Name of Patient: _________________ Hospital: _____________________

Informant: ______________________ Department: __________________

Reliability: _______________________ Preceptor: ____________________
Historian: _______________________ Date Taken: __________________
Group No.: _____________________ Date Submitted: _______________

CLINICAL HISTORY
I. GENERAL DATA
Name: ______________________ Age: _______________________
Civil Status: _________________ Nationality: _________________
Sex: _______________________ Religion: ___________________
Birth Place: _________________ Birth Date: _________________
Address: ____________________ Handedness: _______________
Nth visit: ___________________ Date and Time of admission: ___________

II. CHIEF COMPLAINT: __________________________________

III. HISTORY OF PRESENT ILLNESS

_______ PTA Symptom: ___________________________
Onset: ______________________________
Duration: ____________________________
Character: ___________________________
Frequency: __________________________
Intensity: ____________________________
Precipitating factors: ______________________________
Aggravating factors: ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
_______ PTA Symptom: ___________________________
Onset: ______________________________
Duration: ____________________________
Character: ___________________________
Frequency: __________________________
Intensity: ____________________________
Precipitating factors: ______________________________
Aggravating factors: ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
Associated symptoms? ___________________________
_______ PTA Symptom: ___________________________
Onset: ______________________________
Duration: ____________________________
Character: ___________________________
Frequency: __________________________
Intensity: ____________________________
Precipitating factors: ______________________________
Aggravating factors: ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
Associated symptoms? ___________________________
_______ PTA Symptom: ___________________________
Onset: ______________________________
Duration: ____________________________
Character: ___________________________
Frequency: __________________________
Intensity: ____________________________
Precipitating factors: ______________________________
Aggravating factors: ______________________________
Relieving factors: Medications? _____________________
Position? _________________________
Associated symptoms? ___________________________

IV. PAST MEDICAL HISTORY

_______ PTA Presenting symptom:

How diagnosed:
Hospitalization:
Medications and compliance:
Follow up consultation:
_______ PTA Presenting symptom:
How diagnosed:
Hospitalization:
Medications and compliance:
Follow up consultation:
History of surgery: ________________________________________________________
Hospitalizations: _________________________________________________________
Accidents: ______________________________________________________________
Allergies: _______________________________________________________________
Immunization status: ______________________________________________________

V. PERSONAL AND SOCIAL HISTORY

Education: __elementary __high school __college __post-grad __vocational course: ________________
Occupation: ____________________ hours of work per day: _____________________
Usual daily activities: _____________
Financial Status: _______
Housing: # of household members: _________
House: __concrete __wood others: _______ one storey two storey
__good lighting __good ventilation
Toilet: ___flush type ___pour flush
Diet: ________________
Water Supply: __deep well __NAWASA others: _______
Drinking water: boiled? yes no
Garbage disposal: segregate? __ yes __ no collected? __yes __no (if yes, when?______________)

Risk habits:
Smoking age started:____ age stopped: ____ cig/day: _____ pack/yrs: _______
Alcohol drinking: age started:____ age stopped: ____ frequency: ______ bottles: _______
Drugs:

VI. FAMILY HISTORY

Ask the following diseases (specify who and what side)
HPN:________ DM: ________ Asthma: _________ TB: _________
Cardiac dse: _____ Cancer: ____

VII. OB GYNE HISTORY

Menarche: _________ LNMP: ______________
Cycle: __ regular __ irregular
Quantity:
# of napkins : ________
# of pregnancies : ________
# of abortions : ________
# of children : ________
Menopause: _______
Contraceptives: _______
VIII. REVIEW OF SYSTEMS
General ___weakness (___%) ___loss of appetite __low-grade fever __weight loss (___%)
___easy fatigability
Integument ___wound ___rashes ___erythema ___pallor ___clubbing of nails
___hyperpigmentation ___hypopigmentation ___mass
Head & Neck ___stiffness ___headache ___distension of veins ___mass ___dizziness
___swelling
Eyes ___pain ___redness ___corrective lenses ___discharge ___ineteric sclera
Ears ___otalgia ___vertigo ___tinnitus ____difficulty in hearing
Nose & ___watery discharge ___epistaxis ___obstruction
Sinuses
Mouth & ___toothache ___hoarseness ___dysphagia ___ulcers ___tongue fasciculation
Throat ___sore throat
Respiratory ___cough ___dyspnea ___hemoptysis ___tachypnea ___pleuritic chest pain
___greenish phlegm
Cardiovascular ___angina ___dyspnea ___palpitations ____orthopnea __paroxysmal nocturnal dyspnea
GIT ___anorexia ___nausea ___vomiting ___diarrhea ___abdominal distention
___abdominal pain ___ constipation ___melena ___hematemesis ___hematochezia
___retching
GUT ___frequency ___nausea ___polyuria ___oliguria ___nocturia ___dysuria
___flank pains ___palpable mass
Vascular ___claudication ___ulcers
Hematologic ___easy bruising ___easy bleeding ___pallor
 Endocrine ___polyuria ___polyphagia ___polydypsia ___diaphoresis ___heat/cold intolerance
MSS/ ___fractures ___joint pains ___edema
Extremities
Nervous ___seizures ___syncope ___tremors ____one-sded weakness ___slurring of speech
System ___headache

Autonomic ___fecal incontinence ___urinary incontinence

Deficiency

PHYSICAL EXAMINATION
GENERAL SURVEY
Development: ___poorly ___fairly ___well
Nutrition: ___poorly ___fairly ___well
Consciousness: ___conscious ___comatose ___drowsy ___stuporous
Coherence: ___coherent ___incoherent
Oriented to: ___time ___place ___person ___dyspneic ___tachypneic
Cardio-respiratory distress: ___mild ___moderate ____severe
Orthopneic: ___no ___yes Relieved by: ____ pillows
___bedridden ___weak but ambulatory ___ambulatory
Appears his/her chronological age: ___yes ___no
IV line: ___yes (left/right) ___no
Foley catheter: ___yes ___no
O2 via nasal cannula: ___yes ___no
NGT: ___yes ___no
Endotracheal tube: ___yes ___no

Vital Signs:
BP: _____________ mmHg, sitting/supine
CR: _____________ beats/min
PR: _____________ beats/min
RR: _____________ cycles/min
Temp: ___________ C

SKIN
A. General Characteristics:
I. Inspection
A. Color: ___pallor ___jaundice ___erythema ___normal (no pallor/jaundice/erythema)
B. Edema: ___yes ___ no (if yes, generalized___ localized___ location?
II. Palpation
A. Temperature __febrile __cool to touch ___normal (not febrile nor cool to touch)
B. Turgor: ___ prompt return of skin (normal) ___ delayed return of skin (dehydration is present)
C. Degree of moisture: ___dry ___moist __normal (no excessive dryness or moisture)
D. Hardness (sclerosity) or Laxity (nonresiliences)
__ normal skin: soft and resilient
__ sclerotic (like scarred tissue) eg. In scleroderma
__ non resilient eg. In cutis laxa

B. Presence or absence of skin lesions

__ no primary skin lesions
__ macule __ patch __ papules __ plaques __ nodules __ tumors __ vesicles
__ bullae __ wheels __ pustules

If primary lesions are present, describe as to:

Color?
Shape or configuration?
Distribution or location?
Pattern?
Presence or absence of secondary lesions:
__scales __crusts __erosions __ulcers __fissures __lichenification
__atrophy __sclerosis __scarring

C. Skin appendages (hairs and nails)

I. Hair
__hair loss if yes, distribution? ___________
__hair excess
II. Nail Unit
Nail plate: ___dystrophy or deformities __clubbing __koilonychia (spoon-shaped)
Good capillary refill: ___yes ___no
HEAD AND NECK
Hair: color:______ density:_____ distribution:_____ texture:______ pattern of loss:______
Scalp: ___lumps ___scales ___flakes
Skull: ___normocephalic others _______
___symmetrical ___assymmetrical
___lumps Location: _______
___tenderness Location: _______
Facial Symmetry:
___symmetrical, if not give location: ______
___deformities ___mass/swelling ___tenderness
Enlarged parotid/submandibular glands: ___yes ___no
Cervical lymphadenopathy: ___yes ___ no If yes, where in particular: _________
Trachea: ___midline ___deviated (left/right)
Thyroid palpable? ___yes ___no
Thyroid cartilage moves with deglutition: ___yes ___no

JVP: _____
Carotid pulsations?: ___equal
Carotid bruit: ___present __absent

EYES
Symmetrical: __yes __no
Color of conjunctiva:__pale __pink __red
Direct light reflex: __present __absent
Consensual light reflex: __present __absent
Pupil reactive to light? ___yes (size _____mm) __no
Cornea & lens opacities: __yes __no
Visual acuity: _____/_____

For Distant Vision:

Without correction Pinhole With correction With correction &
Pinhole
Right Eye
Left Eye

For Near Vision:

Without Correction With Correction
Right Eye
Left Eye

Tonometry:
__soft __hard

Fundoscopy:
Red-Oran Media Disc Cup Disc Arterio-ve Hemorrha Exudate Foveal
ge Reflex Ratio nous ratio ge reflex
OD
OS

EARS
Auricle/Preauricle:
Mass: __yes __no
Lesions: __yes __no
Patent: __yes __no
Cerumen: __scanty __impacted others:_______
Tympanic Membrane:
__pearly gray __pink __shiny __translucent __intact __perforated \
__lesion __mass __discharge
Tuning Fork Tests:
Weber: __midline __left __right
Rinne: __(+) AC > BC __(-) AC < BC
 Schwabach: __equal __prolonged __shortened

NOSE
Symmetrical: ___yes ___no
Masses: ___yes Describe: __________ ___no
Lesions: ___yes Describe: __________ ___no
Patent: ____yes ___no
Septal deviation: ___midline ___left ___right

MOUTH AND THROAT

Lips
Symmetry: ___yes ___no
Mass: ___yes ___no
Ulceration: ___yes ___no
Oral mucosa & gums:
Color: ___pinkish ___reddish Others: _____
Teeth:
___complete ___incomplete ___absent ___false teeth
___plaque ___stains ___carries
Tongue:
___midline ___deviated to right ___deviated to left
Color: ________
___mass ___ulceration
Wharton’s duct patent? ___yes ___no
Stensen’s duct patent? ___yes ___no
Uvula & palate, symmetric rise? ____yes ____no (Have the patient say "AHH")

CHEST AND LUNGS

Inspection:
Symmetrical chest: __yes __no
Deformities: __pectus excavatum __pectus carinatum __kyphosis __scoliosis
Chest expansion: ___symmetrical ___local lagging
Use of accessory muscle:__yes ___no
AP:transverse diameter: ________
Assoc. extra-pulmonary findings: __clubbing __facial puffiness __prominent veins(anterior chest wall)
Palpation:
Tactile fremitus: ___equal ___increased (left/right) __decreased (left/right)
Percussion:
__ hyperresonant (if yes, in what areas?___________________)
__ resonant (if yes, in what areas?___________________)
__ dull (if yes, in what areas?___________________)
Relative Relative Relative location Examples
intensity pitch duration
Flatness Soft high Short Thigh Pleural effusion
Dullness Medium Medium Medium Liver Lobar pneumonia
Resonance Loud Low Long Normal lung Chronic bronchitis
Hyperresonanc Very loud Lower longer None Emphysema,
e pneumothorax
tympany loud High Gastric air Large pneumothorax
bubble
Auscultation:
__ normal breath sounds:
___Bronchial
___Vesicular
___Bronchovesicular
___Tracheal
Breath sound Duration of sounds Intensity of Pitch of Location where normally heard
expiratory sounds expiratory sound
Vesicular Inspiratory sounds last longer Soft Relatively low Over most of the lungs
than expiratory ones
Bronchovesicular Inspiratory and expiratory Intermediate Intermediate Commonly in the 1st and 2nd ICS
sounds are about equal anteriorly and between the scapulae
Bronchial Expiratory sounds last longer Loud Relatively high Over the manubrium, if heard at all
than inspiratory ones.
Tracheal Inspiratory and expiratory Very loud Relatively high Over the trachea in the neck
sounds are about equal.
__ adventitious sounds sounds:
___crackles (Short (less than 12-15 msec), discontinuous, explosive sound, primarily an inspiratory sound)
___wheezing (Continuous sound of musical quality, high-pitched, primarily expiratory)
___rhonchi (Low-pitched, snoring quality, continuous, early expiratory)
___stridor (High-pitched, continuous, purely inspiratory, similar to wheezing except that its inspiratory)
__ decreased breath sounds (left/right)
CARDIOVASCULAR
Inspection
Precordial bulgge: ___present __absent
Point of Maximal Impulse: ___________________ (area of the cardiac surface that maximally pulsates)
(normally at or medial to the left midclavicular line in the 5th or possibly the 4th ICS)
Palpation
Apex Beat:
Heaves: ___present ___absent (If present, location? ________)
Thrills (a palpable murmur): ___present ___absent (If present, location? ________)
Percussion
Heart span: _____ ICS to _____ ICS (cardiac area of dullness from the point of reference (midsternal line)
Auscultation
Rate: ___Normal (60-100bpm) ___Bradycardia (<60bpm) ___Tachycardic (>100bpm)
Rhythm: ___regular ___irregular (report regularly irregular or irregularly irregular)
Heart sounds: S1 > S2: ___base __apex S2 > S1: ___base __apex
Presence of S3 and S4: ________
Murmurs: ___yes ___no
intensity (grading):____
Timing: ___________
Character: ___blowing ___harsh ___rumbling ___ejection ___continuous
Location: _________

ABDOMEN
Inspection
Contour: __scaphoid __flat __globular
Symmetry: __symmetrical __asymmetrically enlarged (identify quadrants: ________)
Lesions
Scars: __yes __no (if yes, location:________, shape:________, length:________)
___ Discoloration ___Visible mass ___Visible peristalsis ___Visible pulsations
Umbilicus: ___inverted ___everted
Auscultation
(Best appreciated at or just below the area of the RLQ but generally all over the abdomen)
Bowel sounds: _____/min
___normal (low pitched, 5-30 bowel sounds/min
__hypoactive (4 or less) __hyperactive (>30 or + bowel sounds every 2 seconds)
Palpation
Tenderness: __yes __no __direct __rebound (If yes, what quadrants? ______)
Kidneys: __Palpable (Left/Right) ___Not palpable
Liver (RUQ Palpation): __Palpable __Not palpable
Liver (Hooking Technique): __Palpable __Not palpable
Spleen: __Palpable __Not palpable
Aorta: __Palpable __Not palpable
Percussion
Liver span: ___cm along the right midclavicular line (normal: 8-12cms)
Abdominal quadrants: ________ (normally, tympanitic all over)
Traube's space: ___resonant (intact) ___dull (obliterated)
Special Maneuvers:
___ Fluid wave ___Shifting dullness ___Succussion splash
___ Murphy’s sign ___Rovsing’s sign ___Psoas sign __Obturator sign
___ Kidney punch/Costovertebral angle tenderness (Left/right)

EXTREMITIES
Do you have any pains in your joints? ___yes ___no
Can you dress yourself without difficulty? ___yes ___no
Can you walk without difficulty? ___yes ___no
Axial Skeleton:
TMJ: ___redness ___mass ___swelling ___deformity ___tenderness ___crepitus
__limitation of motion
 Spine: __cervical &lumbar lordosis __thoracic kyphosis __lateral deviation ___redness ___mass
___swelling ___tenderness ___limitation of motion of the cervical & lumbar spines
Sacroiliac Joint: ___redness ___swelling ___tenderness
Upper Extremities:
Tinel's Test: ___________
Phalen's Test: _________
Finkelstein's test: _______
Arm circumference: _____
Lower Extremities
Test for knee stability:
Anterior drawer test: __________
Posterior drawer test: _________
Valgus & Vargus test: _________
Mc Murray Test: _____________
Thigh circumference: ______
True leg length: _____
Apparent Leg Length: ____

NEUROLOGIC EXAM
Mental Status:
General behavior:
___normal ___immobile ___hyperactive ___slovenly dressed ___agitated ___quiet ___neat
___dressed appropriately according to age and occasion
Stream of talk:
___normal ___rapid ___slow ___scarce ___verbose
Mood:
____appropriate ___labile ___silent ___euphoric ___hostile ___agitated
Content of Thoughts:
___illusions ___delusions ____paranoia ____misinterpretation ____hyperchondriasis
___auditory/visual hallucination
Intellectual Capacity:
___bright ___average ___dull ___demented ___retarded
Sensorium:
Consciousness: ____awake ____drowsy ____obtunded ___delirious ___stupor ___coma
Attention Span: ____normal ___short
Orientation: ____normal ____disoriented
Memory
Remote: ____good ____poor ____fair
Recent: ____good ____poor ____fair
Immediate: ____good _____poor ____fair
Fund of Information: ____well-informed ____uninformed
Calculation: ____able ___dyscalculia
Insight/Judgment _________________

Cranial Nerves:
I: able to smell: ____yes ____no
II, III, IV, VI: (already assessed)
V: good masseter and temporalis tone, V1, V2 and V3 equal facial sensation: ____yes ___no
VII: facial symmetry: ___yes ___no can taste on the anterior 2/3 of tounge: ___yes ___no
IX, X: swallow: ____yes ___no, cough: ____yes ___no gag reflex: ____(+) ____(-)
XI: good trapezius tone: ___yes ____no good SCM tone: ___yes ____no
XII: tongue midline: ___yes ___no fasciculations: ___yes ___no

Sensory

Touch: ___intact ___not intact

Pain: ____intact ___not intact
Vibratory sense: ____intact ___not intact
Position sense: _____intact ___not intact
Romberg: ____intact ___not intact
Motor
Inspection:
Posture/Gait:_______________
Somatotype:________________
General Activity:_____________
Tremors (distribution type):______________
Involuntary Movements:________________
Palpation:
Muscle bulk: ___atrophy ___hypertrophy ___normal bulk
Body symmetry:
Joint malalignments:
Fasciculations:
Muscle tone: ___flaccid ___spastic ___rigid ___normal

Manual Muscle Strength Testing:

Reflexes

Deep Tendon Reflexes:

___biceps ___triceps ___patellar ___brachioradialis ___Achilles tendon
Physiologic Reflexes: ___anal wink ___abdominal reflex ___jaw jerk
Pathologic Reflexes:
___Babinski (left/right) ___ankle clonus (left/right) ___snout ___grasp reflex ___palmomental

Cerebellar
Nystagmus: ____(+) ____(-)
Tandem Walk: _____(+) _____(-)
Dysmetria:
Finger to nose: _____(+) ____(-)
Heel to shin: _______(+) ____(-)
Dysdiadokinesia: _______(+) ____(-)
Tandem gait: ______(+) _____(-)
Rebound phenomenon: ______(+) ____(-)

Meningeals
Passive Neck Flexion: ____(+) ____(-)
Kernig’s: ____(+) _____(-) (a positive response is sudden flexion of the knee)
Brudzinski: ____(+) _____(-) (observe for a response- neck flexion)
Higher Cerebral Functions
Aphasia
Expressive (of spoken language): ____(+) ____(-) (name 10 fruits, objects)
Expressive (of written language): ____(+) ____(-) (writing complete sentence, spelling)
Word repetition: ____(+) _____(-) (wala nang pero-pero pa) (no-ifs-and-orbuts)
Apraxia
Ideomotor Apraxia: ____(+) ____(-) (gives direction or requests patient to do a voluntary movement: light a candle)
Dressing Apraxia: ____(+) ____(-) (asks patient to put on hospital gown or jacket)
Constructional Apraxia: ____(+) ____(-) (asks patient to draw any shape ex clock drawing test)
Gait Apraxia: ____(+) ____(-) (asks patient to walk)
Agnosia:
Astereognosia: ____(+) ____(-) (asks patient to identify objects by palpating its texture & form in his hand )
 Agraphognosia: ____(+) ____(-) (asks patient to identify numbers drawn by examiner on his palm)
Finger Agnosia: ____(+) ____(-) (asks patient to identify examiner's fingers)
R-L Disorientation: ____(+) ____(-) (asks patient to identify right and left side of body)

Autonomics (optional/when necessary)

Anal sphincter tone:
Sweating patterns:
Orthostatic BP measurements

---------------------------------------------------------------------------------------------------------------------------------------------------

PRIMARY IMPRESSION: __________________________

Differential Diagnosis:
1. _______________________
2. _______________________
3. _______________________