MED 2B

Group 8
College of Medicine
October 12, 2017

Dermatology Preceptorial
I. General Information
Initials Relationship
Informant A.G. Patient
R.A.
Relationship to the patient A.G. – Patient herself
R.A. – Daughter
Reliability
Patient’s name A.G.
Chronological age
Sex
Address
Birthday
Birthplace
Nationality
Race
Religion
Room/Ward
Date and time of admission
Number of previous admissions
Date and time of history-taking

II. Chief Complaint

Lingin ulo.

III. History of Present Illness

    Pertinent Negatives:

   
    Pertinent Positives:

IV. Past Medical History

IV. Personal, Social, and Environmental History
IV. Physical Examination
A. General Survey
B. Vital Signs
C. Anthropometrics
D. Skin
E. HEENT
a. Head
b. Eyes
c. Ears
d. Nose
e. Mouth
f. Neck
B. Chest and Lungs
C. Cardiovascular
D. Breasts and Axilla
E. Abdomen
F. Genitalia
G. Anus and Rectum
H. Musculoskeletal
a. Upper extremities
b. Hands
c. Nails
d. Lower extremities
B. Neurologic
C. Immune/Lymphatic
D.