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MEDICAL HISTORY QCGH (MONDAY WARD)

History #:
Historian:
Proctor:
Informant:

Date of History:
Date of Submission:
Reliability:

GENERAL DATA
Name:
Age:
Civil Status:
Occupation:
Birthday:
Address:
Number of consultation:

Nationality:
Religion:
Birthplace:
Date of admission:

CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
(dont forget the PQRST)

PAST MEDICAL HISTORY


Immunization
___ BCG
___Typhoid
___DPT
___Influenza/Flu
___Polio
___Pneumococcal
___MMR
___Hepa B
___HIB
___Tetanus
Past illnesses:
Accidents:
Hospitalizations:
Blood transfusion:
Surgical Operations:

Childhood diseases:
___Measles
___Mumps
___Chicken pox
___Allergy
_____________________others

FAMILY HISTORY
Father: Age:
Illnesses:
Mother: Age:
Illnesses:
Siblings:
HEREDOFAMILIAL DISEASES:

PERSONAL & SOCIAL HISTORY


Educational Attainment:
Occupational History:
Year

Maternal
___
___
___
___
___
___
___

Work History

Marital Status:
Years:
Health status of spouse:
Health status of children:

Age:
Age:
Age:
Age:

Relationship with spouse:


Exposure to STD:

Paternal
___
___
___
___
___
___
___

___ Cancer
___Epilepsy
___HPN
___DM
___Heart Diseases
___Mental Disorders
___Kidney Diseases

Relationship with children:


Year:

# of sexual partners:
Gender:

Time:

Hours nap:

Habits:
Sleep pattern:
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

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

complication

days

[ ] 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 _______MURPHYS 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?
Kilala nyo po ba ang pambansang kamao ng Pilipinas
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
Rombergs sign

MENINGEAL SIGNS (supine)


KERNIGS 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 (Graenlens test) supine, ilaglag sa dulo yung leg
Other test of the hip joint
ANVILS TEST (sole)
PATRICKS 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