Lyceum-Northwestern University

Dr. Francisco Q. Duque Medical Foundation

College of Medicine
Dagupan City

Tuvera, Christian Mark Gerard T

Date of Interview:
Time of interview:

History

I. General Data
a. Name
b. Age
c. Date
d. Place of birth
e. Sex
f. Race
g. Religion
h. Present address
i. Number and date of hospital admission
j. Informant
k. reliability
II. Chief complaint

III. History of present illness

IV. Review of system vii. Pubertal and adolescent –
a. General menstrual period
i. Weight loss/gain h. Endocrine
ii. Activity level i. Breast asymmetry, pain or
iii. Appetite discharge
iv. Delay in growth ii. Palpitation
b. Cutaneous iii. Cold/heat intolerance
i. Rash iv. Polyuria
ii. Pigmentation v. Polydipsia
iii. Hair loss vi. Polyphagia
iv. Pruritus i. Nervous/behavioral
c. Head i. Tremors
i. Headache ii. Sleep problems
ii. Dizziness iii. Convulsion
iii. Visual/ hearing difficulties iv. Weakness or paralysis
iv. Lacrimation v. Mental deterioration
v. Aural discharge vi. Personality or behavioral
vi. Nasal discharge changes
vii. Epistaxis vii. Memory loss
viii. Toothache viii. Eating problems
ix. Salivation ix. School failures
x. Sore troat x. Mood changes
d. Cardivascular xi. Temper outburst
i. Orthopnea xii. Hallucination
ii. Cyanosis xiii. Musculoskeletal
iii. Easy fatigability 1. Pain or swelling in bones or
iv. Fainting spells joints
e. Respiratory 2. Mucle limitation of motion
i. Chest pain 3. Stiffness
ii. Cough 4. Limping
iii. Difficulty in breathing
f. Gastrointestinal V. Past personal history
i. Constipation a. Gestational
ii. Vomiting i. Mother age during pregnancy
iii. Bowel movement – diarrhea ii. Parity
iv. Jaundice iii. Health
v. Passage of worms iv. Nutrition
vi. Abdominal pain v. Infection
vii. Encopresis vi. Intake of drugs
viii. Food intolerance vii. Roentgen exposure
ix. pica viii. Duration of gestation
g. Genitourinary b. Birth
i. Discoloration of urine i. Term
ii. Burning sensation ii. Manner of delivery
iii. Frequency of discharge iii. Person attending delivery
iv. Enuresis iv. Birth weight
v. Edema of hands and feet
vi. Female -discharge and itchiness c. Neonatal
i. Apgar score
ii. Spontaneous respiration or Cyanosis
resuscitation iv. Pallor
iii. v. Jaundice
vi. Cry
vii. Convulsions
viii. Hemorrhage
ix. Respiratory or feeding
difficulties
x. Congenital abnormalities
xi. Birth injury

$ gestational, birth and neonatal <2 or related

d. Feeding
i. Infancy
1. Breastfeeding
2. Formula
3. Complimentary
a. Calorie computed
ii. Childhood and adolescent (2-20
)
1. Appetite or picky eater
2. Food intake – amount per day
3. Compute for ACI compare with
RENI
4. Sample food
e. Developmental/behavioral
i. Young 1-5
1. Dental eruption
2. Urinary continence day and
night
3. Completion of toilet training
4. Temper tantrums
5. Head banging
6. Phobias
7. Pics
8. Night terror
9. Sleep disturbances
10. Other behavioral problems
ii. Middle childhood 6-11
1. School performance
2. Sexual development (tanners)
iii. Adolescence 10-20
1. Home
2. Education
3. Eating
4. Behavior
5. Activities
6. Drugs
7. Sexual
 8. Suicide Source of funds
9. Sexual development – tanners’
maturity IX. Environmental history
a. Circumstances
f. Past medical history b. Exposure to cigarette smoke
i. Measles
c. Environmental pollutants
d. Garbage disposal
ii. Varicella
e. Sewage disposal
iii. Mumps
f. Water source
iv. Pertussis
v. Other illness (hospitalized) Physical examination
vi. Allergy, eczema, asthma, food
I. General
or drug sensitivity a. Mental state or sensorium
vii. Injuries i. Level of activity
• Clinical course of disease ii. Shrieking cry
VI. Immunization history iii. Grunting
a. Type iv. Affect
b. Date b. Cardiopulmonary distress
c. Place i. Color
d. Unwanted reaction ii. Chest retraction
VII. Family history c. Gait
a. Parents i. ambulatory
i. Age ii. bedridden (position)
ii. Occupation d. Nutritional state
iii. State of Physical/mental i. Well, under over
health e. Looks
iv. Living or cause of death i. Well, mildly ill, severely ill
b. Siblings II. Vital signs
i. Number a. Temperature
ii. Ages b. Cardiac rate
iii. State of health c. Pulse rate
iv. Age and cause of death d. Respiratory rate
c. Familial illness or anomalies e. Blood pressure 3 years old up
i. TB f. Anthropometric
ii. Diabetes i. Weight
iii. Syphilis ii. Length < 3yr
iv. Cancer iii. Height > 3 year
v. Epilepsy iv. Head circumference < 3
vi. Rheumatic fever years
vii. Allergy 1. Other measurement
viii. Hematology for special
ix. Mental retardation a. Chest
x. Congenital defects b. Abdomen
v. BMI = Wt kg/ M3
VIII. Socioeconomic history vi. Z score
a. Living circumstances III. Skin
i. Place a. Color
ii. Nature of dwelling b. Turgor (wrinkle or loss or elasticity)
iii. Number of persons c. Loss of subcutaneous tissue
iv. Living in house d. Rash or eruptions
b. Economic e. Hemorrhage
i. Working members f. Scars
ii. g. Edema
 h. jaundice Mucus membrane
IV. HEENT v. Dentition
a. Shape or contour vi. Palate
b. Scalp vii. Posterior pharyngeal wall
i. Hematoma viii. Tonsils (color)
ii. Abscess 1. Tonsil grade
iii. Edema
c. Fontanels in infant V. Neck
i. Sutures a. Masses
1. Open b. Venus engorgement
2. Overlapping c. Flexibility
3. Gaping d. Rigidity
ii. Posterior 2-4 months e. Lymph node
iii. Anterior 9-18 months f. Torticollis
d. Hair g. Thyroid
i. Color VI. Chest/ lungs
ii. Quantity a. Retractions
e. Face b. Lung expansion
i. Symmetry c. Asymmetry
ii. Unusual facies d. Tactile fremitus
iii. Deformities e. Breath sounds
f. Eyes f. Adventitious sounds
i. Lid i. Crackle
ii. Conjunctivae ii. Wheezed
iii. Sclerae iii. Ronchi
iv. Opacities iv. Friction rub
v. Discharge v. Stridor
vi. Red orange reflex (infants) vi. Grunting
vii. Corneal light reflex VII. Heart
viii. Vision (snelles, E chart) a. Precordium
g. Ears b. Visible pulsation
i. Size c. Apex beat (4th until 7)
ii. Shape d. Thrills
iii. Location e. Heart sound
iv. Position f. Rhythm
v. Tympanic membrane g. pulses
h. Nose
i. Patency VIII. Abdomen
ii. Alar flaring a. Distension
iii. Discharge (character b. Prominent vessls
iv. Septum c. Striate
v. Sinus tenderness d. Pulsation
i. Mouth and throat e. Peristaltic movement
i. Lips f. Bowel sound (high pitch)
ii. Gums g. Percussion
iii. Tongue h. Ascites
iv. i. Liver span
j. Tenderness direct rebound
k. Spleen (normally not palpable
unless 2-3x enlarge
l. CVA tenderness
IX. Inguinal region
a. Hydrocele
 b. Undescended testes
c. Lymph nodes
X. Genitalia
a. Prepuce – easily retractable
b. Cryptorchidism
c. Female genitalia
XI. Anus and rectum
a. Patency
b. Anal tags
c. Hemorrhoids
d. Presence of pinworms
e. Prolapse
XII. Extremities
a. Clubbing
b. Cynosis
c. Mobility of joints
d. Deformities
XIII. Spine
a. Sacrococegeal dimple
b. Pilnodial sinus
c. Local tenderness
XIV. Lymph nodes
a. Occipital
b. Posterior hairline
c. Post auricular before going
downward

Neurologic Examination
I. Cerebrum
II. Cerebellar
III. Cranial nerves
IV. Motor
V. Sensory
VI. Reflex
Admitting impression