Far Eastern University History and Physical Examination

Nicanor Reyes Medical Foundation

Department of Internal Medicine Proctor’s Signature:

Faderugao, Martina Patient

Name of Interviewer: Informant:
August 14, 2020 90%
CD - A Section G Date of Interview: Reliability:

I. General Data
ACOSTA, Alden 28/F SINGLE FILIPINO Completeness
(Name of Patient) (Age) (Sex) (Civil Status) (Nationality) (0) N/A (1) <9 data
(2) >9 data (3) Complete
ROMAN CATHOLIC Call Center Agent 02/23/1992
2/3/1992 Manila

(Religion) (Occupation) (Birthdate) (Birthplace) Recorded in a telegraphed

West Fairview, Quezon City manner
(0) N/A (1) No (2) Yes
(Present Address)
NONE

(No. of times admitted) (Date Admitted)

II. Chief Complaint Briefly written using phrases,

“Sumasakit kanang binti”
and not sentences
(0) N/A (4) No (8) Yes

III. History of Present Illness

8 days prior to consultation the patient experienced an “insect bite” on her right leg, 2 inches below the knee. The Recorded time of onset
patient experience pruritus that provoked her to scratch the area then the area started to bleed. The pain is localized on her properly
right leg. She describes the pain as sponataneuous and increasingly painful. She rated the pain as 8/10 on a pain scale
For the first few days the patient put alcohol as a means to alleviate the pain (0) N/A (3) No (6) Yes
6 days ago she felt a burning sensation on the area and her friend suggested to her a chinese menthol topical solution
and amoxicillin which she is now taking 3 time a day for 5 days, she stated that the pain was reduced only for about 10%.
Observed chronology of
1 day ago, the patient couldn’t walk and can’t her daily tasks because of the pain
symptoms
(0) N/A (4) No (8) Yes

Described symptoms
adequately
(2) <25% (5) 25-50%
(7) 50-75% (10) >75%

Included all pertinent positive

and negative information
regarding the system that may
be associated with each
symptom
(2) <25% (5) 25-50%
(7) 50-75% (10) >75%

Noted consultation done

(0) N/A
(2) Recorded, but inadequate
(4) Recorded data is adequate

Noted medications given

(0) N/A
(2) Recorded, but inadequate
(4) Recorded data is adequate

THE WRITTEN HISTORY IS:

Neat
(1) <50% (2) 50% (3) >50%

Legible
(1) <50% (2) 50% (3) >50%

Properly paragraphed
(1) <50% (2) 50% (3) >50%

Grammatically correct
(2) <50% (3) 50% (5) >50%

With minimal use of

universally accepted
abbreviations
(1) <50% (2) 50% (3) >50%

Brief and concise

(2) <50% (3) 50% (5) >50%
I. Past Medical History [[ ifClick
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measles and chicken pox
Childhood Diseases: (✔) Childhood diseases /
Immunizations: (✔) Hepa B and BCG Immunizations / Adult
Adult Diseases: Diseases / Psychiatric Illnesses
Hypertension: ( ) none (0) (1) (3)
Diabetes: ( ) none
Bronchial Asthma: ( ) none
COPD: ( ) none
Pulmonary Tuberculosis: ( ) none
Myocardial Infarction: ( ) none
Cerebrovascular Accident: ( ) none
Malignancy: ( ) none
Allergies: ( ) none
Psychiatric Illnesses: ( ) none
Previous Surgery: ( ) none Surgical diseases / Gynecologic
Gynecologic Diseases: ( ) none Diseases / Accidents and
Injuries / History of blood
Accidents / Injuries: ( ) none
transfusion
Blood Transfusion: ( ) none
(0) (2) (4)
Others (please specify):

II. Family History Family History

Father: 50 y/o; Hypertensive (0) (1) (3)
Mother: 52y/o; No illness
Siblings: 19; No illness, 18; no illness, 16; no illness
Others: N/A

III. Personal and Social History Personal and Social History

Education: currently in university Marital Status: single (0) (3) (5)
Occupation: part-timer in a call cernter company Lives with: None
Living Condition: Safe, not prone to flood Food Preference: Fatty foods e.g. chicharon
Leisure Activities: take naps Exercise Regimen: 1-2 times per month
Sexual Practices: none Smoking History: 0.4 - 0.6 pack years (2-3 stick 4yrs)
Alcohol Intake: occasional Use of Illicit Drugs: N/A
Others (if applicable):

IV. Obstetric and Menstrual History Obstetric / Menstrual History

12years
Menarche: 12 y/o Interval: regular
Duration: 3-5 days Amount: 2-3 pads / day
(0) (1) (3)
Symptoms: N/A G: 0 P: 0 (T: 0 P: 0 A: 0 L: 0 )
Manner of Delivery: N/A Complications: N/A

V. Review of Systems [[ ifClick

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Constitutional: ( ) weight loss (0) (3) (5)
Skin: (✔) itchiness, ( ) change in color, ( ) dryness
Head: ( ) vertigo, ( ) dizziness
Eyes: ( ) pain, ( ) blurring of vision, ( ) double vision,
( ) excessive lacrimation, ( ) photophobia, (✔) use of eyeglasses (Reading glasses)
Ears: ( ) earache, ( ) deafness, ( ) tinnitus, ( ) ear discharge
Nose / Sinuses: ( ) change in smell, ( ) nose bleeding, ( ) nasal obstruction, TOTAL SCORE: ___________
( ) nasal discharge, ( ) pain over paranasal sinuses REMARKS:
Mouth / Throat: ( ) toothache, ( ) gum bleeding, ( ) disturbance in taste,
( ) sore throat, ( ) hoarseness
Neck: ( ) pain, ( ) limitation of movement, ( ) presence of mass
Respiratory: ( ) shortness of breath, ( ) difficulty of breathing
Cardiovascular: ( ) substernal pain, ( ) orthopnea, ( ) syncope,
( ) paroxysmal nocturnal dyspnea
Gastrointestinal: ( ) dysphagia, ( ) melena, ( ) hematochezia, ( ) regurgitation
Genitourinary: ( ) anuria, ( ) incontinence, ( ) dysuria, ( ) urinary frequency,
( ) urethral discharge
Extremities: ( ) stiffness, ( ) intermittent claudication,
( ) limitation of movements
Nervous ( ) syncope, ( ) loss of consciousness, ( ) focal weakness,
System: ( ) paralysis, ( ) numbness, ( ) paresthesia, ( ) speech disorder,
( ) loss of memory, ( ) confusion
Hematopoietic: ( ) bleeding tendency, ( ) easy bruising, ( ) pallor
Endocrine: ( ) intolerance to heat and cold, ( ) polyuria, ( ) polydipsia