. Sclera is ______. Conjunctiva is ______. (No)

discharge noted. Cornea is _____. Iris is ____ in color. Pt does/not use corrective glasses. (If yes, what

grade? And since when?) Visual fields are present/absent at _____. Upon fundoscopic exam, red-

orange reflex ( ). Blood vessels (not) distended. (No) papilledema noted. (No) periorbital tenderness,

pt (denies) pain.

Ears are C-shaped, symmetrical. (No) tenderness, pt (denies) pain. (No) discharge, scaling

noted. Upon otoscopy, eardrum is (pearly white) in color. Auditory canals are _____, cerumen _____.

Pt’s hearing is/not impaired upon snapping/rubbing fingers test.

Nose is symmetrical. Septum midline and (no) discharges noted. Vibrissae noted. (No)

lesions/ulcers. (No) nasal flaring noted.

Lips are symmetrical, moist, (color), (no) lesions noted. Oral mucosa is moist, (no) lesions

noted, Pt not/has dentures. (If yes, up and/or down? Since when?) Pt’s teeth are (color),

(intact/cavities), (complete? Which are missing?), Gums have (no) lesions. (No) bleeding, (no)

receding. Tongue is midline, (no) lesions. Uvula is midline, tonsils (not) inflamed. (No) lesions at

pharyngeal wall.

Neck has (no) lesions or masses. ____ in color, symmetrical, round. Lymph nodes are (not)

swollen. (If swollen, which lymph nodes? Movable or not? Size? Tender or not? Soft or hard? Since

when? Probable cause?) Trachea is midline. Thyroid gland is (not) enlarged.

Chest and Lungs

Skin is ___ in color. (No) lesions/masses noted. Thorax is elliptical and symmetrical. A:P ratio

is ____. Chest expansion is (symmetrical). (No) chest lagging or intercostal retractions or bulging. (No)

crepitus, tenderness, bruises noted. Breathing pattern is even/uneven, shallowed/deep. Tactile fremitus

is _____ at ____ lung fields. Upon percussion, it is (resonant/hyperresonant/dull/flat) on ____ lung

fields. Upon auscultation, (Crackles,Wheezes,Stridor) noted at _______. (If none, No crackles,

wheezes, stridor noted). ( ) for egophony @ _____. ( ) for bronchophony @ ______. ( ) for whispered

pectoriloquy @ ______. Vocal fremitus is _____ at ____ lung fields.

(If Female, Breasts symmetrical, (no) dimpling, masses, discharge, tenderness noted.)

Cardiovascular

JVP is ___ cm above the sternum when HOB is @ ___ degrees. Jugular vein is/not distended.

Carotid bruits (not) noted. Precordium is a/dynamic. Ectopic pulsations @ _____. Apex beat @ _th ICS

____. Heaves, thrills and lifts (not) noted on any area. S1 loud @ ____. S2 loud @ _____. S3/S4

can/cannot be heard. (No) murmurs noted. Peripheral pulses are symmetrical and bilateral and

(non)bounding.

Abdomen

Shape is (flat/globular/scaphoid/protuberant), symmetrical, color is ______. (No) lesions,

dilated vessels, striae, visible masses noted. (No) visible pulsations, visible peristalsis noted.

Abdominal circumference is __ inches. Umbilicus is _______. Bowel sounds are _______ per minute

at (which quadrants?), (Normal/hyper/hypoactive). Bruits (absent). Upon percussion, dull @ _____

regions. Tympanic @ _____ regions. Liver span is _____ cm MCL, _______ cm MSL. Liver

tenderness is (not) noted. Spleen’s Traube’s space is tympanitic/dull. Tenderness (not) noted. Kidney

punch test is ( ). CVA tenderness (absent). Pt does/not complain of pain, or wince, upon palpation of

organs. No palpable masses are (noted) (if present, indicate where). ( ) for Murphy’s sign, ( ) for

Rovsing’s sign, ( ) for Psoas sign, ( ) for shifting dullness, ( ) for puddle sign, ( ) for fluid wave, ( )

for Obturator sign, ( ) for direct tenderness (if (+) please indicate where.)

Extremities

Hands, wrists and fingers

Color is ______. (No) lesions, swelling, nodules noted. (No) crepitations. Pt does/not wince,

(nor) complains of pain. (Symmetrical) on both extremities in shape and size. (Can/Cannot) do full

range of motion with (active/passive) ROM (with/without) pain. (No) other deformities noted. (No)

thenar/hypothenar atrophy.

Forearm and Elbow

Color is ______. (No) lesions, swelling, nodules noted. Pt does/not wince, (nor) complains of

pain. (Symmetrical) on both extremities in muscle mass and shape. (No) atrophy/hypertrophy.

(Can/Cannot) do full range of motion with (active/passive) ROM (with/without) pain. (No) other

deformities noted.

Arms and Shoulders

Color is ______. (No) lesions, swelling, nodules noted. Pt does/not wince, (nor) complains of

pain. (Symmetrical) on both extremities in muscle mass and shape. (No) atrophy/hypertrophy.

(Can/Cannot) do full range of motion with (active/passive) ROM (with/without) pain. (No) other

deformities noted. (Equal) in length from acromion process to ulnar tuberosity.

Spine

Color is ______. (No) lesions, swelling, nodules noted. (No) crepitations. Pt does/not wince,

(nor) complains of pain. (Symmetrical) on distance between shoulders and Posterior superior iliac

spine. (No) atrophy/hypertrophy. (Can/Cannot) do full range of motion with active ROM

(with/without) pain. (No) other deformities noted. (No) abnormal curvatures noted)

Hips and Thighs

Color is ______. (No) lesions, swelling, nodules noted. Pt does/not wince, (nor) complains of

pain. (Symmetrical) on both sides especially bony prominences and muscle mass. (No)

atrophy/hypertrophy. (Can/Cannot) do full range of motion with (passive/active) ROM (with/without)

pain. (No) other deformities noted. (No) internal and external rotations noted.

Knee

Color is ______. (No) lesions, swelling, nodules/masses noted. (No) crepitations. Pt does/not

wince, (nor) complains of pain. (Symmetrical) on size of both knees. (No) atrophy/hypertrophy.

(Can/Cannot) do full range of motion with (passive/active) ROM (with/without) pain. (No) other

deformities noted.

Ankle and Feet

Color is ______. (No) lesions, swelling, nodules/masses noted. (No) crepitations. Pt does/not

wince, (nor) complains of pain. (Symmetrical) on size and shape. (No) atrophy/hypertrophy.

(Can/Cannot) do full range of motion with (passive/active) ROM (with/without) pain. (No) other

deformities noted.

Toes and Soles

Color is ______. (No) lesions, swelling, nodules/masses noted. (No) crepitations. Pt does/not

wince, (nor) complains of pain. (Symmetrical) on size and shape. (No) atrophy/hypertrophy.

(Can/Cannot) do full range of motion with (passive/active) ROM (with/without) pain. (No) other

deformities noted.

Neurologic Examination

Patient is awake, alert, coherent, oriented to time, place and person, pt’s mood is ______.

(Not) on delirium. Pt can follow simple commands by ______, has functional memory in immediate,

recent and remote, can do simple math calculations, has good abstract thinking and appropriate

judgement. Pt is ____-handed.

Pt’s posture is ______, with/out difficulty. (No) truncal ataxia. (No) tremors noted. Able to do

( ) finger-to-Nose test, ( ) rapid alternating movements and ( ) heel-to-shin test. ( ) Rhomberg’s test.

Cranial Nerves:

I: Can smell bilaterally, no nasal flaring

II: Has _____ visual acuity, (wears) glasses, ( ) red-orange reflex on fundoscopy, (no) distended blood

vessels noted

II, III: Pupils non/reactive to light (bilaterally), brisk/slow, pupil size _mm, iris color is ______, able to

accomodate (Not black please)

III, IV, VI: Extraocular muscles can follow stimulus

V: Can sense on 3 nerve branches of Trigeminal

V, VII: (+) corneal reflex

VII: Facial expressions symmetrical

VIII: Can/not hear on both ears

IX, X: Uvula is/not midline upon swallowing (If not, deviation to what side?)

XI: Can equally elevate shoulders (with/out) resistance

XII: Tongue (midline) upon protrusion

Pt’s motor movements are as follow: RUE ____, RLE ______, LUE _____, LLE _______

(No) fasciculations, atrophy, rigidity noted.

Pt’s sensory are as follow: RUE _____, RLE _____, LUE ______, LLE________

Sensory modalities that are functional are ( ) pain/temp, ( ) crude touch, ( ) vibration, ( ) light touch, (

) position. ( ) for stereognosis and graphestesia

(If hemiplegic, please indicate until what level the sensory/motor functions can go. And please assess

for each quadrant)

Reflexes of pt are ( ) for Babinski’s. Bicep and Tricep reflexes are _______ (uni/bilaterally). Knee

reflexes are _______ (uni/bilaterally).

Meninges show (no) sign of Nuchal rigidity, as well as ( ) for Brudzinski’s and Kernig’s Signs.