University of St.

La Salle – College of Medicine

Jevi Marie P. Ortoño, MD3

General Data: (name, age, sex, marital status, religion, occupation, address. Admission date and time,
interview date and time. Number of admissions.) ______________________________________________
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Source of History: __________________

Reliability: _____________________

Chief Complaint: ______________________________________________

History of Present Illness:

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Past Medical and Surgical History:
 Medical History – __________________________________________________________________
 Surgical History – __________________________________________________________________
 Psychiatric History – ________________________________________________________________

Family History:
 Father – age ____ alive/deceased, ( ) CA, ( )DM, ( )TB, ( )Asthma, ( )HPN, others _______________
 Mother – age ____ alive/deceased, ( ) CA, ( )DM, ( )TB, ( )Asthma, ( )HPN , others ______________
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________

Personal and Social History:

 Occupation _______________________________________________________________________
 Lives with ________________________________________________________________________
 Siblings __________________________________________________________________________
 Educational attainment _____________________________________________________________
 Diet _____________________________________________________________________________
 ( ) Smoker ______________________; ( ) Alcoholic Drinker ________________________________
 Allergies _________________________________________________________________________
 Exercise _________________________________________________________________________
 Hobbies _________________________________________________________________________

Obstetrical History:
 OB Score G__P__(__ __ __ __)
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________
 ________________________________________________________________________________

Gynecological History:
Menstrual History
 Menarche ____ years old
 Has ( ) regular / ( ) irregular monthly cycle of ___ days with ___ days of menstrual flow, consuming
___ napkins/cloths per day, ( ) regular / ( ) irregular flow of menses, and ( ) dysmenorrhea.

Sexual History
  Coitarche ____ years old.
 ( ) heterosexual and has a ______ partner.
 ( ) Dyspareunia, ( ) post-coital bleeding, ( ) vaginal discharges, and ( ) history of STDs.
 Contraception: ( ) Pills, ( ) IV, ( ) Calendar Method
 ( ) PAP Smear

Review of Systems (separate form)

General Survey: (Patient is awake, coherent, responds to the interviewer appropriately, and maintains eye
contact. Patient is cooperative and oriented to time and place. No signs of respiratory and cardiac distress
observed. Patient is groomed accordingly to her age. No body or breath odors were noted. Movements are
coordinated and purposeful, without assistance.)

Vital Signs:
 Blood Pressure: ________ mmHg ( ) Normtensive, ( ) Hypotensive, ( ) Hypertensive
 Cardiac Rate: ____ beats/minute ( ) eucardic, ( ) bradycardic, ( ) tachycardic
 Respiratory Rate: _____ breaths/minute ( ) eupneic, ( ) bradypneic, ( ) tachypneic
 Temperature: _____°C ( ) febrile, ( ) afebrile
 Weight: ____ kg
 Height: ___ ft ___ in
 BMI: ____ kg/m2 ( ) normal, ( ) underweight, ( ) overweight, ( ) obese

Physical Examination

HEENT – Inspection, Palpation

Head
 Head Hair is ( ) thin / ( ) thick , ( ) smooth / ( ) rough and ( ) dry / ( ) oily, ( ) evenly distributed.
 Scalp has ( ) dandruff, nits, or lice.
 Face is ( ) symmetrical with ( ) involuntary movements.
 Skull is ( ) normocephalic with ( ) signs of past head injury.
 ( ) Lumps and ( ) lesions. ( ) Signs of tenderness.

Eyes
 ( ) Anicteric sclera and ( ) pale / ( ) pink conjunctiva.
 ( ) Lid lag and ( ) ptosis.
 ( ) Pupils are equally round and reactive to light and accommodation.

Ears
 ( ) Symmetric auricles. ( ) Deformities, ( ) skin lesions, or ( ) lumps.
 ( ) Discharges, ( ) foreign bodies and ( ) swelling of the ear canal.
 Signs of ( ) tenderness, ( ) lumps, or ( ) masses.
 ( ) Hearing problems noted.

Nose and Sinuses

  ( ) Alar flaring. Nasal septum ( ) midline.
 ( ) Septal perforation. ( ) Pale / ( ) Pink nasal mucosa.
 ( ) Bleeding, ( ) discharges, and ( ) swelling noted.
 Frontal and maxillary sinus ( ) tenderness.

Mouth and Pharynx

 ( ) Pale / ( ) Pink oral mucosa with ( ) ulcerations and ( ) lesions.
 ( ) Pale / ( ) Pink gums with ( ) lesions and ( ) bleeding.
 Uvula and Tongue at ( ) midline with ( ) deviation and ( ) lesions.
 Soft palate rises ( ) symmetrically during inspection.

Neck
 ( ) Trachea midline.
 ( ) Neck veins distended.
 ( ) Palpable thyroid isthmus, ( ) lobes not felt.
 ( ) Thyroid gland rises during swallowing upon palpation.
 ( ) Submandibular or ( ) cervical lymphadenopathy.
 ( ) Masses and ( ) signs of tenderness noted.
 ( ) Bruit

THORAX – Inspection, Palpation, Percussion, Auscultation

 Patient ( ) breathes quietly without the ( ) use of accessory muscles.
 ( ) Trachea is midline.
 Thorax is ( ) symmetric upon inspection.
 Visible chest wall ( ) deformities, ( ) unilateral lag, or ( ) abnormal retraction during inspiration.
 ( ) Areas of tenderness upon palpation. ____________
 ( ) Presence of tactile fremitus felt in most lung fields.
 Breath sounds ( ) vesicular / ( ) bronchovesicular / ( ) bronchial.
 Diaphragms descend ___ cm, ( ) bilaterally.
 ( ) Crackles, ( ) wheezes, and ( ) rhonchi.
 ( ) Absence of bronchophony, egophony, and whispered pectoriloquy.

CARDIOVASCULAR SYSTEM – Inspection, Palpation, Percussion, Auscultation

 Carotid pulse upstroke ( ) brisk, ( ) rapid and ( ) follows S1.
 ( ) Thrills and ( ) bruit observed.
 Point of maximal impulse is ( ) brisk and ( ) tapping, midclavicular line in the ___ intercostal space
at around ___cm.
 ( ) Heaves, ( ) lifts, or ( ) thrills.
 ( ) Normal S1 and S2 with ( ) S3, ( ) S4, ( ) rubs, or ( ) murmurs.
 JVP: ________ CVP: ________

PERIPHERAL VASCULAR SYSTEM

Arms
  Arms were ( ) symmetrical, with ( ) edema.
 ( ) pallor and ( ) signs of hair loss.
 ( ) Both / ( ) left / ( ) right limbs were ( ) cool / ( ) warm to touch.
 ( ) Epitrochlear lymph nodes were felt.

Abdomen
 Abdomen was ( ) cool / ( ) warm to touch, ( ) edema.
 ( ) Abdominal bruits.
 ( ) Aortic pulse palpable.

Legs
 Legs were ( ) symmetrical, with ( ) edema on the ( ) left / ( ) right.
 ( ) Pallor and signs of ( ) hair loss.
 Limbs were ( ) cool / ( ) warm to touch.
 Inguinal lymph nodes were ( ) palpable.

Allen's Test
 ( ) normal, ( ) less than 2 seconds

Arterial Pulses
Radial Brachial Femoral Popliteal Dorsalis Pedis Posterior Tibial

RT 2+ 2+ 2+ 1+ 2+ 1+

LT 2+ 2+ 2+ 1+ 2+ 1+

BREAST – Inspection, Palpation

Inspection
 Breasts are ( ) symmetric and ( ) smooth with visible ( ) masses and ( ) scars.
 Skin around the breasts had ( ) signs of redness.

Palpation
 ( ) Masses and ( ) tenderness upon palpation both the breast and axilla, including the
supraclavicular and infraclavicular area.
 Breast was ( ) soft / ( ) hard with ( ) discharges.

ABDOMEN – Inspection, Auscultation, Percussion, Percussion

Inspection.
 Abdomen is ( ) flat, ( ) protuberant, ( ) symmetrical. Skin is __________________________ (loose
with several folds).
 ( ) Umbilicus midline.
 ( ) Visible aortic pulsation.
 ( ) striae, ( ) dilated veins, ( ) bulges.

Auscultation
 Upon auscultation ___/min gurgles with occasional borborygmi.
 ( ) bruits, ( ) friction rubs
Percussion
 ( ) Tympanic and ( ) dullness ______________________
 ( ) tenderness

Palpation
 ( ) Palpable aortic pulse (2+) ___ cm wide.
 ( ) masses, ( ) tenderness, ( ) peristalsis, ( ) guarding, ( ) nodules

Kidneys
 ( ) palpable, ( ) costovertebral angle tenderness

Liver
 ( ) sharp and ( ) smooth edges, ( ) tender, with a span of ___ cm right midclavicular line and ___ cm
midsternal line

Spleen
 ( ) Splenomegaly

Bladder
 ( ) Distended

Special Techniques
 ( ) Murphy’s sign
 ( ) Fluid wave test
 ( ) Rovsing’s sign
 ( ) Psoas sign
 ( ) Obturator sign

MUSCULOSKELETAL SYSTEM
 ( ) Full range of motion in all joints of the ( ) upper and ( ) lower extremities.
 ( ) swelling, ( ) redness, ( ) tenderness or ( ) deformities noted.

NEUROLOGIC EXAM
Mental Status
Patient is ( ) conscious and ( ) oriented to person, place and time. Patient is ( ) euthymic and ( ) attentive.
( ) Clothes are appropriate. Speech is ( ) fluent and ( ) words are understandable. ( ) Recent and ( ) remote
memory are intact. ( ) Thought processes are coherent. ( ) Insight is clear. ( ) Serial 7s are correct.
( ) Calculations are intact. ( ) No delusions observed. The patient has ( ) intact cognition.

Cranial Nerves
I
  (Olfactory)

II
 Visual Acuity: ___/___ ( ) glasses
 ( ) PERRLA
 pupils constricting from __mm to __mm
 ( ) Red-orange reflex
 ( ) Optic disc

III, IV, VI
 ( ) EOMs intact; ( ) nystagmus

V
 ( ) Sensory
 ( ) Motor

VII
 ( ) Sensory
 ( ) Motor

VIII
 Weber's test: ( ) Midline, ( ) Left, ( ) Right
 Rinne's test: Air Conduction ( ) > or ( ) < Bone Conduction

IX-XII
 ( ) Sensory
 ( ) Motor

Sensory
 ( ) Light touch, pain, position, and vibration senses intact
 ( ) Stereognosis, ( ) Graphesthesia, and ( ) Romberg Sign

Motor
 ( ) Good muscle bulk and tone.
 Muscle Strength: grade ___ /5 ( ) all throughout ___________________________________

Reflexes
 Biceps, triceps, brachioradialis, knee, ankle reflexes - ____ (2+) and ( ) symmetric
 ( ) Plantar reflexes

Cerebellar
 Gait – ( ) Normal base; ( ) balanced
 ( ) Finger to nose, ( ) rapid alternating movements, ( ) heel to shin tests