LYCEUM NORTHWESTERN UNIVERSITY

Francisco Q. Duque Foundation

College of Medicine
MONIQUE ANGELA T. GANGAN
Doctor of Medicine III

Date of Interview:
Name of Preceptor:

MEDICINE HISTORY
Case No.

GENERAL DATA

II

CHIEF COMPLAINT:

III HISTORY OF PRESENT ILLNESS

IV. PAST MEDICAL HISTORY
V. FAMILY HISTORY
VI. PERSONAL AND SOCIAL HISTORY
VII. REVIEW OF SYSTEMS
VIII. PHYSICAL EXAMINATION
GENERAL SURVEY:
SKIN:
HEENT
Head:
Eyes:
Ears:
Nose:
Throat (or Mouth):
Neck:
THORAX AND LUNGS:
CARDIOVASCULAR:
GASTROINTESTINAL:
PERIPHERAL VASCULAR SYSTEM:
MUSCULOSKELETAL:
NERVOUS SYSTEM:
CN I:
CN II, III:
CN III, IV, VI:
CN V:
CN VII:
CN VIII:
CN XI:
CN XII:

IX. INITIAL IMPRESSION

X. DIFFERENTIAL DIAGNOSIS
XI. MANAGEMENT

CASE DISCUSSION: