Historian:

SectionBGroup14

Patientsname:

Preceptor:Dr.E.Lim

Informant:

DateofInterview:

Reliability:

DateofSubmission:

GeneralData
Initials,Age,Sex,CivilStatus,Citizenship,Religion,Work,bornon________,at
_________,residingat____________,admittedforthe_thtimeatQCGHon________,2014.
ChiefComplaint
(CC)
HistoryofPresentIllness
________PTA,experienced__________
________PTA,experienced__________
(Whatwasthepatientdoing?Sitting?Standing?Playing?)
(Pain:characteristic,scale,location,time,radiation,aggravatingfactors,reducingfactors,
*Medications,Continuousornot,Time,*Consultations)
(Dyspnea:Time,accompaniedbypain?Aggravatingfactors,reducingfactors,*meds,*consultation,
continuous?)
(Hypertensive:HighestBP,usualBP,lowestBP,*meds,*consultation,dizziness?Headache?
Associatedpain?Visualacuity?)
(Meds*:Name,dose,prescribedbywhom,forwhatcondition,frequency,howmanydaystherapy?)
(Consultation*:Where?Doctor?Medsprescribed?Diagnostictestsdone?Results?)
Recenttravel?
Anyaccompanyingsigns/symptoms?
____________Duetothepersistenceofthe______,ptsoughtconsultatQCGHforadmission.
PastMedicalHistory
Allergies?Whathappensduringallergicreactions?Immunizations?Whenandwhere?Blood
transfusions?(askforMMR,DTap,Varicella)Childhoodillnesses?Adultillnesses?Howoften
contractingheadache,colds,cough?Previoushospitalizations?Previoussurgeries?(Cause,Time,
Result)AnyhistoryofDM,Hypertension,TB,Asthma?Medicationspreviouslytaken.Medications
currentlytaking.Herbalstaking.
FamilyHistory
Fatherillnesses,motherillnesses,siblingsillnesses.(Askforillness,age,whattreatment,what
diagnostics,duration,whyillnesswasbecome).Nootherfamilydiseasesreportedsuchas
(hypertension,DM,Tuberculosis,Asthma,Cancer,Stroke,Rheuma,Liverdiseases)
PersonalandSocialHistory
A_______graduate,workedasa________in_________on_____until______,thenworkedasa
_______in_______on_______until_______.Does/notsmokecigarette.(Ifyes,packyears?)(Ifno,
secondhandsmoke)Does/notdrinkalcohol.(Ifyes,frequency,typeofalcohol(beer?Harddrink?
Scotch?,volume)Hasa/nohistoryofsubstanceabuse.(Ifyes,whatsubstance?When?Howmuch?
Why?)Does/notdrinkcoffee/tea/milo/energydrink.(Ifyes,howmuch?Whattime?Howfrequently?

Whattype?)Ptsinterests,lifestyleare_________.Ptdoes/notexercise.(ifyes,whattype?How
frequently?)Ptsleepsanaverageof___hoursadayfrom___to____,interrupted/uninterrupted.(If
interrupted,why?Howoften?Whatmanifestations?)Ptsfavoritedishesare_______.(Doesheeata
largeamountofrice?Sugars?Chocolates?Canned/junkgoods?)Ptlivesina_______house,___
sqm,w/___famil/ies,_____members,___rooms,___windows,___asventilation,____bathrooms.
Bathroomtoiletis____.Watersupplyis____.Drinkingwatersupplyis_____.Garbageiscollected
____.Housepestsare______.(Methodstocontrolpests?)
OBGyneHistory
(refertoExamForm)
ReviewofSystems
General:()fever,()headache,()weightchange
Integumentary:()pigmentation,()pruritus,()lesions/sores
HEENT:()headache,()dizziness,()syncope,()blurringofvision,()tinnitus,()earpain,()
hearingloss
Respiratory:()cough,()dyspnea,()chestpain,()tachypnea,()orthopnea
Cardiovascular:()chestpain,()palpitations,()SOB,()easyfatiguability
GI:()vomiting,()hematemesis,Bowelelimination:()regular,()constipation,()diarrhea
GUT:()Dysuria,()Oliguria,()Hematuria
MS:()musclepain,()jointpain,()weakness,()dislocation
Neuropsychiatric:()syncope,()seizures,()tremors
Endocrine:()heat/coldintolerance,()polyphagia,()polydipsia
Hematologic:()easybruisability,()bleeding,()pallor
PhysicalExamination
GeneralSurvey
Ptisfound(position:sitting,lyingsupine,lyingonside).Ptis(alert,conscious,coherent,lethargic,
obtunded,stuporous,comatose).Ptis(calm,apathetic,anxious,depressed,sedated,combative,
paranoid)Ptisnon/cooperativeanddoes/notrespondtoquestionsasked.(Good)eyecontact.Pts
postureis_____.Ptsgaitis______.Ptsgroomingis______.Ptcanmove____extremities.Ptis
(bodybuild).Ptisnot/incardiopulmonarydistress.(No)grossdeformitiesnoted.
Vitalsigns:BP____mmHg,PR/CR___bpm,regular/irregular,bounding,@_____.RR_____cpm
regular/irregular,Temp:_____@____.
Skinis____incolor,normaltexture,nolesionsnotedexcept________.Skiniswarm/cold,moist/dry,
equallydistributedhair.Skinturgoris____.Nailbedshave(no)______.(Clubbing?Swelling?)
Capillaryrefillis___seconds.
HEENT
Headisnormocephalic,(no)lumpsordepressionsortendernessnoted.Temporalarteryis
(not)palpable,bilaterally,(not)bounding,(weak).Hairiscolor____,______distributed,dry/oily,
with/outdandruffs.(No)scalplesionsnoted.
Faceis(color),symmetrical/nonsymmetrical,movementissymmetrical/nonsymmetrical,
lesionsnotedat______.(No)abnormalfacies,tremors,twitchesnoted.

Pupilsequal/unequal,reactive/nonreactivetolight,_mmbilaterally.Eyebrowsareevenly
distributed.Coloris____.Eyelidsaresymmetricallyopen,(no)ptosis,swelling,laggingnoted.
Eyelashesarescanty/many.Pointingup/downward.Sclerais______.Conjunctivais______.(No)
dischargenoted.Corneais_____.Irisis____incolor.Ptdoes/notusecorrectiveglasses.(Ifyes,what
grade?Andsincewhen?)Visualfieldsarepresent/absentat_____.Uponfundoscopicexam,red
orangereflex().Bloodvessels(not)distended.(No)papilledemanoted.(No)periorbitaltenderness,
pt(denies)pain.
EarsareCshaped,symmetrical.(No)tenderness,pt(denies)pain.(No)discharge,scaling
noted.Uponotoscopy,eardrumis(pearlywhite)incolor.Auditorycanalsare_____,cerumen_____.
Ptshearingis/notimpaireduponsnapping/rubbingfingerstest.
Noseissymmetrical.Septummidlineand(no)dischargesnoted.Vibrissaenoted.(No)
lesions/ulcers.(No)nasalflaringnoted.
Lipsaresymmetrical,moist,(color),(no)lesionsnoted.Oralmucosaismoist,(no)lesions
noted,Ptnot/hasdentures.(Ifyes,upand/ordown?Sincewhen?)Ptsteethare(color),
(intact/cavities),(complete?Whicharemissing?),Gumshave(no)lesions.(No)bleeding,(no)
receding.Tongueismidline,(no)lesions.Uvulaismidline,tonsils(not)inflamed.(No)lesionsat
pharyngealwall.
Neckhas(no)lesionsormasses.____incolor,symmetrical,round.Lymphnodesare(not)
swollen.(Ifswollen,whichlymphnodes?Movableornot?Size?Tenderornot?Softorhard?Since
when?Probablecause?)Tracheaismidline.Thyroidglandis(not)enlarged.
ChestandLungs
Skinis___incolor.(No)lesions/massesnoted.Thoraxisellipticalandsymmetrical.A:Pratio
is____.Chestexpansionis(symmetrical).(No)chestlaggingorintercostalretractionsorbulging.(No)
crepitus,tenderness,bruisesnoted.Breathingpatterniseven/uneven,shallowed/deep.Tactilefremitus
is_____at____lungfields.Uponpercussion,itis(resonant/hyperresonant/dull/flat)on____lung
fields.Uponauscultation,(Crackles,Wheezes,Stridor)notedat_______.(Ifnone,Nocrackles,
wheezes,stridornoted).()foregophony@_____.()forbronchophony@______.()forwhispered
pectoriloquy@______.Vocalfremitusis_____at____lungfields.
(IfFemale,Breastssymmetrical,(no)dimpling,masses,discharge,tendernessnoted.)
Cardiovascular
JVPis___cmabovethesternumwhenHOBis@___degrees.Jugularveinis/notdistended.
Carotidbruits(not)noted.Precordiumisa/dynamic.Ectopicpulsations@_____.Apexbeat@_thICS
____.Heaves,thrillsandlifts(not)notedonanyarea.S1loud@____.S2loud@_____.S3/S4
can/cannotbeheard.(No)murmursnoted.Peripheralpulsesaresymmetricalandbilateraland
(non)bounding.
Abdomen
Shapeis(flat/globular/scaphoid/protuberant),symmetrical,coloris______.(No)lesions,
dilatedvessels,striae,visiblemassesnoted.(No)visiblepulsations,visibleperistalsisnoted.
Abdominalcircumferenceis__inches.Umbilicusis_______.Bowelsoundsare_______perminute
at(whichquadrants?),(Normal/hyper/hypoactive).Bruits(absent).Uponpercussion,dull@_____
regions.Tympanic@_____regions.Liverspanis_____cmMCL,_______cmMSL.Liver

tendernessis(not)noted.SpleensTraubesspaceistympanitic/dull.Tenderness(not)noted.Kidney
punchtestis().CVAtenderness(absent).Ptdoes/notcomplainofpain,orwince,uponpalpationof
organs.Nopalpablemassesare(noted)(ifpresent,indicatewhere).()forMurphyssign,()for
Rovsingssign,()forPsoassign,()forshiftingdullness,()forpuddlesign,()forfluidwave,()
forObturatorsign,()fordirecttenderness(if(+)pleaseindicatewhere.)
Extremities
Hands,wristsandfingers
Coloris______.(No)lesions,swelling,nodulesnoted.(No)crepitations.Ptdoes/notwince,
(nor)complainsofpain.(Symmetrical)onbothextremitiesinshapeandsize.(Can/Cannot)dofull
rangeofmotionwith(active/passive)ROM(with/without)pain.(No)otherdeformitiesnoted.(No)
thenar/hypothenaratrophy.
ForearmandElbow
Coloris______.(No)lesions,swelling,nodulesnoted.Ptdoes/notwince,(nor)complainsof
pain.(Symmetrical)onbothextremitiesinmusclemassandshape.(No)atrophy/hypertrophy.
(Can/Cannot)dofullrangeofmotionwith(active/passive)ROM(with/without)pain.(No)other
deformitiesnoted.
ArmsandShoulders
Coloris______.(No)lesions,swelling,nodulesnoted.Ptdoes/notwince,(nor)complainsof
pain.(Symmetrical)onbothextremitiesinmusclemassandshape.(No)atrophy/hypertrophy.
(Can/Cannot)dofullrangeofmotionwith(active/passive)ROM(with/without)pain.(No)other
deformitiesnoted.(Equal)inlengthfromacromionprocesstoulnartuberosity.
Spine
Coloris______.(No)lesions,swelling,nodulesnoted.(No)crepitations.Ptdoes/notwince,
(nor)complainsofpain.(Symmetrical)ondistancebetweenshouldersandPosteriorsuperioriliac
spine.(No)atrophy/hypertrophy.(Can/Cannot)dofullrangeofmotionwithactiveROM
(with/without)pain.(No)otherdeformitiesnoted.(No)abnormalcurvaturesnoted)
HipsandThighs
Coloris______.(No)lesions,swelling,nodulesnoted.Ptdoes/notwince,(nor)complainsof
pain.(Symmetrical)onbothsidesespeciallybonyprominencesandmusclemass.(No)
atrophy/hypertrophy.(Can/Cannot)dofullrangeofmotionwith(passive/active)ROM(with/without)
pain.(No)otherdeformitiesnoted.(No)internalandexternalrotationsnoted.
Knee
Coloris______.(No)lesions,swelling,nodules/massesnoted.(No)crepitations.Ptdoes/not
wince,(nor)complainsofpain.(Symmetrical)onsizeofbothknees.(No)atrophy/hypertrophy.
(Can/Cannot)dofullrangeofmotionwith(passive/active)ROM(with/without)pain.(No)other
deformitiesnoted.
AnkleandFeet
Coloris______.(No)lesions,swelling,nodules/massesnoted.(No)crepitations.Ptdoes/not
wince,(nor)complainsofpain.(Symmetrical)onsizeandshape.(No)atrophy/hypertrophy.
(Can/Cannot)dofullrangeofmotionwith(passive/active)ROM(with/without)pain.(No)other
deformitiesnoted.

ToesandSoles
Coloris______.(No)lesions,swelling,nodules/massesnoted.(No)crepitations.Ptdoes/not
wince,(nor)complainsofpain.(Symmetrical)onsizeandshape.(No)atrophy/hypertrophy.
(Can/Cannot)dofullrangeofmotionwith(passive/active)ROM(with/without)pain.(No)other
deformitiesnoted.
NeurologicExamination
Patientisawake,alert,coherent,orientedtotime,placeandperson,ptsmoodis______.
(Not)ondelirium.Ptcanfollowsimplecommandsby______,hasfunctionalmemoryinimmediate,
recentandremote,candosimplemathcalculations,hasgoodabstractthinkingandappropriate
judgement.Ptis____handed.
Ptspostureis______,with/outdifficulty.(No)truncalataxia.(No)tremorsnoted.Abletodo
()fingertoNosetest,()rapidalternatingmovementsand()heeltoshintest.()Rhombergstest.
CranialNerves:
I:Cansmellbilaterally,nonasalflaring
II:Has_____visualacuity,(wears)glasses,()redorangereflexonfundoscopy,(no)distendedblood
vesselsnoted
II,III:Pupilsnon/reactivetolight(bilaterally),brisk/slow,pupilsize_mm,iriscoloris______,ableto
accomodate(Notblackplease)
III,IV,VI:Extraocularmusclescanfollowstimulus
V:Cansenseon3nervebranchesofTrigeminal
V,VII:(+)cornealreflex
VII:Facialexpressionssymmetrical
VIII:Can/nothearonbothears
IX,X:Uvulais/notmidlineuponswallowing(Ifnot,deviationtowhatside?)
XI:Canequallyelevateshoulders(with/out)resistance
XII:Tongue(midline)uponprotrusion
Ptsmotormovementsareasfollow:RUE____,RLE______,LUE_____,LLE_______
(No)fasciculations,atrophy,rigiditynoted.
Ptssensoryareasfollow:RUE_____,RLE_____,LUE______,LLE________
Sensorymodalitiesthatarefunctionalare()pain/temp,()crudetouch,()vibration,()lighttouch,(
)position.()forstereognosisandgraphestesia
(Ifhemiplegic,pleaseindicateuntilwhatlevelthesensory/motorfunctionscango.Andpleaseassess
foreachquadrant)
Reflexesofptare()forBabinskis.BicepandTricepreflexesare_______(uni/bilaterally).Knee
reflexesare_______(uni/bilaterally).
Meningesshow(no)signofNuchalrigidity,aswellas()forBrudzinskisandKernigsSigns.