Date of Interview: ______________________________ Past Medical History:

Time of History: _______________________________ Current Medications:

Informant: ____________________________________ Generic Brand Dosage Frequency Purpose
Relationship to the Patient: ______________________
% Reliability: _________

General Data:
Pa ie Na e: _____________________________ Immunizations:
Age: ______ Sex: _______ Marital Status: ________ BCG DPT Polio Hepa B Rotavirus DPT Hib
Address: _________________________________________________ Pneumococcal Polio Influenza MMR Varicella
Birthday: ________________ Birthplace: _______________________ Hepa A HPV Meningococcal
Nationality: ______________ Religion: _________________________ Others: ________________________________________
Occupation: __________________________ Allergies:
Left-handed or Right handed Asthma: __________
Last attack:_________________
Date of Admission: ______________________ Admission to ER: ______________________
Time of Admission: ______________________ Medicine given:______________________
No. of times admitted at OM: ______________ Food: ___________________________________
Medications: ______________________________
Chief Complaint: ________________________________________ Pollen/Animals/Others: ______________________
Medication taken for allergies:__________________
History of Present Illness: Dermatitis Vasomotor rhinitis
Onset: _______________________________ Urticaria Asthma
Duration: _____________________________ Angioedema Migraine conjunctivitis
Frequency: ___________________________
Eczema Sensitivity to pollens
Periodicity:____________________________
Hay fever Bee stings
Typically Day Night No particular time
Childhood Illness:
Setting at which the Symptom Occurred: _______________________
rheumatic fever polio
_______________________________________________________
Time of onset of symptoms: ___________________ chicken pox measles
Last time patient felt well: _________________ mumps
others: ______________________________
Manifestations: ___________________________________________
Location: ________________________________________ Adult Illness:
Precipitating Factors: _______________________________ Illness Age Date of Diagnosis
Quality: _________________________________________ Hypertension
Radiation: _______________________________________ Stroke
Intensity:_________________________________________ Renal
Severity: ________________________________________ Asthma
Volume: ___________________ Number: ____________________ TB
Size: ____________________ Extent: _______________________ DM
Cardiac
Comparison with previous GI
experience:_________________________________________________ STD
Others
Aggravating Factors: ______________________________________
Alleviating Factors: ________________________________________
Previous Treatment for the Problem: __________________________ Blood pressure: Regular BP: __________________
Associated Signs and Symptoms: _____________________________ Highest BP:____________________
________________________________________________________ Lowest BP:___________________
Pertinent Positives and Negatives: ____________________________ Blood sugar level:_________________________
________________________________________________________ Medications taken:________________________
Compliance:_____________________________
I ac fI e a ie ife: Duration of Illness:____________________________
Relationship:_____________________________________
Exercise tolerance:________________________________ Surgical Procedures:
Ability to concentrate:_______________________________ Date: _______________________________
Leisure activities:__________________________________ Type of Operation: _____________________
Purpose: _____________________________
Associated symptoms and info w/c might help in DDx:
Additional Notes: __________________________________________ Previous Hospitalizations:
________________________________________________________ Date Cause Hospital Treatment
________________________________________________________

Accidents/Trauma:___________________________

Screening Tests:
Test Date Result
Tuberculin test
Pap Smear
Mammogram
Occult blood in stool
Cholesterol test
Urinalysis
Xray/CT Scan/MRI

1
Menstrual and Obstetric History: Medical Problems for any blood-relative
LMP: ____________ PMP: _______________ Relationship to Px Age & Date of Dx
Age of menarche: ____________ Period: regular/irregular Cancer
Character of flow: ____________ Hypertension
Duration of period (range): ____________ Diabetes
No. of pads used per day: ____________ Tuberculosis
PMS: ___________________________________________________
Heart Disease
Leukorrhea
Stroke
Dysmenorrhea
Kidney Disease
Other symptoms:_____________________
Arthritis
Age of Menopause: _______ Post-menopausal bleeding:____________ Blood Disorder
Asthma
Age of 1st coitus: ________ No. of sexual partners: __________ Epilepsy/Muscular
Last coitus: __________________________ disorder
Sexual orientation/Gender of sexual partner:_________________ Mental Disorder
History of post-coital bleeding, pelvic infection, dyspareunia? Osteoporosis
Substance Abuse

Birth control methods used: Personal and Social History:

Artificial Natural Place of Birth:________________
condom rhythm method Current Residence:_________________________________________
pills withdrawal Home situation:
spermicidal abstinence Significant others:___________________
Others: ____________________________________ No. of years married: ______
Length of time used: _________ Health Status of Spouse: ______________
Complications: ______________________________ No. of Children: _______
Health Status of Children: ___________________________________
Surgical procedure done: _____________________________ Highest Educational Attainment: ______________________________
Occupational History: _______________________________________
Gravidity: ______ Parity: _______ _________________________________________________________
OB Index: ________ Term Past work:____________________________
________ Preterm Duration of present work:___________________________
________ Abortions/Miscarriages Occupational Hazards: _____________________________________
________ Living Children Financial situation:_____________________________________
Personality traits: Outgoing quiet moody
Date of Birth Sex Manner of Delivery Smoking Habits:
______________________ ____________________ non-smoker smoker ex-smoker
______________________ ____________________ No. of sticks/packs per day: _________
______________________ ____________________ Year started: ______ Year quitted: ______
Alcohol Consumption
OB Hx: G _ P_ (T-P-A-L) never occasionally
G1: When _________, NSD or CS d/t _________, delivered by daily weekly
_________, where _________, M/F, weight _________, fetomaternal Alcohol type: ___________________
complications _____________________, present status __________. Amount Consumed: ______________
Nutrition:
No. of meals per day: ________
Male History Food preferences: ___________________
Erectile dysfunction Coffee/tea/soda intake: _______________
Premature ejaculation Nutrient Supplement:: ________________
Blood in semen Weight: Usual weight: ______________
Chancre History of weight loss/gain:_________________________
Bubo Prohibited Drugs: _____________
Urethral discharge Substance Abuse: _____________
Treatment of venereal disease Exercise: ___________________________________
Regularity of Sleep: ___________________________
Contraceptives methods:_____________________________________ Habits/hobbies: ______________________________
Condom use: _________________________ Sources of Stress: ___________________________
Coping Strategies: ___________________________
Sexual activity: Living Conditions:
Age of 1st coitus: ________ No. of sexual partners: __________ No. of years in current residence: ____________________
Last coitus: __________________________ Previous place of residence: ________________________
Sexual activities: _____________________ Type of residence: ________________________________
Sexual orientation/Gender of sexual partner:_________________ No. of rooms: _______________________
No. of occupants: ____________________
Relationship to occupants: __________________________
Family History: Ventilation inside the house:_____________________
Family Age Health/ Age & Date Cause of Water source: Maynilad Nawasa
Member Diseases of Dx death Source of Drinking Water: ___________________________
Father Garbage Disposal: _________________________________
Mother Fecal Disposal: ___________________________________
Pet/s: __________________________________________
Siblings Personally gives bath to pets? Y/N

General State of neighborhood: _____________________

Congested proximity to unusual places
Type of House:_____________________________________ ____

2
 Review of System

Constitutional Hemoptysis Stiffness

Weakness (hina) Dyspnea Backache
Fatigue (pagod) Wheezing Swelling
Weight gain (pagsikip ng mga damit, Redness
pagsikip ng sinturon) Cardiovascular Pain
Weight loss (pagluwag ng mga damit) Chest pain or discomfort Tenderness
Fever (lagnat) Palpitations Stiffness
Chills (ginaw) Dyspnea Weakness
Orthopnea Limitation of motion or activity
Skin Paroxysmal nocturnal dyspnea Neck pain
Rashes Edema Low back pain
Lumps (bukol) Cyanosis
Sores Psychiatric
Itching (pangangati) Gastrointestinal Nervousness
Dryness (panunuyo) Trouble swallowing Tension
Changes in color Heartburn Mood
Changes in hair or nails Loss of appetite (walang gana) Depression
Changes in size or color of moles Nausea (parang masusuka) Memory change
Vomiting (pagsusuka) Hallucinations
Hair Hematemesis (pagsuka ng dugo) Anxiety
Baldness (pagkakalbo) Bowel movements Suicide attempts
Excess hair Stool color and size______________
Stool consistency:____________ Neurologic
Head Stool odor:___________________ Changes in mood
Headache (sakit ng ulo) Change in bowel habits Attention
Dizziness (hilo) Pain with defecation Speech
Lightheadedness (walang laman o Rectal bleeding Changes in orientation
magaan ang ulo) Black or tarry stools Memory loss
Syncope (walang malay) Hemorrhoids Insight
Constipation Judgment
Eyes Diarrhea Headache
Loss of vision Abdominal pain Dizziness
Pain Food intolerance Vertigo
Redness Excessive belching____________ Fainting
Excessive tearing Passing of gas ____________________ Blackouts
Double Jaundice Weakness
Blurred vision Hematochezia Paralysis
Spots Numbness
Specks Peripheral vascular Loss of sensation
Flashing lights Intermittent claudication Tingling
Photalgia Leg cramps (pinupulikat) Pins and needles
Varicose veins Tremors
Ears Swelling in calves, legs or feet Involuntary movements
Loss of hearing Color change in fingertips or toes during Seizures
Tinnitus cold weather
Vertigo (pagikot ng paligid o ng sarili) Swelling with redness or tenderness Hematologic
Earaches Easy bruising or bleeding
Discharge Urinary Pallor (maputla)
Frequency of urination________________
Nose and sinuses Polyuria Endocrine
Frequent colds Nocturia (paggising sa gabi para umihi) Heat intolerance
Nasal stuffiness Urgency Cold intolerance
Discharge Burning or pain during urination Excessive sweating
Itching Hematuria (pagihi ng dugo) Excessive thirst or hunger
Nosebleeds Flank pain Polyuria
Ureteral colic Change in glove or shoe siz
Throat, mouth and pharynx
Suprapubic pain
Bleeding gums
Incontinence
Use of dentures
Reduced caliber or force of the urinary
Sore tongue
stream
Dry mouth Hesitancy
Sore throats Dribbling
Hoarseness Dysuria (hirap umihi)
Dysphagia Urinary retention
Toothache Tea-colored urine
Neck
Swollen glands Male genital
Goiter Hernias
Lumps Discharge from or sores on the penis
Pain Testicular pain or masses
Stiffness in the neck Scrotal pain or swelling
Breasts Female genital
Lump Vaginal discharge
Pain Itching
Discomfort Sores
Nipple discharge Lumps
Dyspareunia
Respiratory
Cough Musculoskeletal
Sputum (color, quantity) Muscle or joint pain

3
 PHYSICAL EXAMINATION Shape:
Size/diameter:
General Survey: Edges: diffuse distinct outline outlined with wound
Apparent State of Health:______________ Necrotic tissue type:
None
Development: White/gray slough
Endomorph Mesomorph Ectomorph Yellow slough
Well Fairly Poorly Black eschar
Looks according to age Looks younger/older
Exudate type:
Nutrition Well-nourished Obese Cachexic None Serosanguinous Serous Purulent Foul
Surrounding skin
Pink/skin tone Purple
Mental status: Reddish/blanchable Black
Mood: ______________ White/pallor
Distress/ Unusual Position: _____________ Depth
Preferred posture:_________________ 1 non blanchable
Cooperative/ Non-cooperative 2 loss of dermis/epidermis
Irritable/ agitated/ pleasant 3 damage to subcutaneous tissue/underlying fascia
State or awareness:_____________________ 4 necrosis to subcutaneous tissue/fascia
Level of Consciousness: _______________ 5 damage/necrosis extending to muscle or bone
Facial expression HEENT
LOC Head:
Alert Lethargic Obtunded
Hair
Stuporous Comatose
Quantity: ______________________________________
Coherence Coherent Incoherent Distribution: ______________________________________
Appears alert and attentive to questions: Yes No Texture (fine, coarse):
Makes eye contact: Yes No Pattern of loss (if any): _____________________________
Presence of lice eggs/lice/other parasites: ___________
Expression:
Calm Worried Restless Scalp
Tense Confused Angry Scaliness (note distribution): __________________________
Impatient Masses/Lumps: ____________________________________
Nevi:
General Appearance Location: __________________________
signs of distress in pain anxious Distribution: __________________________
Borders: __________________________
Grooming: clean, well-groomed disheveled Color: __________________________
Personal Hygiene: _______________ Tenderness: __________________________
Body odor:____________ Other lesions:

Language and Speech Skull

difficulty in articulating Configuration
losing train of thought when answering Normocephalic
gives understandable responses Masses
easily distracted Fontanelles
garbled speech Closed Open
Sunken Bulging
Mood and Behavior Skull
unusual mannerisms/reaction Deformities Lumps
sudden outbursts/uncontrollable cry Depressions Tenderness
inappropriate laughter
feeling of unreality, anger, fear General size and contour: __________________________
Shape: __________________________
Memory long term memory short term memory Tenderness: __________________________
Orientation Time Person Place
Face
Height: ____________ Symmetry:
Weight: ____________ Symmetrical movements
BMI: ______________ Asymmetrical movements
Involuntary movements ______________________
Vital Signs: Paralysis _____________________
Temperature: ________ Oral Axillary Rectal Masses _______________________
Respiration: _________ Normal Labored Scars: __________________________
Pulse: _____________ Regular R. Irreg. Irr. irreg. Other lesions: __________________________
Blood Pressure: _______ Lying Sitting Standing Sensation of the face (ophthalmic/maxillary/mandibular)
intact
SKIN decreased
General Color absent
Pallor Jaundice Muscle strength of jaw: normal decreased
Flushed Cyanotic Eyes:
Texture: Smooth Rough Visual acuity: both corrected and uncorrected
Turgor: Good Fair Poor
Temperature: Warm Cool Patient with glasses
Snellen (20 feet): (R) ________ (L) ________
Moisture: Dry Wet/clammy Oily
Near (14 inches): (R) ________ (L) ________
Others:
Petechiae Ecchymosis Rashes
Edema (pitting/non-pitting) grading: _____ Visual Fields
Ulceration (Static Finger Wriggle Test): ___________________
Pressure ulcers Further test (eye with defect, if any is detected):

4
 Remarks: __________________________ Deviation: __________________________
Presence of lid lag: __________________________
Inspection
Without light Convergence test (using pencil or finger) uniform unequal
Eyes (Gross) Remarks: __________________________
Position and alignment: inward deviation Reaction to accommodation: uniform unequal
outward deviation Reaction to light
abnormal deviation R brisk sluggish fixed
Excessive tearing __________________________ L brisk sluggish fixed
Excessive dryness: __________________________ Corneal reflex: intact impaired
Protrusion of eye ball: __________________________ Fundoscopic
Others _____________________________________ Red orange reflex: ______________
Optic Disc: ________________________
Eyebrows: normal distribution scaliness Outline (sharp, dull): __________________________
Quantity: ______________________________ Color: ______________________________________
Others _______________________________ Size of cup (if present): __________________________
Symmetry: ________________________
Eyelids: Papilledema: ________________________
symmetrical edema/swelling Retina:
ptosis abnormal eyelid closure Blood vessels: _________________
Position in relation to eyeballs: _______________________ Spontaneous venous pulsations (if suspecting papilledema):
Color: ________________________________ __________________________
Edema: __________________________ Lesions (size, shape, color, distribution) if any:
Lesions (describe): __________________________ __________________________________________
Condition and direction of eyelashes:
_____________________________________ Fovea and Macula: __________________________________
Adequacy of eyelid closure: __________________________ Lesions
Opacities in vitreous or lens:
Periorbital region: edema sunken discoloration _____________________________________________

Lacrimal apparatus: Ears:

swelling (Gross Inspection)
excessive tearing Auricle
dry Symmetry and position: __________________________
redness Deformities: __________________________
Lumps: __________________________
Conjunctiva Discharge (external): __________________________
pinkish pale discharge lesions Other lesions: __________________________
Bulbar: __________________________ Presence of Hearing aid: __________________________
Palpebral: __________________________ Tenderness (ear tug test, tragal test):
Vascular pattern: __________________________ __________________________
Nodules/swelling: __________________________ External pinnae
Other lesions/discharge__________________________ normoset symmetrical
tenderness gross abnormalities
Sclera Tragus: tenderness
anicteric subicteric icteric hemorrhages
Color (both): __________________________
Acuity
Vascular pattern: __________________________
Nodules/swelling: __________________________ If there is reported hearing loss, do the whispered voice test/finger rub, If
Other lesions/discharge__________________________ none, report as gross hearing intact
(page 237 of Bates, 11th ed)
Remarks: __________________________
With Light
Whispered voice test: symmetrical deafness R L
Cornea and Lens
smooth clear lesions opacity arcus senilis
Conductive vs Neurosensory Hearing Loss
Opacities (if any): R:_________ L: __________
(in Bates, oblique lighting is used, so if ever, do this before Weber test: symmetrical lateralization R L
accommodation) Rinne Test: (R) AC __________ BC ___________
Remarks: __________________________ (L) AC __________ BC ___________

Iris Otoscope (Inspection of middle and inner ear)

defined markings undefined markings Ear canal
Markings: R:_________ L: __________ Hair distribution: __________________________
Remarks: __________________________ Discharge
Other lesions (eg. Crescentic shadow)______________________ Cerumen (describe color, consistency, quantity, location):
__________________________
Pupils Others (blood, etc, describe same as above):
equal unequal __________________________
R = _____ mm L = _____ mm Foreign bodies: __________________________
Shape: R:_________ L: __________ Redness of skin __________________________
Symmetry: Swelling __________________________
Light reflex test (PERLA):
Direct Reaction: ____________ External canal
Consensual Reaction: ____________ impacted cerumen
(if a i ai e , d he ea eac i , e ci fi ge 10c f discharge (foul smelling/serous/purulent/mucoid)
eyes, Ask px to look alternately at it and into the distance directly behind it) Others:
Remarks: __________________________ swelling
redness
use of hearing aid
EOMs
(H-test) Tympanic membrane:
Nystagmus (pause during upward and lateral gaze) if any: intact
__________________________________________ concave
5
 convex
swelling Thyroid gland nonpalpable palpable/enlarged tender
pearly-gray color Others:
normal ROM neck rigidity masses
Ear drum Upward movement __________________________
Color: __________________________ Size __________________________
Contour: __________________________ Shape __________________________
Structures Consistency __________________________
Handle of malleus (position, size, etc.): Nodules
__________________________ Consistency __________________________
Short process of handle of malleus (position, size, etc):
__________________________ Jugular vein distention: present absent
Perforations: __________________________ Carotid pulsation: present absent
Swallowing: intact
Nose: Gag reflex: intact
Sternocleidomastoid strength: normal decreased
External
Anterior and posterior surfaces of the nose Throat
Symmetry __________________________ Speech: intact slurred aphasic
Deformity __________________________ Lips
Lesions __________________________ Color (cyanosis)__________________________
Moisture __________________________
Lumps __________________________
Ulcers __________________________
Internal
Cracking __________________________
Nasolabial fold: symmetrical shallow R L Scaliness __________________________
Patency:
both patent obstructed R L Oral mucosa
masses/lesions congestion pinkish pale cyanotic nodules lesions
Hair (quantity, distribution): __________________________ Color __________________________
Ulcers__________________________
Nasal mucosa White patches__________________________
pinkish pale reddish Nodules__________________________
blood crusts ulceration polyp
discharge (serous/purulent/mucoid/bloody) Gums and teeth
Swelling __________________________ pinkish pale bleeding tenderness
Bleeding__________________________ Color __________________________
Exudate/Discharge (clear, mucopurulent, purulent) Swelling __________________________
__________________________ Gum margins __________________________
Interdental papillae __________________________
Nasal septum
midline deviated perforated Teeth
Inflammation __________________________ complete missing: _______________________________
Perforation __________________________ caries discolored
Ulcers __________________________ misshapen dentures
Polyps __________________________ braces/retainers
Other lesions __________________________ Color __________________________
Sinus tenderness Shape __________________________
Frontal snius __________________________ Margin __________________________
Maxillary sinus __________________________ Position __________________________
Sense of olfaction: Other remarks __________________________
Right: Roof of mouth
intact Color __________________________
able to differentiate odors Architecture __________________________
unable to differentiate coffee and cigarette
Left: Tongue and floor of mouth
intact midline deviation R L
able to differentiate odors atrophy fasciculation
unable to differentiate coffee and cigarette Color __________________________
Texture __________________________
Neck Ulcerations __________________________
Lymph nodes Lesions __________________________
Preauricular nonpalpable palpable/enlarged tender Uvula: midline deviation R L
Posterioe auricular nonpalpable palpable/enlarged tender Tonsils: normal inflamed exudates
Occipital nonpalpable palpable/enlarged tender Pharynx
Tonsillar nonpalpable palpable/enlarged tender Lesions: ______________ Erythema: _____________
Submandibular nonpalpable palpable/enlarged tender Exudates: _____________ Tonsillar Size: _________
Submental nonpalpable palpable/enlarged tender
Superficial cervical nonpalpable palpable/enlarged tender Soft palate, anterior and posterior pillars, uvula, tonsils, pharynx
Posterior cervical nonpalpable palpable/enlarged tender Color __________________________
Deep cervical chain nonpalpable palpable/enlarged tender Symmetry __________________________
Supraclavicular nonpalpable palpable/enlarged tender Exudate __________________________
Ulceration __________________________
Size __________________________ Tonsillar enlargment __________________________
Shape __________________________
Delimitation __________________________ CHEST AND LUNGS
Mobility __________________________
Consistency __________________________
Inspection
Tenderness __________________________
symmetric
Trachea deviation R L
Deviation from midline __________________________ masses/lesions
Symmetry __________________________
6
Comfort and Breathing Pattern: eupnea hyperpnea PALPATION
tachypnea dyspnea (palpate the precordium in aortic, pulmonic, tricuspid (parasternal heave),
distressed diaphoretic labored and mitral area, or the presence of thrills/ palpable murmur)
audible wheezing
PMI at ___________________________________________________
Shape of chest: AP ___:L ___ ratio heaves thrills
barrel funnel pigeon others____ friction rub
Inspiration-expiration ratio: ____:____
AUSCULTATION
Chest Movement: ________________________________
Use of Accessory Muscles of Breathing: ______________ Apical beat: ______ /minute
Deformities of Asymmetry: _________________________ Rhythm:__________ Irregularity:____________
A/N Retraction of Interspaces on Inspiration: ___________
Impairment of Respiratory Movement: ________________ Heart sounds: distinct faint
Ability to speak: regular breathing while speaking few words S1 ___ S2 at base S1 ___ S2 at apex
Color of Patient (Lips & Nail Bed): cyanosis Extra sounds: S3 S4
clubbing of fingernails Timing:________________
Chest veins: prominent not seen Intensity:_______________
Scars: _______________ Pitch:__________________

Murmurs
Palpation
Type:
Tender Areas: ___________________________________ midsystolic pansystolic
Respiratory Expansion (10th rib): Symmetry Yes No (Lag R/L) the late systolic early diastolic
Tactile Fremitus: symmetrical middiastolic late diastolic
increased decreased (at R/L) absent Location: _______________________________________________
Quality: _________________________________________________
Intensity: ________________________________________________
Timing: _________________________________________________
Pitch: high low medium
Radiation: _______________________________________________

BREAST
Symmetry: _____________
Dimpling/Skin Retraction: _____________________
Swelling: ____________________
Discoloration (Skin changes): _________________
Orange Peel Effect: _________________
Position and Characteristic of Nipple: _________________
Trachea: deviation _________ no deviation
Gynecomastia (Male): _________________
Percussion: Mass: Location: _____________________________
resonant dull (R/L) over ___________ Size: ___________ Consistency: _________________
hyperresonant (R/L) over ___________ Tenderness: ______________ Mobility: _____________
Borders: _________________

Nipple and areola:

inversion flattening or retraction edema
ulceration deviation to R L discharge

Axillae:
rashes pigmentation tenderness
lymphadenopathy
lesions discharge

ABDOMEN
Inspection
Irregular Contours: ____________ Scars
Auscultation Discoloration: ________________
Breath Sounds: vesicular bronchovesicular bronchial Bulges: _____________________
Adventitious Sounds: Shape: _____________________
rhonchi over ________ Striae: ______________________
wheezes over _______ Distance of umbilicus from xiphoid process: __________
crackles/rales pleural friction rub stridor Abdominal Girth: __________________
Duration: ________________ sec. Skin:
Frequency: ______________ times/min. dilated veins striae
Relieved upon change of position scars rashes
Relieved upon coughing
Umbilicus: everted inverted inflammed
Transmitted Voice Sounds: sunken bulging hernia
bronchophony whispered petoriloquy
egophony Configuration: flat globular protuberant scaphoid

CHEST AND HEART Symmetry: symmetrical asymmetrical

INSPECTION visible peristaltic waves
visible pulsations
Precordial area:
flat bulging
normodynamic hyperdynamic Auscultation
Pericordial impulse:_______________________ Bowel Sounds: Frequency: ___________ Character: ____________
Apical impulse:__________________ normoactive (5-34/min)
Parasternal lift:___________________ hyperactive
hypoactive
absent
7
Bruit: Kunin itong papel gamit ang kanan/kaliwang kamay,
absent tiklupin sa gitna, at
present at (aorta/renal/iliac/femoral) R L ilagay sa mesa .
d. Reading comprehension (1): Basahin ninyo ito ng malakas at
Friction rub: gawin ang nakasaad o ang nakasulat dito Ipikit
absent
ang mga mata
hepatic friction rub
splenic friction rub e. Writing (1): Mag a a gi a g a g g a . subject
+ verb + sense
Venous hum: positive negative f. Copying and visuo-spatial function (1): K ahi i di
a a e intersection
Percussion
tympanitic hypertympanitic
Fluid wave:________________________________

Liver dullness:
____ cm along right midclavicular line (normal 6-12 cm)
____ cm along midsternal line (normal 4-8 cm)

Spleen
positive splenic percussion sign
negative splenic percussion sign
Ascites: fluid wave shifting dullness

Other Areas of Dullness: _______________

Palpation:
muscle guarding at ______________________________________
direct tenderness at _____________________________________
rebound tenderness at ___________________________________

Liver: masses tenderness

Spleen: nonpalpable palpable tenderness

Special Tests
Reb d Te de e : R i g , B be g
Costovertebral Tenderness
Shifting Dullness
Psoas Sign
M h Sig

NEUROLOGIC EXAM
Mini- Mental Status Examination
Handedness:
Left Right
Orientation (5/5): Ano ang petsa ngayon?
Taon: ________ Araw:
__________ Buwan: _____________
Araw: ________ Panahon
(wet/dry): ___________
Pangalan ng lugar: _________________________
Palapag: _____________
Kalye/Barangay: ________________________
Lungsod: ___________
Probinsya: ______________ Bansa: ____________
Registration (3): (6 trials) Ngayon, susuriin ko ang inyong memorya.
Magsasabi ako ng tatlong bagay. Matapos ko silang sabihin, uulitin ninyo
ang mga ito sa akin. Tandaan ang mga bagay na ito dahil pagkatapos ng 5
minuto ay tatanungkin ko muli kayo tungkol dito. Ito ang tatlong salita
Pakiulit po sa akin
Manga Mesa Pera
Attention and Calculation (5): Paki-spell (o baybayin) ang salitang M-U-
N-D-O Nga , a i-spell (o baybayin) i g aba i ad
O D N U M
Recall (3): Ano yung tatlong bagay na sinabi ko sa inyo kanina .
Manga Mesa Pera
Language:
a. Naming (2): Ano ang tawag sa bagay na ito
Relo Lapis
b. Repetition (1): Ulitin ng eksakto ang pangungusap na sasabihin
ko:
Minikaniko ni Monika ang Makina No ifs, and or
buts.
c. 3-step command (3):
8
Cranial Nerves
CN Primary functions Tests Result
Olfactory (S) Smell Identify odor
Optic (S) Vision VA, VF, Color, Nerve head
Oculomotor (M) Upper lid elevation, EOM, Pupil Physiologic H
constriction, accommodation Near point response
Trochlear (M) SO muscle Physiologic H
Trigeminal (M) Muscle of mastication While palpating the temporal and masseter muscles in
turn, ask the patient to clench the teeth.
Ask the patient to move the jaw side to side.

Trigeminal (S) Scalp, conjunctiva, teeth A he a ie e he he i i ha d

and to compare sides.

forehead, cheeks, and jaw

Abducens (M) LR muscles Abduction, physiologic H

Facial (M) Facial expression Smile, puff cheeks, wrinkle forehead, pry open closed
lids
Facial (S) Taste on ant 2/3
Vestibulocochlear Hearing and balance Weber test
(S) RInne test
Glossopharyngeal Tongue and pharynx
(M) A he a ie a ah a a a ch
Glossopharyngeal Taste on post 1/3 the movements of the soft palate and the pharynx.
(S)
Vagus (M) Pharynx, tongue, larynx, The soft palate normally rises symmetrically, the uvula
thoracic, abdominal viscera remains in the midline, and each side of the posterior
Vagus (S) Larynx, trachea, seophagus pharynx moves medially, like a curtain.
Gag
Accessory (M) SCM and trapezius Shrug, head turn against resistance
Hypoglossal (M) Muscles of tongue Tongue deviation

Motor System Examination

Observation
Body position: _____________________
involuntary movements: ______________________
tremor: location:__________________ rate: __________________ rhythym: ______________
hypokinesia location:__________________ rate: ____________ rhythym: ________________
Inspection (Muscle Bulk)
atrophy (body part): _________________________ Unilateral/bilateral__________ proximal/distal__________
Palpation
tenderness (body part): ______________________________________
fasciculations (body part): ______________________________________
Muscle Tone:
Upper Ex: Take one hand support the elbow rotate the forearm rotate the shoulder
Lower Ex: Hold one leg at the back of the knee rotate the foot
should move easily with little resistance hypotonic/hypertonic spastic/rigid
Functional testing
drift (body part): ______________________________________
fine finger movements: ______________________________________
rapid toe tapping: ______________________________________

MUSCLE STRENGTH
Scoring:
0 No contraction/Flaccid 3 Movement against gravity, not against resistance
1 Muscle flickers, no movement 4 Movement against gravity and resistance
2 Movement possible, not against gravity 5 Normal strength

Notes:
Support the joint away from the muscle being tested
U e f ce c a ib e i h e gh
Compare each side
P d i a ide a be ge ha he he ide
Muscle Groups Nerve Procedure Score
Elbow flexion Support the elbow Fle ion: P ll/Bend o r elbo
Biceps brachii against m hand
Brachialis C5, C6
Brachiradialis E tension: P sh/Straighten o r elbo against m hand
Elbow extension
Triceps brachii
C6, C7, C8
Anconeus
Wrist extension C6, C7, C8 Make a fist Put resistance on the knucles Bend
E. carpi radialis longus Radial nerve o r fist back or Resist hile I p ll the rist do n
 E. carpi radialis brevis
Grip Use your index and middle finger Sq ee e m fingers
C7, C8, T1
as hard as possible and do not let them go.
Finger abduction C8, T1 Palm do n and spread o r fingers Force the fingers
Ulnar nerve together
Thumb opposition C8, T1 To ch the tip of the little finger ith the th mb against
Median nerve m resistance
Hip flexion Place your hand on the anterior thigh (just above the
Iliopsoas L2 L4, knee) apply resistance Raise o r leg against o r
hand)
Hip extension Place your hand on the posterior thigh Apply resistance
S1
Gluteus max P h high d agai ha d
Hip abduction P ace ha d ide he a ie ee ( a e a )
L4- S1
Gluteus medius and minimun S ead eg agai ha d )
Hip adduction P ace ha d be ee he a ie ees (medial)
L2-L4
Adductors (brevis, longus, magnus, pectineus, gracilis) Bi g eg ge he agai ha d )
Knee extension Place support on the posterior side of the knee Apply
Quadriceps (Rectus femoris, Vastus medialis, lateralis, L2-L4 resistance on the anterior foot Lif ff he ab e
intermedius) S aigh e eg agai ha d
Knee flexion P eg i f e ed a he ee; he f e i g he bed
Hamstrings (Biceps femoris, Semitendinosus, Support the anterior knee While you pull the foot up
L4-S2
Semimembranosus Kee f d d e e aigh e
eg
Ankle dorsiflexion
Tibialis anterior Put your hand on the foot (on top of the toes) P
L4, L5
E. digitorum longus agai ha d
E. halluces longus
Ankle plantar flexion
Gastrocnemius Put your hand on the sole of the foot P hd
S1
Soleus plantaris agai ha d
Tibialis psterior

Sensory Examination
PRIMARY MODALITIES TESTED RIGHT EXTREMITIES LEFT EXTREMITIES
Light touch Upper: Upper: %
Yes if patient feels the cotton wisp Lower: % Lower: %

Touch one side and the same spot on the

opposite side of the body

Extinction Upper: % Upper: %

Simultaneously stimulate 2 symmetric areas of the body Lower: % Lower: %
Vibration Lower % Lower: %
Start at distal interphalangeal joints
Ask patient if the vibration stopped
Proprioception % %
Pain Upper: % Upper: %
Closed eyes Lower: % Lower: %

Say dull , sharp , or don t know

Two point discrmination

identify the letter drawn on palm of both upper extremities.
Discrimination
identify a pen when placed on both hands

Coordination and Gait

Rapid alternating movement
o Supinator-pronator
o Plantarflexion-Dorsiflexion
Finger to nose coordination
Gait (if ambulatory)
Coordinated Uncoordinated Staggering
Shuffling Stumbling Unable to walk alone
Walks with assistive devices
Ba a ce: R be g ig
Pronator Drift
both arms straight forward, palms up, with eyes closed (may be done sitting if cannot stand)
after a few seconds, tap arms briskly downwards and ask patient to still keep arms in horizontal position

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