Informant:_____________________________________ First part to hit the ground (head, back,
Date and time of hands etc.) interview:_______________________ _______________________ Reliability:_____________________________________ Interventions done (forced movement, Patients name:________________________________ hilot etc.) Age: _____ Gender: M F __________________________________________ Date of birth:__________________________________ Encourage the patient to tell story, use open to Place of birth:______________________________ close ended, dont interrupt, listen carefully, Civil Status: ____________________________________ summarize periodically, and check out vague Citizenship: ____________________________________ statements Religion: ______________________________________ Onset: Occupation: ___________________________________ _____________________________________________ Residence: ____________________________________ Location: _____________________________________________ _____________________________________________ Date of Duration: admission/consultation____________________ _____________________________________________ Time of Character: admission:______________________________ _____________________________________________ Number of Aggravating factors: hospitalization:_______________________ _____________________________________________ Date of Last hospitalization and reasons: Alleviating factors: ____________ _____________________________________________ _____________________________________________ Radiation: Where: _______________________________________ _____________________________________________ CHIEF COMPLAINT: Timing: __________________________________________________ _____________________________________________ __________________________________________________ Severity (pain scale of 1-10) HISTORY OF PRESENT ILLNESS ____________________________________________ AMPLE Associated manifestations/ signs and Allergies: symptoms _____________________________________________ __________________________________________________ Medications: ________________________________________ _____________________________________________ Medications, dose and frequency: Past medical illnesses/surgery: __________________________________________________ _____________________________________________ ________________________________________ Last meal: Laboratories done and results: _____________________________________________ __________________________________________________ Events preceeding the injury: ________________________________________ _____________________________________________ Clinical impression of the doctor and For trauma patients: (NOI/TOI/POI/DOI) instructions: Nature Of Incidence: __________________________________________________ _____________________________________________ ________________________________________ Time Of Incidence: PAST MEDICAL HISTORY _____________________________________________ MEDICAL: Place Of Incidence: Previous hospitalization, previous diseases _____________________________________________ (date, reason of hospitalization): Date Of Incidence: __________________________________________________ _____________________________________________ __________________________________________________ For BURN PATIENTS: ___________________________________ Chemical Electrical Flame Medications:___________________________________ Rule of 9: _____ _____________________________________________ For VEHICULAR ACCIDENT PATIENTS: Immunizations:_________________________________ Where is the patient seated _____________________________________________ __________________________ (driver seat, (For Trauma: Tetanus Toxoid vaccine) passenger seat, crossing the pedestrian) Childhood diseases: For FALL patients: _______________________________ Level or number of stairs Childhood immunizations: ____________________ ___________________________ Blood transfusion: _________________________________ __________________ Allergies (food, drugs): Meal preference meat or veggies: ______________________________ _____________________ SURGICAL: Like salty foods, soy sauce or patis: Dates:________________________________________ ___________________ Indication:____________________________________ Like sweets: Type of operation: ______________________________________ _____________________________________________ Any food restrictions: OB/GYNE _______________________________ MIDAS: Vit.supplements: Menarche:____________________________________ __________________________________ Interval:______________________________________ Herbal medicines: Duration:______________________________________ _________________________________ Amount:______________________________________ Glasses of water/day: S Smoker Last menstrual period: Brand:________________________________ __________________________ Since when he/she started: GP (FPAL): __________________________ Gravida, # of When did you quit: pregnancy:________________________ _________________________________ Para, # of # of sticks or packs per day: deliveries:___________________________ _________________________ Termed Pack years: deliveries:______________________________ ______________________________________ Preterm Alcoholic drinker deliveries:______________________________ What Brand: __________________________ Aborted pregnancy: ___________________________ Since when he/she started: Living:________________________________________ __________________________ Birth control Methods: When did you quit: _____________________________ _________________________________ Age of menopause: ________ Bottles per drinking session: Menopausal symptoms: _________________________ _____________________________ Do you drink? softdrinks Post menopausal bleeding: How __________________________ frequent_____________________________________ PSYCHIATRICS:_________________________________ What _____________________________________________ brand:______________________________________ FAMILY MEDICAL HISTORY Activity of daily living: Are parents still living, how is their health ___________________________________________ __________________________________________________ Exercises and physical activities: ________________________________________ __________________________________________________ Any family member who passed way due to ___________________ a disease? What disease? Sleep: __________________________________________________ ___________________________________________ _______________________________________ Sources of stress: Any family member or relatives with Heart _________________________________ Disease, chole, stroke, kidney disease, Coping mechanism: arthritis, cancer, diabetes, thyroid problem, ________________________________ mental illness, asthma, PTB/lung disease Work history: hematologic problems, depression, suicide: __________________________________________________ __________________________________________________ ___________________________________ ________________________________________ Type of Family: Nuclear Extended How many brothers and sisters? How many people in your house: ___________________ _____________________________________________ Rank in the family: Place of residence: _________________________________ __________________________________________________ Hows their health? ______________________________ ________________________________ Owned Rented Boarding house PERSONAL AND SOCIAL HISTORY Eating habit: (frequency and amount) Apartment 2 Floors 3 Floors No. of cr. __________ Type of toilet: Manual Itching Flush Nose bleed Source of water: Sinus trouble ___________________________________ NECK drinking water: Swollen glands ____________________________________ Goiter/lumps: Garbage disposal: __________________________________ _________________________________ Pain: ________________________________________ if collected how frequent: Stiffness ____________________________ Are there prevalent diseases in the THROAT community: Soreness __________________________________________________ MOUTH ________________________________________ Bleeding Dentures Sore tongue REVIEW OF SYSTEMS dry mouth SYMPTOMS BEFORE ADMISSION, ILLNESS BREASTS GENERAL Lumps Weight loss: ______________________________ Pain/discomfort Weight gain: _______________________________ Nipple discharge Weakness Self examination Feels tired CARDIAC Fever: ______________________________________ BP: ________ SKIN Previous ECG: Changes in skin color ___________________________________ Changes in hair Rheumatic fever Changes in nails Murmurs Changes in moles Chest pain Sores Dyspnea Dryness Orthopnea Rashes Edema Lumps Palpitations HEAD RESPIRATORY Head injury Difficulty of Breathing Headache Hemoptysis Quantity: __________________ Dizziness Cough lightheadedness Sputum Color/Quantity: ______________ EYES Wheezing Vision: ______ Eyeglasses Contact Last Chest X- lenses ray:_________________________________ Pain: _______ Redness Cataract GIT Spots/specks Excessive tearing Trouble swallowing Double/blurred vision Heart burn Flashing lights Nausea EARS Vomiting Difficulty of hearing Hepatitis Tinnitus Jaundice Vertigo Constipation Ear pain Diarrhea: Infection Appetite:____________________________________ Discharge ___ NOSE Bowel habits: Frequent colds __________________________________ Congestion Pain:_________________________________________ Discharge _ Stool color: PSYCHIATRIC ____________________________________ Nervousness Food Tension intolerance:________________________________ Changes in mood PERIPHERAL/VASCULAR Depression Leg cramps Memory change Claudication Suicidal attempts Past clots in vein NEUROLOGIC Swelling In attention or speech Color change in fingertips during cold Headache Swelling with redness and pain Dizziness GENITOURINARY Fainting Frequency Seizures Polyuria Blackouts Nocturia Weakness Urgency Paralysis Pain (burning, suprapubic): Tremors _______________________ Numbness Hematuria Tingling pins and needles Hesistancy: HEMATOLOGIC ___________________________________ Easy bruising/ bleeding Incontinence Anemia Dribbling Past blood transfusion GENITALS FOR MALES Reason:_________________________________ Hernias ENDOCRINE Discharges Thyroid trouble Sores Heat/cold intolerance Testicular pain Excessive thirst/hunger Swelling Excessive sweating History of STI: Change in shoe size _________________________________ PHYSICAL EXAMINATION (SIGNS) Sexual habits/interest/satisfaction: GENERAL SURVEY _____________________________ ____________________ Apparent state of health: GENITALS FOR FEMALES ____________________________ Bleeding after intercourse Appropriate body built for age: Itching _______________________ Vaginal discharges Ambulatory: (color/characteristics): ______________________________________ ______________________________________________ Level of consciousness: Lumps _____________________________ Sores Skin color/ obvious lesions; History of STI: __________________________ _________________________________ Dress grooming and personal hygiene; Sexual habits/interest/satisfaction: Clothing, clean and appropriate for profession _____________________________________________ and weather, shoes/ slippers, body piercings, MUSCULOSKELETAL hygiene and grooming appropriate for age, Muscle or joint pain nail polish Stiffness ______________________________________________ Gout ______________________________________________ Back ache Facial Swelling expression:________________________________ Limitation of motion Body History of trauma/fall odor:______________________________________ Systemic features: Fevers Chills Posture and Rash gait:_________________________________ Height_________________ Weight: BREAST _________________ Inspection: shape, color, discharge, lump, BMI ___________________ swelling, inflammation Signs of distress: Palpation: nodule, mass _________________________________ CHEST AND LUNGS VITAL SIGNS Inspection: deformity, lesions, chest BP (palpatory first): ________________ retractions PULSE: _________________________ Palpation: tactile fremitus (tres-tres use base RESPI RATE : ____________________ of palms), lung expansion TEMPERATURE: _________________ Percussion: tympanitic, consolidation SKIN L R to compare both sides Inspection: lesion, jaundice, nevi, scar Auscultation: (vocal fremitus tres-tres, breath Palpation: skin turgor, hydration, nodules, sounds, adventitious sounds like wheezes, cyst, mass rales, egophony) HEAD L R to compare both sides Inspection: symmetry, hair distribution, CARDIOVASCULAR alopecia, scar, visible lesion Inspection: bulging, adynamic precordium, Palpation: depression, lump, lesion, skull Palpation: PMI, thrills (use palm), JVP (jugular symmetry pulsation to sternal angle, normal: <3-4cm, EYES bed at 30 degrees) Inspection: symmetry, redness, hematoma, Percussion: cardiac size (area of resonance to excessive tearing, color of the sclera and the dullness, 3rd-6th ICS) conjunctiva Auscultation: aortic regurgitation (lean Palpation: tenderness forward then exhale completely and stop Fundoscopy: red orange reflex, macula, blood breathing in expiration during exhalation) vessels murmurs, valve sounds, PMI, check for pupilary reflex, accommodation Aortic (2nd R ICS) reflex, direct & consensual reflex Pulmonic (2ndL ICS) check for extraocular muscles integrity Tricuspid (lower L parasternal) convergence test Mitral (apex PMI- 5th ICS L midclavicular line) NOSE GASTROINTESTINAL Inspection: midline, deformity, discharges Inspection: shape, lesion, ascites, jaundice, Palpation: tenderness of sinuses, epistaxis, umbilical vein dilation, caput medusa scars, mass Ausculation: bowel sounds, abdominal aorta, check the turbinates bruits EARS Percussion: tympanic, mass or air or fluid Inspection: shape, deformity, lesions, Palpation:, deep and light palpation, swelling, impacted cerumen tenderness, mass Palpation: tenderness Rovsings sign, psoas sign, obturator sign,(+) using the otoscope check for the integrity of ankle jarring- appendicitis, the tympanic membrane (pearly white/gray) murphys sign- cholecystitis and look for perforation and inflammation liver span, check for the spleen- if palpation using tunning fork, assess Rinnes and there is splenomegaly Webers Test fluid wave test and shifting dullness for THROAT ascites Inspection: lesion in the oral, buccal mucosa, tongue, position of the uvula, tonsilar inflammation, gag reflex, difficulty in swallowing NECK Inspection: lesions, scars Palpation: thyroid gland (below cricoids cartilage, ask patient to swallow), mass, lymph node Ausculation: (if hypertensive check for carotid bruits)