MEDICAL HISTORY – QCGH (THURSDAY WARD)

History #:
Historian: Date of History:
Proctor: Date of Submission:
Informant: Reliability:

GENERAL DATA

Name:
Age: Civil Status: Nationality:
Occupation: Religion:
Birthday: Birthplace:
Address:
Number of consultation: Date of admission:

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

PAST MEDICAL HISTORY

Immunization Childhood diseases:
___ BCG ___Typhoid ___Measles
___DPT ___Influenza/Flu ___Mumps
___Polio ___Pneumococcal ___Chicken pox
___MMR ___Hepa B ___Allergy
___HIB ___Tetanus _____________________othersp
Past illnesses:
Accidents:
Hospitalizations:
Blood transfusion:
Surgical Operations:

FAMILY HISTORY
Father: Age: Illnesses:
Mother: Age: Illnesses:
Siblings: Paternal Maternal
HEREDOFAMILIAL DISEASES: ___ Cancer ___ ___
___Epilepsy ___ ___
___HPN ___ ___
___DM ___ ___
___Heart Diseases ___ ___
___Mental Disorders ___ ___
___Kidney Diseases ___ ___

PERSONAL & SOCIAL HISTORY

Educational Attainment:
Occupational History:
Year Work History
Marital Status:
Years:
Health status of spouse: Age:
Health status of children: Age:
Age:
Age:

Relationship with spouse: Relationship with children:

Exposure to STD: Year: # of sexual partners:

Gender:

Habits:
Sleep pattern: Time: Hours nap:
Diet:

___Coffee
___Alcohol No. of bottles: Age started:
___Smoking: ___sticks/day ____packs/day; ____per year Quit:____ Year/age:____
___Drugs of abuse:___________________________________________

Hobbies:
Exercise:
Living conditions:
Living with:
Housing conditions
Source of water supply:
Waste disposal:

OBSTETRICAL HISTORY
Menarche: Age: Duration: #of pads: Symptoms:
Interval: _______ regular _______irregular
Premenstrual symptoms:______________________________________________________
Last Menstrual Period:
Menopausal Age:
History of contraceptives:
OB SCORE: G P (F P A L )
Gravida Year manner Term Place of birth delivered by complication days

REVIEW OF SYSTEMS
General
[ ] fever, [ ] chills, [ ] malaise, [ ] fatigability, [ ] weight change
Integumentary
[ ] pruritus, [ ] pigmentation or texture change
Head and Neck
[ ]headache, [ ]dizziness, [ ] head injuries, [ ] syncope
[ ]blurring, [ ] diplopia, [ ] photophobia, [ ] eye pain
[ ] hearing loss, [ ] ear pain, [ ] discharge, [ ] tinnitus, [ ] vertigo
[ ] sense of smell, [ ] nasal obstruction, [ ] epistaxis
[ ] horseness, [ ] sore throat, [ ] disturbance of taste
Respiratory
[ ] dyspnea, [ ] chest pain, [ ]cough, [ ] back pain
Cardiovascular
[ ] chest pain, [ ] palpitation, [ ] dyspnea, [ ] orthopnea
[ ] easy fatigability, [ ] shortness of breath
Gastro-intestinal
[ ] poor appetite, [ ] dysphagia, [ ] nausea, [ ] vomiting
[ ] diarrhea, [ ] constipation, [ ] abdominal pain, [ ] flatulence
[ ]abdominal enlargement, [ ] steatorrhea, [ ] melena,
[ ] hematemesis, [ ] hematochezia
Genito-urinary
[ ] dysuria, [ ] flank or suprapubic pain, [ ] frequency
[ ] dribbling, [ ] incontinence, [ ] hematuria, [ ] polyuria
[ ] oliguria, [ ] passage of stone, [ ] discharge
Musculoskeletal
[ ] muscles pain, [ ] joint pain & stiffness, [ ] swelling
[ ] bone deformity, [ ] weakness, [ ] atrophy
[ ] restriction of motion
Neurologic
[ ] syncope, [ ] seizures, [ ] weakness or paralysis
[ ] headache, [ ] tremors, [ ] loss of memory, [ ] dizziness
Endocrine
[ ] weight change, [ ] goiter, [ ] heat or cold intolerance
[ ] polyuria, [ ] polydypsia, [ ] polyphagia
[ ] abnormal growth
Hematologic
[ ] easy bruisability, [ ] easy fatigability, [ ] pallor

PHYSICAL EXAMINATION
GENERAL SURVEY
___conscious ____unconscious ___coherence Attitude: ____________________________
Nutritional/developmental status: ___________________ gross deformity: _______________________
Posture: ___________ Gait: ___________ ____ambulatory _____nonambulatory
___febrile ___afebrile Cardiac/ respiratory distress: ________________________

VITAL SIGNS
BP_______________ PR_______________ RR________________ TEMP________

SKIN
Color_______ texture_________ temp_________ moisture____________
Mobility____ Turgor____ Elasticity_____
Skin lesions __________________________________________________________
Hair ___________________ Nails ________________________________

HEENT
CRANIUM

FACE

EYES

EARS

NOSE

MOUTH AND THROAT

NECK

CHEST AND LUNGS

INSPECTON

PALPATION

PERCUSSION

AUSCULTATION

CARDIOVASCULAR
NECK VEINS JVP ________ Palpate carotid___________________________
Auscultate carotid: _____________________________________

PRECORDIUM
Inspect chest
Apical impulse

Palpate for thrills, lifts, heaves

AUSCULTATION
PERIPHERAL PULSES
Carotid, brachial, radial, femoral, popliteal, dorsalis pedis arteries

ABDOMEN
INSPECTION
Inspect shape
- Globular, flat, scaphoid, rounded
Measure size (tape measure)
Check for skin lesions
Inspect umbilicus
Check symmetry
Inspect movement

AUSCULTATION (STET)
Supine (right side of patient)
All 4 quadrants
Start from the RUQ, LUQ, LLQ,
1 min at the RLQ
Auscultate for aortic and renal bruit

PALPATION
Light papation (4 quadrants)
Note for tenderness

Deep palpation
Note for tenderness

Palpate the liver

Note for tenderness, superficial mass

Percuss the liver span

Use tape measure

PERCUSSION
Percuss four quadrants
Perform costovertebral angle test
(kidney punch test)

SPECIAL EXAM
TEST FOR CHOLECYSTITIS _______MURPHY’ S SIGN
Hook liver, ask the patient to inhale, look for inspiratory arrest

TEST FOR PERITONITIS _______Direct tenderness (RLQ) _________Rebound tenderness

TEST FOR APPENDICITIS ________PSOAS SIGN

Raise leg and flex, ask for tenderness at RLQ

OBTURATOR SIGN
Flex leg, rotate lateral, internal, note for tenderness at RLQ

ROVSING SIGN
Palpate LLQ, ask tenderness at RLQ

TEST FOR ASCITES ________FLUID WAVE TEST ______SHIFTING DULLNESS

NEUROLOGICAL EXAMINATION
CEREBRAL FUNCTIONING
Ano pong pangalan nyo?
Ano na pong oras ngayon?
Asan po kayo ngayon?
Kuya 10+10 = 20 – 5 = 15
Kuya pakitandaan po tong 4 na bagay na sasabihin ko – tapos mamaya itatanong kop o ulit
BOLA, PAGKAIN, BAHAY, PAPEL
Ano pong petsa ang araw ng mga patay?
Ano po ulit yung 4 na bagay na sinabi ko sa inyo?
Sino po ang president ng pilipinas bago si P.NOY?

CRANIAL NERVE TESTING

CN I – OLFACTORY
CNII – OPTIC
Ask patient to read the print.
Peripheral visual field test
CN III – OCCULOMOTOR
Penlight, light reflex
CN III, IV, VI – OCCULAR MUSCLE
Move 1 finger up, down, left right, diagonal
CN V – TRIGEMINAL
SENSORY –light touch on face
MOTOR – chin, jaw - resistance
Corneal reflex (sensory)
CN VII – FACIAL
MOTOR – raise eyebrows, wrinkle forehead, purse lips, smile
SENSORY – TASTE
Dropper juice, sabihin nyo po sa kin kung anong lasa.

CN VIII – VESTIBULOCOCHLEAR
Rubbing fingers, close eyes, whisper
CN IX – GLOSSOPHARYNGEAL
CN X – VAGUS
Pharyngeal wall elevates upon stimulation of the gag reflex, Uvula is at the midline
CN XI – ACCESSORY
Apply pressure on shoulder and neck
CN XII – HYPOGLOSSAL
Tongue out and move, inspect for atrophy

MOTOR TESTING
Inspect upper and lower extremities for atrophy, tenderness, muscle tone, muscle strength (resistance upper/lower ext)

CEREBELLAR FUNCTIONING
Finger to nose test
Rapid alternating test
Heel to shin test
Gait

REFLEXES
Biceps, triceps, kness, ankles
Babinski, Chadock

SENSORY
Pain sensation on arms
Position sense (thumb)
Stereognosia
Romberg’s sign

MENINGEAL SIGNS (supine)

KERNIG’ S BRUDZINSKI, NUCHAL
EXTREMITIES
HANDS AND WRIST
Inspect the nail beds, nail plates, clubbing of fingers,
Inspect for tenderness, swelling and nodules of the hand and wrist
Perform ROM
Close fist, open, abduct, adduct
Flex, extend, abduct adduct
FOREARM
Palpate radius and ulna
Ask for tenderness, inspect muscle symmetry and atrophy
Pronation, supination

ELBOW JOINT
Landmarks – olecranon process, lateral and middle epicondyle
Look for symmetry, atrophy
Extend, flex, pronation, suponation

UPPER ARM
Check symmetry and tenderness of biceps, triceps

SHOULDER JOINT
Landmarks – acromion, greater tuberosity of the humerus, coracoids process
ROM – abduct, adduct, external and internal rotation

CERVICAL SPINE
Flex neck, extend, hyperextension, lateral bending, lateral rotation

HIP JOINT
Lnadmark – ASIS
ROM – extend, flex, abduct, adduct, internal and external rotation

Active hyperextension (prone – raise leg)

Passive hypertension (Graenlen’s test) – supine, ilaglag sa dulo yung leg

Other test of the hip joint

ANVIL’ S TEST (sole)
PATRICK’ S TEST (de quarto supine)
STRAIGHT LEG RAISING TEST
TRENDELENBERG SIGN

KNEE JOINTS
Check for tenderness, deformities, atrophy, symmetry
ROM – supine – flex and extend

ANKLE JOINT AND FOOT

Landmarks – lateral and medial malleolus
ROM – standing – plantar flex (toes) and dorsi flex (heel), inversion, evertion
Inspect pedal deformities, toe and cutaneous deformities