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: Civil Status: Place of Residence: Admitting Complaints: No. of prior admissions in CVGH: Source of Hx/Data: Name: Reasons for seeking health care/CC: Chief complaint? Feelings about seeking health care? History of Present illness: Can you narrate to me exactly what happened prior to your admission? When did it start? What symptoms did you observe? For how long? Precipitating factors? What did you do or what were you doing when it happened? Relieving factors? What activity relieves problem? Did you self medicate? What were these drugs? Any relief? Did you practice herbal medication or folk medication? If yes, what were these? Who advised you on them? Any consultations done? Who was the doctor? Did the doctor prescribe any medications? What were these? Compliance? Relief noted? Diagnosis made by doctor PTA? Any laboratory exams done before admission? Results? Who recommended hospitalization? What prompted you to seek medical attention? Character? Onset? Better, worse? Duration? Severity? Aggravating factors? Other symptoms with it? Able to do ADL's? Ward & Room/Bed#: Case No.:
Sex: Religion: Date of Admission: How patient was admitted: Date complaints were noted: Doctor:
Location? Relieving factors?
Past Health History: Hypertensive? If yes: for how many years now? When diagnosed? By whom? Normal average BP? Highest BP? Any maintenance medication? What are these? Relief noted? Compliance? Diabetic? If yes: for how many years now? When diagnosed? By whom? last known blood sugar? Highest? Average? Maintenance medication? What are these? Relief noted? Compliance? smoker? If yes: how many sticks per day? For how long now? When and why do you smoke? How often do you smoke? Alcoholic? If yes: how many bottles of beer a day? How long have you been drinking? How often do you drink? When do you usually drink? Why do you drink? Food and drug allergies? Heredo-familial diseases? On maternal side? On paternal side? Problems at birth? Childhood illnesses? Accidents/Injuries? Previous hospitalization: How many times have you been hospitalized? For each hospitalization: When were you hospitalized? Admitting complaints? Who was your doctor? Rehabilitation done after? Compliance to prescribed meds? Environmental History: Where do you live? How long have you lived there? How far from nearest health center? Urban/ suburban/ rural? Is house and lot owned? How many people sleep in every room? Pets? How many? Elaborate Accessible to basic services?
Can you recall the exact date or year? Did condition improve upon discharge? How long did you stay in the hospital? Procedures performed? Actions taken? How was the final diagnosis? Surgery done? Medications given during hospitalization? Take home medications prescribed? Alteration in ADL¶s / body function after? Where hospitalized?
How many bedrooms? How far is it from church? How far from brgy hall? Water source? Supplied by? How many people live in house? How many windows? how accessible to market? Peace and order situation in area?
How many stories? How far from main road? Describe neighborhood? Congested? Electricity? Supplied by? Adequate sleeping quarters? Space around house? Or firewall? How accessible to transportation?
Gordon¶s functional health pattern: HEALTH PERCEPTION HEALTH MANAGEMENT How do you look at life and your health? Good? Bad? How would you rate your health? Why? Do you have any medical check ups? Who do you usually go to for primary health care? How often or when do you usually see a doctor? Do you see quack doctors or practice folk medicine? Do you practice self medication? Why or why not? Do you perform BSE or TSE? Are you aware of your condition? How much do you know about your illness? Elaborate What do you think caused it? Are you fully immunized? When prescribed medicines. what do you do to help remedy the problem? How often do you void? How many times do you void per day? Describe your urine« color? Clear? How strong is your urine flow? How much do you usually void per setting? Per day? Any problems with voiding? Pain? Blood? Has your sickness or hospitalization changed your elimination pattern? How? ACTIVITY EXERCISE PATTERN What is your occupation in life? Describe your job. how often? Why or why not? What do you do for recreation? Who do you usually spend recreational time with? Has your sickness changed your activity pattern? How? SLEEP AND REST PATTERN When do you usually sleep? What time do you usually wake up? Do you use any sleeping aids? What are these? Do you take drugs or sedatives to facilitate sleep? How many pillows do you use? Do you have any problems sleeping? What do you usually do or take in if you have a hard time sleeping at night? Before onset After onset In hospital Before onset After onset In hospital Before onset After onset In hospital Before onset After onset In hospital Before onset After onset In hospital . what are these? Do you have any problems in eating like difficulty in chewing or swallowing? Do you have regular dental exams? How often or when do you see a dentist? Have you ever consulted one? Do you have any dentures? How about fillings? Any missing teeth? Do you take supplements? What are these if any? Do you take in fruits daily? What are these? Has your diet changed with your sickness and subsequent hospitalization? How? How much liquids do you usually take in per day? Any weight loss noted? ELIMINATION PATTERN How often do you eliminate your bowel? What are your bowel habits? When do you usually move your bowel? Describe your stools« color? Form? Do you use laxatives? Any difficulty eliminating your bowel? Do you experience constipation? If so. do you follow the prescription? Do you take any measures to safeguard you health? What are these? Has your sickness and hospitalization changed the way you view your health? How? NUTRITION METABOLIC PATTERN Height: Weight: IBW: Kind of diet in hospital: Banana per meal included? If with NGT: Kind of diet: calories per day: cc per day: Feedings per day: cc per feeding: grams fat: Grams CHO: grams CHON: How often do you eat in a day? What do you usually eat during your meals? Breakfast? Lunch? Dinner? When do you eat breakfast? Lunch? Dinner? With whom do you usually eat? Where? Any favorite foods? If so. Stressful? Physical? What do you do? What time do you usually report for work? How about going home? When do you usually wake up? What do you do upon waking? What do you usually do after breakfast? Lunch? Dinner? What do you usually do in the morning? Afternoon? Evening? Do you have siesta time after meals? Do you take naps in the morning? Afternoon? What do you usually do before going to bed? Do you practice regular exercise? If so.
beliefs and rituals? (if not catholic) Do you have the same religion as your parents and with the rest of the family? Do you believe in God? What is your concept of him? How often do you attend religious services? With whom? From a religious point of view.Is your sleep restful? Do you feel refreshed upon waking up? Has your current condition affected your sleep and rest? How? Have you been getting enough rest lately? COGNITIVE PERCEPTUIAL PATTERN Is patient oriented to time. or neighbors happen? How do you usually solve your problems? What do you usually do to relieve stress? Has your current condition stressed you or in any way affected you in the way you cope with and manage your problems? In what way? VALUE BELIEF PATTERN What is your religion? Can you tell us about it? Your practices. friends. place and people? Patient¶s sensory status? Is patient able to recall past events? Does patient know his name or how old he is? Is patient able to recall the events that happened yesterday? Has patient¶s current condition markedly affected his cognition and perception? How? SELF PERCEPTION AND SELF CONCEPT PATTERN How do you see yourself? Is it in a positive or negative way? What can you say about yourself? How about your accomplishments in life? What can you say about your life? How have you lived it? Are you satisfied with how things have gone for you? Are you happy with yourself and what you have done with your life? Any problems? Worries? Or concerns as of now? Fears about your illness? Do you believe that you will be cured? Has your current condition affected your perception or the way you view yourself? How ROLE RELATIONSHIP PATTERN What place do you occupy in your family? Are you the eldest? Youngest? How many siblings do you have? How good is your relationship with them? How many children do you have? How good is your relationship with them? How long have you been married to your wife? How is your relationship with your wife? Any problems? Has your marriage been satisfying and fulfilling for the both of you? What is your role in your current family today? Are you satisfied or happy with it? Do you have a lot of friends? Acquaintances? Relatives? How is your relationship with these people? Has your current condition affected your relationships or the way you interact with other people? How? What have you done to adjust? SEXUALITY REPRODUCTIVE PATTERN When did your puberty start? What did you notice? When were you circumcised? When was your first sexual contact? With whom? How many partners have you had since then? Are you choosy when it comes to partners? (if multiple) Any history of STD? Any history of contraceptive use? Are you currently sexually active? How often do you usually do the act? Has your illness affected your sexual activities? How? COPING STRESS TOLERANCE PATTERN How would you view or define stress? Do you believe you are stressed right now? Why or why not? Who makes most of the major decisions in your family? Do you consult with other members before making such decisions? Who runs the everyday activities of the house? What can you say about your current illness? What is your outlook on life? Good or bad? Do you currently have any major family problems? What are these? What do you do when personal problems arise? With whom do you share your problems with? What do you do when conflicts with your relatives. how would you describe yourself? Do you pray? How often do you do so? Do you ask help from a higher being in times of need and crisis? Before onset After onset In hospital Before onset After onset In hospital Before onset After onset In hospital Before onset After onset In hospital Before onset After onset In hospital Before onset After onset In hospital .
s lesions or lumps symmetric Still. (responsive / nonresponsive). and with the ff V/S: BP _______ mmHG. dry Symmetric. does not remain indented Equally Not equally Clean. firm.Has your current condition affected you in the way you practice your faith? GENOGRAM: ECOMAP: PHYSICAL EXAMINATION: General appearance: Seen patient (sitting / lying / ________________) on (bed / chair / ___________). weight _______. lower lid at bottom edge. hard. erect Hard. with ISA. crepitation c mov't. upright. T _________C/ (orem / axilla / rectum). moist s opacities. RR _________cpm. with IVF of _________ (1 liter / 1 pint) regulated at ________ (gtts / ugtts)/min infusing well at (left / right) (arm / leg). evenly spaced. 1-2cm in each direction NAILS Color shape condition Transparent. (coherent / incoherent) with NGT in place with oxygen inhalation flowing well via (nasal cannula / face mask / ET tube) regulated at 2 L/min. O2 sat:_________. IBW:_________ BMI & interpretation:___________ Attachments on px: Breast : Uterus: Bladder: Bowel: Lochia: Episiotomy: Homan¶s sign: Emotional Status: SKIN Jaundice Lesions POSITIVE Redness Tenderness Edema Distribution/Config Ecchymosis Discharges Approximation Evenly colored skin tone Good warm Slightly moist Smooth and even Thin c calluses noted on plantar surface Not noted NEGATIVE Color Turgor Temp Moisture Texture Thickness Edema HEAD AND HAIR Dandruff Lice Tenderness Distribution Color of hair Normocephalic Condition Configuration and symmetry consistency Facial symmetry Involuntary mov'ts TMJ Poor / senile Rebounds. minimal lacrimation Transparent. nailplate firmly attached to nailbed EYES PERRLA Discharges eyeballs eyelids Lacrimal apparatus Cornea and lens Symmetrically aligned in sockets s protruding/sinking Lashes short. no tenderness/drainage. lid margins pink and moist s swelling/lesions. closes and opens fully. smooth. no clubbing Clean. with colostomy bag in place at (right / left) abdomen. tenderness. well-trimmed. with FBC ± CDU draining well. Nail base & skin. pinkish 160 angle bet. no abn facial mov'ts noted Oiliness. PR ________bpm. height _______. curled outward. round. lesions No swelling. close easily Puncta visible s swelling/redness. smooth. lenses are clear . upper lid covers 2mm or iris. (awake / asleep).. with hemovac in place and draining well at __________.
smooth s nodules. moist. moist. lesions. smooth. stenson's ducts visible s redness. pearly gray External ear External canal HEARING Whisper test Watch tick test Weber test Rinne test NOSE External portion patency Internal portion Repeats 2-syllable word at 3-ft distance Reports hearing watch tick within 5 in from ear Vibrations heard equally well in both ears. firm. lumps or nodules. palpation of sinuses Flaring Discharges Transillumination Septum at midline MOUTH Lips Gag reflex Teeth and gums Color consistent c rest o e face. no lateralization of sound AC>BC Percussion. smooth. covered eye does not move as cover is removed Both move in smooth coordinated manner in all 6 directions VISION Color vision Visual acuity: distant Visual acuity: near Peripheral vision (Confrontation test) Able to identify primary colors around the room 20/20 OU s hesitation. moist. papillae present on dorsal surface. nodules or fasciculations. frowning or squinting Reads print at 14 in s difficulty Sees examiner finger at same time examiner sees it/visual fields full by confrontation EARS Cerumen Tenderness (auricle. moist. smooth. color consistent c face Canal walls pink. symmetric. moist. ventral surface smooth & shiny. at midline. no tenderness Able to sniff. no dental appliance. mastoid process. redness. trauma/ abn discharges Equal hair distribution Red Pale Unequal Reflexions of light noted at same location on both eyes Uncovered eye remains fixed. swelling or pain Moist. pink. hangs freely in midline s redness pale . small visible veins present. foreign bodies. moist and s lesions.iris Color of sclerae Bulbar conjunctiva Palpebral conjunctiva Eyebrows EXTRAOCULAR MUSCLE FX Corneal light reflex test Cover test Cardinal gaze Round. tympanic membrane shiny. no lesions. tiny vessels visible Pink. smooth. pink gums. canal) Discharges Symmetrical Can hear whispered voices Auricle position Equal in size bilaterally about 5 cm Outer pinna in line with inner canthus. 10 degree angle of vertical position. no decayed areas. free of ulcers or perforation non-tender Clear frontal and maxillary sinuses Oral mucosa Tongue Uvula Pink. septum at midline. moist s swelling. tight margins to the tooth. free earlobes (attached soldered) Smooth s lesions. blow through each nostril while other is occluded Nasal muscosa is dark pink. s lesions. pinkish. frenulum in midline c visible wharton's ducts on each side Pink. uniform color White Clear. free of exudate. s lesions or swelling intact 32 white-yellowish teeth. swelling noted Pink.
lesions Pink. quiet s use of accessory muscles Not noted Symmetric. 5 cm apart anteriorly and posteriorly Unequal S1 distinct. AP less than T. soft) Breath odor Tonsils Oropharynx/posterior pharyngeal wall NECK Symmetry or exudate Whitish hard palate c firm transverse rugae. sternum straight at midline. muffled. pink. nonprotruding.Palate (hard. letter E distinguishable whispered pectoriloquy ± very faint. effortless. bronchovesicular over major bronchi & vesicular over peripheral lung fields Broncophony ± soft. hepatojugular reflux Jugular venous pressure Bruits (carotid arteries) PERIPHERAL VASCULATURE arm/leg edema Not noted Scapulae symmetric. no edema (pitting/non- . smooth. retraction. non-tender. palpable when swallowing. pendulous R slightly larger than L Everted bilaterally c light brown areola. easily identified in upper regions of lungs. sontrolled Midline Landmarks at midline. rhythm and quality o respiration Crepitus Fremitus Percussion tone Diaphragmatic excursions Breath sounds Voice sounds Tenderness Chest expansion HEART Distinct s1 and s2 Heaves (visible pulsations) Apical impulse Abnormal pulsations (thrills. thyroid cartilage. s exudate or lesions ROM Trachea Thyroid gland Lymph nodes BREAST Shape Symmetry Nipples Symmetric c head centered. decreases in intensity at bases Resonant on all lung fields 4cm. heard best at apex s2 distinct. firm. cricoid cartilage. relaxed. symmetric s exudate. no dimpling. muffled. swelling. equal bilaterally Bronchial sounds noted over trachea. indistinct egophony ± soft. lesions/inflammation No masses/tenderness noted Minimal amount Nonpalpable Masses Discharges Lymph nodes THORAX AND LUNGS Adventitious breath sounds Configuration Retractions and bulging Depth. montgomery tubercules present. thryroid gland move upward symmetrically when swallowing Full. smooth. no hepato-jugular reflux 1 cm above sternal angle c head of bed elevated to 30 deg Not noted obstructed/too narrow Bilaterally symmetric. heard best at base Not noted 5 ICS at left MCL Not noted 70 bpm. etc) Rate and rhythm of apical pulse Pulse deficit Extra heart sounds Murmurs Chest pain Normal rate and rhythm NECK VESSELS Jugular vein distention. regular 0 Not noted th Not noted when ct is sitting upright. s nodules/bruits Palpable Not palpable Round. ribs slope downward c symmetric ICS. moist soft palate. pink. smooth. muffled nontender Equal. costal angle c/in 90 deg Not noted Regular. no lesions No unusual or foul odor noted 1+.
globular. contour Bowel sounds Symmetry Striae Umbilicus Aortic pulsations Peristaltic waves Bowel sounds Vascular sounds. s bulging Slight pulsations noted Not seen Soft gurgles. <2 sec R ulnar and radial arteries patent L ulnar and radial arteries patent Not noted R . no tenderness None Nontender at blunt percussion of CVA. COLDSPA Strong Strong < 2 sec Weak Weak > 2 sec Male Female Sacrococcygeal area: Rectum: Shaft: Urethral opening and discharge: Scrotal skin: Masses: Lymph nodes: Inguinal lymph nodes: Labia minora. round. clicks heard at 15 per min No bruits. not palpable Constant borders between tympany and dullness throughout position changes No fluid wave transmitted Not noted Not noted negative Yes No cm. recessed.pitting) Nail beds. thin or muscular/flat. scaphoid Normal. vaginal opening: Bartholin's glands: Cervix: Posture/Stature: Symmetry: . capillary refill time Allen test Varicosities Homan's sign Rate and amplitude of peripheral pulses ABDOMEN Gross appearance. not palpable. MSL ± 6 cm Not palpable. friction rubs Percussion tone Liver span Liver palpation Spleen All pinkish. no bulges noted when ct raises head Not noted Midline. venous hums. clitoris. L negative Masses palpated Kidneys Urinary bladder Shifting dullness Fluid wave test Rebound tenderness Psoas sign Obturator sign Mass present Abdominal girth Abdominal pain EXTREMITIES Full ROM Peripheral pulses Strength Edema CRT GENITO URINARY Grossly Pain in urination Lesions Discharges RECTUM: Perianal area: Anus: MALE GENITALIA & PROSTATE: Penis ± Base & Pubic Hair: Foreskin and glans: Scrotum ± Size. not palpable Flat percussion tone on empty bladder. hyperactive. shape and position: Testicles & nearby structures: Inguinal area ± Hernias: Prostate: FEMALE GENITALIA: External genitalia ± Mons pubis: Labia majora and perineum: Urethra: Internal genitals ± Vaginal mucosa: BACK AND EXTREMITIES: Gait: ROM: (full or limited) Flabby. th 7cm wide near left 10 rib posterior to MAL. no tenderness Percussion discloses a dull oval area approx. or friction rubs Generalized tympany over all quadrants MCL ± 8 cm. or hypoactive Symmetric s bulges or lumps.
purse lips. raise eyebrows.10 ± GLOSSOPHARYNGEAL. AC>BC. close eyes against resistance ± whispered words heard within 3 ft bilaterally. ABDUCENS (M) 5 ± TRIGEMINAL (B) GCS: Facial expressions: Vocabulary: Place: Memory: Remote: Abstract reasoning: Judgment: Mood/Affect: Thought processes: Time: Recent: Finger thumb test: Heel to shin: Tandem walk: Involuntary mov'ts: Discrimination bet. gag reflex present.4. reads print 14 in away. sharp and dull: 2-pt discrimination: graphesthesia: ± correctly identifies scent ± 20/20 OU.6 ± OCULOMOTOR. vibration heard equally well in both ears. dull touch to forehead. maintains balance even when eyes are closed ± Uvula and palate rise symmetrically when client says ³ah´. frown. wrinkle forehead. hygiene and grooming: Speech: Orientation: Person: Attention: Fund of Info: Similarities: Visual Perceptual & Constructional Ability: Motor/Cerebellar Fx: Rapid alternating mov'ts: Finger-nose: Button-unbutton: Romberg test: Sensory Fx: Light touch sensation: Vibratory: stereognosis: kinesthesia: CN testing: 1 ± OLFACTORY (S) 2 ± OPTIC (S) 3. TROCHLEAR. able to push tongue blade to R and L s difficulty SUPERFICIAL REFLEXES: abdominal: PATHOLOGIC REFLEXES: brudzinki's sign: cremasteric: Kernig's sign: plantar: . cheek and chin. identifies light. turns head in both directions against resistance ± Protrudes tongue in midline. PERRLA ± corneal reflex present. full peripheral vision ± full extraocular mov't. able to smile. VAGUS (B) 11 ± SPINAL ACCESSORY (M) 12 ± HYPOGLOSSAL (M) DEEP TENDON REFLEXES: ± Equal shoulder shrug against resistance. clenches teeth ± correctly identifies taste of sugar and salt. sharp.spine: cervical : upper extremities: shoulders: lower extremities: hips: crepitus: fasciculations: bony deformities: muscle strength: special tests: phalen's test: lasegue test: ³ballottement´ knee test thoracic and lumbar: elbows: knees: arms: ankles and feet: wrist: hands and fingers: tinel's test: ³bulge knee´ test: mcmurray's test: NEUROLOGIC ASSESSMENT: Mental status/Cerebral Fx: LOC: Dress. puff out cheeks. swallows s difficulty 7 ± FACIAL (B) 8 ± VESTIBULOCOCHLEAR (S) 9. show teeth.
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