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Date: Time:

Initials of Patient: Occupation:


Age: Gender: Marital status:
Source:
Reliability:

Chief Complaint:

History of Present Illness:


Ask about Feelings of the patient
Every Symptom: Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation , Timing,
Associated manifestations

Medications

Allergies.

Tobacco
Alcohol and Drugs
Past History:
Childhood Illnesses:

Adult Illnesses:
Medical:

Surgical: (note: dont forget year and place where the procedure was done, if w/ complications, if na
blood transfusion na)

Ob/Gyn: G_P_ (_-_-_-_) ; ND CS ; menarche __, menopause __

Health Maintenance:
Immunizations

Screening Tests

Family History (mga kapatid: age, sex, kung sakit din; then parents: age, kung may sakit or ano ikinamatay)

Personal and Social History


Source of support
Home situation
Source of stress
Activities of daily living
Religion and beliefs
Exercise
Diet
Review of Systems:

General: fevers , chills, night sweats( pagpapawis na malamig), fatigue (pagod, nanlalambot)), weakness,
weight loss or gain, changes in appetite (pagbabago sa mga gustong pagkain), trouble sleeping, recent trauma

Skin: rash (butlig), itching, lesions, moles, ulcers (butas), bruises, edema( manas), cyanosis (pasa, bahaging
napapansing nagiging asul ang kulay), diaphoresis (pagpapawis), abscess (nana), sunburns, dryness,
pigmentation (pasa), texture , changes in hair growth or loss (naglalagas ang buhok), nail changes

Head: headache (location, time of onset, duration, precipitating factors), vertigo (umiikot yung paningin),
lightheadedness , dizziness (nahihilo), trauma, hair changes (color, texture, distribution, loss), jaw pain, sinus
pain

Ears: hearing changes, tinnitus (masakit o may tumutunog sa tenga), pain, vertigo, drainage (may lumalabas
na luga)

Eyes: vision changes, glasses/contacts, double vision, blurring, redness, tearing, blind spots, pain, discharge,
inflammation, dry eyes, photophobia, glaucoma, cataracts, specks, flashing lights, trauma, last eye exam

Nose: nose bleeding, obstruction, sneezing, discharge, congestion, itching, hay fever (sumusumpong na
sipon), anosmia (pagkawala ng pang amoy), rhinorrhea, sinus pain

Mouth/Throat: oral ulcers or sores (singaw), pain, dry mouth, sore tongue, dysphagia (hirap lumunok),
odynophagia (masakit pag lumunok), hoarseness , sore throat, thrush (na infection na nagkukulay puti), dental
difficulties, gingival bleeding, dentures, last dental exam

Neck: neck stiffness, pain, tenderness, lumps (bukol), swollen glands, masses in thyroid or other areas

Breasts: pain, breast lumps/masses, tenderness, swelling, nipple discharge, change in appearance, trauma,
breast-feeding, self exam

Respiratory: shortness of breath, wheezing (may tunog na naririnig pag humihinga), stridor, cough (time of day,
dry or wet, productive), sputum (color, amount in tablespoons or cups per day), hemoptysis (umuubo ng dugo),
respiratory infections, asthma (hika), bronchitis, emphysema (sakit sa baga), pneumonia (pulmonya), pain
(location, quality, relation to respiration, pleuritic pain?), tuberculosis (or exposure to TB), fever or night sweats,
clubbing, last CXR

Cardiovascular: chest pain or discomfort, tightness (naninikip ang dibdib), pressure (may nakadagan),
palpitations (mabilis na tibok ng puso), syncope (nawalan ng malay), dyspnea on exertion( hirap huminga),
murmurs, irregular rhythm (hindi regular ang tibok ng puso), orthopnea (hirap matulog ng walang unan) (# of
pillows), platypnea (hirap huminga pag tumatayo o nakaupo), paroxysmal nocturnal dyspnea, edema,
cyanosis, hypertension, claudication

Gastrointestinal: appetite changes, dysphagia, odynophagia, indigestion (hindi natutunawan), food intolerance
(may hindi nakakain), abdominal pain, heartburn, eructation (kabag) (belching), bloating, lactose intolerance
(hindi makakain o makainom ng anuman na may gatas), nausea, vomiting, hematemesis (nagsusuka ng
dugo), jaundice, constipation, diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling),
flatulence, hemorrhoids (almoranas), recent changes in bowel habits, rectal bleeding, BRBPR, hematochezia
(maroon-colored stool), melena (black tarry stool), hepatitis

Urinary: urgency, frequency, burning or pain, nocturia (#/night), hematuria, polyuria, oliguria (kaunti ang ihi),
unusual/change in color or smell of urine, stones, infections, nephritis, flank pain, suprapubic pain, enuresis
(umiihi sa kama), hesitancy, change in stream, dribbling, acute retention, incontinence

Genital (Male): dyspareunia, change in libido, potency, genital sores, discharge, venereal disease, hernia
(luslos), penile pain, scrotal masses or pain, erectile dysfunction, self exam

Genital (Female): dyspareunia, change in libido, vaginal discharge, itching, rash, genital sores, masses,
venereal disease, hernia, pelvic pain, periods (onset, length, frequency, duration), amenorrhea, dysmenorrhea,
menorrhagia (labis na pagdudugo), metrorrhagia, intermenstrual bleeding/spotting, menopause, post-
menopausal bleeding, vaginal dryness, last menstrual period

Vascular: varicosities, leg cramps (pulikat), blood clots, claudication (calf pain w/walking)

Musculoskeletal: pain, swelling, redness, warmth of muscles or joints, limitation of motion, muscular
weakness, atrophy, cramps, arthritis (rayuma), arthralgia, stiffness (morning?), back pain, trauma, gout (piyo),
fractures, dislocations, joint deformities

Neurologic: seizures (epilepsy), paralyses, tremor( panginginig pag may ginagawa), syncope (pagkawala ng
malay), dizziness, incoordination, gait disturbances (hirap sa balanse), parathesias, hyperesthesia, focal
weakness, numbness, difficulties with memory or speech, sensory or motor disturbances, ataxia, aphasia,
clonus

Hematologic: anemia, bleeding tendency, bruising tendency, previous transfusions and reactions, Rh
incompatibility

Endocrine: polydipsia (madalas na uhaw), polyuria (sa ihi), polyphagia (sobra sa pagkain), asthenia (physical
weakness or lack of energy), hormone therapy, growth, change in glove or shoe size, secondary sexual
development, intolerance to heat or cold, increased facial hair (female)

Psychiatric: mood swings, anxiety, depression, nervousness, stress, disturbing thoughts, unusual perceptions,
memory loss, hallucinations, suicidal or homicidal thoughts, previous psychiatric care

Physical Examination:

GS: height: weight: build:


Posture, motor activity, gait, dress, grooming, hygiene, any odors of body or breath. Watch the patients facial
expressions and note manner, affect, and reactions to people and the environment. Listen to the patients
speech, and note the state of awareness or level of consciousness.

Vital Signs. BP: RR: HR: Temp: Rhythm:

Skin. Observe the skin of the face and its characteristics. Assess skin moisture or dryness and temperature.
Identify any lesions, noting their location, distribution, arrangement, type, and color. Inspect and palpate the
hair and nails. Study both surfaces of the patients hands. Continue your assessment of the skin as you
examine the other body regions.

Head, Eyes, Ears, Nose, Throat (HEENT). Head: Examine the hair, scalp, skull, and face. Eyes: Check visual
acuity and screen the visual fields. Note the position and alignment of the eyes. Observe the eyelids and
inspect the sclera and conjunctiva of each eye. With oblique lighting, inspect each cornea, iris, and lens.
Compare the pupils, and test their reactions to light. Assess the extraocular movements. With an
ophthalmoscope, inspect the ocular fundi. Ears: Inspect the auricles, canals, and drums. Check auditory acuity.
If acuity is diminished, check lateralization (Weber test) and compare air and bone conduction (Rinne
test). Nose and sinuses: Examine the external nose; using a light and a nasal speculum, inspect the nasal
mucosa, septum, and turbinates. Palpate for tenderness of the frontal and maxillary sinuses. Throat (or mouth
and pharynx): Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx.

Neck. Inspect and palpate the cervical lymph nodes. Note any masses or unusual pulsations in the neck. Feel
for any deviation of the trachea. Observe the sound and effort of the patients breathing. Inspect and palpate
the thyroid gland.
Back. Inspect and palpate the spine and muscles of the back. Observe shoulder height for symmetry.

Posterior Thorax and Lungs. Inspect and palpate the spine and muscles of the upper back. Inspect, palpate,
and percuss the chest. Identify the level of diaphragmatic dullness on each side. Listen to the breath sounds;
identify any adventitious (or added) sounds, and, if indicated, listen to the transmitted voice sounds

Breasts, Axillae, and Epitrochlear Nodes. In a woman, inspect the breasts with her arms relaxed, then
elevated, and then with her hands pressed on her hips. In either sex, inspect the axillae and feel for the axillary
nodes. Feel for the epitrochlear nodes. Palpate the breasts, while at the same time continuing your inspection.

Anterior Thorax and Lungs. Inspect, palpate, and percuss the chest. Listen to the breath sounds, any
adventitious sounds, and, if indicated, transmitted voice sounds.

Cardiovascular System. Observe the jugular venous pulsations and measure the jugular venous pressure in
relation to the sternal angle. Inspect and palpate the carotid pulsations. Listen for carotid bruits. Elevate the
head of the bed to 30 for the cardiovascular examination, adjusting as necessary to see the jugular venous
pulsations. Inspect and palpate the precordium. Note the location, diameter, amplitude, and duration of the
apical impulse. Listen at each auscultatory area with the diaphragm of the stethoscope. Listen at the apex and
the lower sternal border with the bell. Listen for the first and second heart sounds and for physiologic splitting
of the second heart sound. Listen for any abnormal heart sounds or murmurs.

Abdomen. Inspect, auscultate, and percuss the abdomen. Palpate lightly, then deeply. Assess the liver and
spleen by percussion and then palpation. Try to palpate the kidneys. Palpate the aorta and its pulsations. If you
suspect kidney infection, percuss posteriorly over the costovertebral angles.

Lower Extremities. Examine the legs, assessing three systems while the patient is still supine. Each of these
three systems can be further assessed when the patient stands.

Nervous System. Mental Status. If indicated and not done during the interview, assess the patients orientation,
mood, thought process, thought content, abnormal perceptions, insight and judgment, memory and attention,
information and vocabulary, calculating abilities, abstract thinking, and constructional ability. Cranial Nerves. If
not already examined, check sense of smell, strength of the temporal and masseter muscles, corneal reflexes,
facial movements, gag reflex, and strength of the trapezia and sternocleidomastoid muscles. Motor System.
Assess muscle bulk, tone, and strength of major muscle groups. Cerebellar function: rapid alternating
movements (RAMs), point-to-point movements, such as finger-to-nose (F N) and heel-to-shin (H S), gait.
Sensory System. Assess pain, temperature, light touch, vibration, and discrimination. Compare right with left
sides and distal with proximal areas on the limbs. Reflexes. Including biceps, triceps, brachioradialis, patellar,
Achilles deep tendon reflexes; also plantar reflexes or Babinski response

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