Date Ward:

Name: Attending Physician/s:

Age/Sex: Admitting Resident/s:
Birthday: CC:
Civil status:
HPI:

ROS:
headache dysphagia
dizziness body malaise
loc weight loss
vomiting dob
fever bm changes
dysuria melena

PMHx:
Disease Year Maintenance Medications
Diagnosed/Dur
ation
HPN
DM
BA
PTB
CVD
MI
Kidney
Thyroid
Malignancy
Allergies:
Hospitalization
Operation


OB-Gyne Hx
OB Score: G _ P _ ( _ - _ - _ - _ ) I: ____
LMP: __________ D: ____
Menopause: A: ____
M: ____ S: ____________ Meds: ____________
 Coitarche: OCPs:

FMHx:
Disease SIDE-
Relationship to
Patient
HPN
DM
BA
PTB
CVD
MI
Kidney
Thyroid
Malignancy
Allergies:

P/SHx:
Occupation:_________________
Active Smoker/Passive Smoker/Non Smoker/ Packed years: __________
Alcoholic/Non Alcoholic Beverage Drinker/ Frequency: ______________

PE:
Vital Signs:
BP MAP
T Wt
P Ht
R BMI
CBG IBW -
O2 Sat

Gen Survey: Non Exudative/Exudative Tonsils

Ambulatory/wheelchairborne/stretcher __Cervical Lymphadenopathies
borne
Conscious/Semi- Chest/Lungs:
conscious/unconscious Symmetrical/Asymmetrical Chest
In CPD/not in CPD Expansion
Breath sounds: _______ ___________
HEENT: o Wheeze ______
Icteric/Anicteric Sclerae/Pale/Pinkish o Rales ________
Conjunctivae o Rhonchi_______
Dry/Moist Lips/ Dry/Moist
Tongue/Buccal Mucosa
Enlarged/Non Enlarged
/Hyperemic/Nonhyperemic
 Heart: Adynamic/Dynamic Precordium;
PMI: _____ Extremities: __ Edema: grade ___,
Murmur_______ varicosities: ___
Regular/Irregular Rate; Full/faint peripheral pulses/ ______
Regular/Irregular Rhythm range of motion

Abdomen: Skin:
Flat/Globular/Flabby/ ____bowel Lesions_________ Rashes_______
sounds; Soft/Rigid; Tender/Non tender;
Mass ____

Neuro Exam:

Orientation:
o Person o Place o Time o Situation
o
o GCS ____ ( E ___ V ___ M___)
o Cranial nerve o Response
o CN 1 OLFACTORY o
o CN 2 OPTIC o
o CN 3 o
OCULOMOTOR
o CN 4 TROCHLEAR o
o CN 5 TRIGEMINAL o
o CN 6 ABDUCENS o
o CN 7 FACIAL o
o CN 8 ACOUSTIC o
o CN 9 o
GLOSSOPHARYNGE
AL
o CN 10 VAGUS o

o CN 11 SPINAL o
ACCESSORY

o CN 12 o
HYPOGLOSSAL
o
o Cerebellar:
o
o
o Meningeal:
o
o
o Babinski:
o
o
o
o Working Diagnosis/Admitting Impression:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o CBG:
o
o
o ECG:
o
o
o XRAY:
o
o
o CT SCAN:
o
o
o ABG
o Ph: o tCO2
o PCO2 o FiO2
o PO2 o O2 Sat:
o HCO3:
o
o O2 at ____ LPM
o
o DIET:
o
o IVF:
o
o LABS:
o
o
o
o
o
o
o
o
o
o
o
o
o
o MEDS:
o
o
o
o
o
o
o
o
o
o
o
o
o
o PLANS:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o M o o o o o o o o o o o o o o o o o o o o o o o o o
I 7 8 9 1 1 1 1 2 3 4 5 6 7 8 9 1 1 1 1 2 3 4 5 6 T
O
o I o o o o o o o o o o o o o o o o o o o o o o o o o
n
p
u
t
o I o o o o o o o o o o o o o o o o o o o o o o o o o
V
F
o O o o o o o o o o o o o o o o o o o o o o o o o o o
u
t
p
u
t
o B o o o o o o o o o o o o o o o o o o o o o o o o o
M
o
o _edajosiemonserate/cpumed2016_