Date: ............................ Historian: ....................................

Time:............................ Informant: .................................... Reliability: ..................%

GENERAL DATA:
 Name......................................
 Age..........................................
 Sex................................ ..........
 Status......................................
 DOB/POB................................
 Occupn.....................................  Times of Adm................
 Religion....................................  Adm. Date......................
 Nationality...............................  Adm. Time...................
 Address....................................

CHIEF COMPLAINT: ...........................................................................................................................................................

HPI (PRESENT ATTACK) :
 Site: (where? diffuse/localized? maximal pain?)...................................................................................................
 Onset – When? Sudden or gradual? Progressive/regressive? ...............................................................................
 Character – how? What? (Sharp, dull, crushing, burning, tearing, throbbing, constant, intermittent)………………
 Radiation – Does? ..................................................................................................................................................
 Associations – other S & sx? ...................................................................................................................................
 Time -how long (duration- Y/M/W/D/Hr/Min/S)...................................................................................................
o Episodic (better/worse, frequency, duration)..........................................................................................
o Continuous (any change in severity?)......................................................................................................
 Exacerbating/Relieving factors – Circumstances (food, meds, posture, sleep).......................................................
 Severity - How bad? pain scale O (min) – 10 (max) .................................................................................................
 Previous Lab test (include Pertinent Negatives)......................................................................................................

PAST MEDICAL HISTORY:

 Measles/ mumps /chicken pox /recurrent tonsillitis/ respiratory disease like pneumonia....................................
 Major injuries- trauma /history of fall or operations (date, effects).....................................................................
 Previous hospitalizations/
o Hospital date dx , stay duration attending remarks
o Eg. hosp. X 10.25.2014 Diabetes 1 Week Dr. X -
 Drug History
o Name dose(route) frequency duration remarks (compliance)
o EG. Aspirin 75mg once daily 2 month No allergy
o
o

 Food & drug allergy .....................................................................................................................

 History of asthma, diabetes, HPN, PTB.................................................................................................
 History of similar complaint or present problem in the past (chronic/recurrent)...................................................
 Surgical History (Procedures)
 Tonsillectomy 1952 Hospital X
 COPD since 1990 General practitioner

PERSONAL AND SOCIAL HISTORY:

 Educational attainment..........................................................................................................................................
 Occupation (past & present)...................................................................................................................................
 Hx. of travel.............................................................................................................................................................
 Smoking/ Drinking
 Age started...............................................................................................................................................
 Consumption per day / pack year (No of pack per day X yr smoked)......................................................
 Reason of stopping (financial or health)...................................................................................................
 Drugs (tranquilizers, laxatives), other......................................................................................................................
 Sleeping habits........................................................................................................................................................
 Married
 Duration and health of partner/ Compatibility.........................................................................................
 No of living children/age/health............................................................................................................

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
FAMILY HISTORY:
 Grandparents (if dead, age & COD).........................................................................................................................
 Parents.....................................................................................................................................................................
 Brothers /sisters......................................................................................................................................................
 Heredo-familial disease
 Asthma  Psychiatric  Hematologic
 Diabetes epilepsy disease
 HPN  Migraine,  other
 CA  Allergy
MENSTRUAL AND OBSTETRICAL HISTORY:
 Menarche.............................................................  Vaginal bleeding/discharges................................
 Duration...............................................................  No. Of pregnancies.............................................
 Cycle (monthly or irregular)...............................  Route and No. Deliveries....................................
 Menstrual flow (minimal/moderate/ profuse)....  Complications (HPN, eclampsia, abortions).......
 Associated symptoms (dysmenorrhoea, flow, breast .............................................................................
pains & headache).....................................  Procedures (CS, BTL, hysterectomy -dates,
 Date of last menstruation (LNMP)...................... surgeon).............................................................
 Menopause (age last menstruated).....................  Contraceptives Used............................................

REVIEW OF SYSTEMS: Double check of the HPI

Skin :
 Cyanosis  moisture (cold)  pruritis,
 pallor  eruption /lesion  bruishing
 jaundice  distribution  bleeding
Hair :
 loss /growth (bladness)  premature graying
Nails :
 cyanosis  Clubbing  brittleness
Head :
 headache  convulsive seizures
o location  Migraine
o character  Hx of trauma,
o severity  vertigo
o radiation
Eyes:
 visual loss  inflammation,  Abn discharges(desrice the color),
 color blindness,  photophobia,  use of eyeglasses (date when
 diplopia,  pain started to use )
 hemianopsia,  blurring,  use of contact lens.
 trauma,  abnormal lacrimation,
Ears :
 deafness (L/R)  discharges (L/R , color )  previous operations
 tinnitus  Pain (masoidectomy)
 vertigo  Mastoiditis  hx of infections (otitis)
Nose :
 coryza  sinusitis  epistaxis
 rhinitis  discharges  No smell
Mouth :
 soreness of mouth /tongue  bleeding /swelling of gums  hx of recent tooth extraction
 symptoms of teeth  taste ulcers ,  complications
Throat :
 hoarseness  hx of recurrent tonsillitis,  voice charges
 sorethroat,  pharyngitis,
Neck :
 swelling  LN enlargement  stiffness,
 suppurative lesions (scrofula)  Goiter,  limitation of movement.

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
Breast :  pain  hx of surgical procedure
 development,  discharges from nipple(color), (mastectomy/biopsy )
 lactation,  changes in nipple  Results
 hx of trauma,  gynecomastia,
 lumps,

Respiratory system:
 Pain  Cough  Night sweats,
 SOB o hard  Afternoon or night fever,
o walking short distance o paroxysmal  Hx of pleurisy,
o climbing stairs o productive  Bronchitis,
 Wheezing, o non productive  TB
 Dyspnea o occasional  Pneumonia,
o Exertional  Sputum  Asthma,
o At rest o scanty  Hx of X-ray
 Nocturnal dyspnea o copious  Result.
 Orthopnea ( No of pillows used)  Hemoptysis

Cardiovascular :
 palpitation,  Cyanosis,  Rheumatic fever,
 Irregularity of rhythm ,  Edema,  Angina pectoris,
 Pain in the chest ,  Easy fatigability ,  MI,
 Exertional dyspnea,  Fainting spells,  Hx of EKG done,
 PND,  Legs cramps,  Drugs (digitalis,nitroglycerin,
 Orthopnea(how many pillows  Hx of HPN, diuretic )
used),  RHD
 Cough,

GIT:
 Appetite  Abdominal pain
 increase or loss o S  Constipation
 changes in weight o O o Duration
o Approx. Loss......... o C o Laxatives use
o Approx. Grain...... o R  Changes in color
o highest wt............ o A  Change calliber of stool
 Dysphagia o T  Change in bowel habits,
 Nausea, o E  jaundice
 Vomiting o S  Haemorrhoids,
o Episodes...........  Hematemesis  Hx of operations( appendectomy)
o Vomitus...........  Melena  Hx of procedures (GI series on BA-
o Volume............  Diarrhea enema)
 Flatulence o episodes
o volume
GUT:
 Color of urine................................. o initial
 volume of urine (per void) ............ o terminal  incontinence
 polyuria o all thoughout  pain or colic (passage of stone )
 oliguria  dysuria  hx of recurrent infection
 nocturia(no.of voids)...................... o initial  history procedures like IVP,
 frequency..................................... o terminal  hx of STD,
 dribbing o throughout  penile discharges
 location of pain  vaginal discharge
 hematuria o hypogastric/ penis
Neuromuscular system:
 Disturbances in smell  Convulsions,  Numbness,
 Disturbances in vision,  Paralysis,  Malaise ,
 Parethesiaises,  anethesia,  joint pain.
 Weakness,  loss of concoiusness,
Metabolic :
 wt . loss  wt. Gain  fever

Neuro psychiatric:
 Hallucinations o Auditory  nervousness
o Visual  insomnia,  memory loss

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
PHYSICAL EXAMINATION: (describe, give No diagnosis)
Objective Examination using 4 basic maneuvers; inspection , percussion, palpation and auscultation.

Gen survey:
 Physical appearance  Undernourished  Smells
 apparent age  state of consciousness  Ht/wt/WC.
 Mental state o conscious  febrile /afebrile
 Distress o lethargic  emotional state
 Ambulatory /non o stuporous
 Cooperative/non o comatose

Vital signs:
 BP  PR,  wt.
 RR  Temp  BMI

Skin :
 complexion  pigmentation and location ,
 color (don’t state normal)  lesions,  pallor
 texture  rashes/ eruptions  severity
 turgor(lost/ senile/ good) o location
o distribution

Head:
 Shape:  amount and texture of hair
 normocephalic  fractures  facie
 Scars  asymmetry ,  color changes of face.
o size  abn. Movements ,
o location
Eyes:
 Eye lids edema ,  corneal scars,  acuity confrontation
 ptosis  ulceration,  convergence
 lid lag  arcus senillis  xanthelasma,
 sclera jaundice  corneal opacity,  strabismus,
 hge.  corneal reflex  nystagmus,
 Conjunctiva pallor  Pupils size/ shape,  palpate for IOP
 severity,  equality reactive to light  exopthalmos
 petechiae, injection and accommodation
 vision
Ears :
 ext. Ears-defect  tophi,  mastoid tenderness
 ext. Ears- abnormalities  discharges( L/R) ,color  test for hearing.
 ext. Ears -lesions  foreign body ,
 hold pinna,  cerumen ,

Nose:
 shape ,  polyps,  palpable septal deviation
 discharge (color)  foreign body,  sinus tenderness.
 congestion of turbinates,  epistaxis,

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
Mouth and throat:

 inspect from outside  no. of dental repair  palate deviation

 lips symmetry,  buccal / mucosal pallor,  tonsils
 color changes like cyanosis,  ulcerations,  pharynx congestion,
 ulcerations,  lesions like koplick spots in  enlargement,
 swelling lesions measles  presence of exudates ,
 gums swelling ,  tongue color,  odor of breath
 bleeding/ color  ulceration,
 teeth caries  deviation/tremor

Neck :
 landmarks,  enlarged or not,  note presence of
 pulsation,  tracheal deviation, rigidity
 blood vessels  palpate lump node  auscultate for bruit,
engorgement  described size,  palpate for cupitus.
 position (like 45 angle) location, tenderness,
 palpate thyroid gland no.)

Breast :
 symmetry ,  mass o tenderness ,
 dimpling, o location, o borders ,
 nipple discharges, o size, o no.
 lymph node (axillary) o mobility,
o consistency ,

CHEST AND LUNGS:

Inspection
 contour,  expansion ,  bony abnormalities.
 symmetry,  rate and rhythm of
breathing
Palpation:
 tactile or vocal fremitus o increase/ decrease  tenderness in chest area/
o equal  note the location , sternum,

Percussion :
 changes in  note exact location eg.
remnance/dullnss R basal lung field)

Auscultation :
 type of breath sounds,  abnormal sounds  rub
o bronchial o rales,  exact location
o vesicular o rhonchi,
o wheeze,

HEART:
Inspection
 symmetry PMI  heave  lesion,
 (5 L- MCL)  abn. Pulsation  bony abnormality.
th

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
Palpation :
 PMI  thrill(location and timing),  tenderness.
 location,  pulse rate,

Percussion :
 cardiac dullness

Auscultation:
 heart sounds  friction rub
 distinct or faint  murmur(TLDIPCTQ)
 rate and rhythm,

ABDOMEN:
Inspection
 contour  engorged veins  Pulsations
 shape  spider nevi  bulging like hernia.
 scars (size/location)  visible masses
 state surgical procedure  Striae
Auscultation:
 bowel sounds (normo/ hypohyperactive /  fetal heart ( pregnant )
absent)  special maneuvers
 metallic sounds , o puddle sign –ascites
 bruit, venour hum, o Succession splash-obstruction

Percussion :
 Change in tympany  shifting dullness
 super liver dullness  RUQ fist percussion
 fluid wave  CVA tenderness.

Palpation: (area of pain -last )

 muscles guarding (voluntary or involuntary) 
 muscle spasticity  fetal parts (female)
 consistency (soft / rigid)  aortic pulsation,
 crepitations  rebound tenderness,
 tenderness (location, whether on light or deep  direct tenderness,
palpation)  lmp nodes,
 masses (location , size, shape, consistency,  rovsings sign
mobility, tenderness, borders)  Psoas sign
 engorgement of liver , spleen , spleen, kidney  obturator sign
 bladder distention

BACK AND SPINE

 Mobility  vertebral tenderness
 Curvature  bony abnormality.

EXTREMITIES: (specify whether upper/ lower, R/L)

 Color/ cyanosis  Temperature  tenderness of muscles
 moisture  equality of pulses  abn. Movements
 clubbing  Edema  range of motion
 joint swelling /deformity  Varicosity  signs of inflammation
 Mobility  Atrophy/ Hypertrophy  congenital

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
NEUROLOGIC EXAM:
1.cerebral functions
 level of consciousness  emotional status  recognize object (yes/no)
 appearance  thought content  Communicate(yes/no)
 gen. Behaviour  intellectual performance  carry out skills(yes/no)

2. cereblum functions
 gait  Coordination  heel to shin
 posture. (romberg’s test)  knee pat
 finger to nose

3. motor system :
 strength (weakness or paralysis)
-ranges ( 0/5-5/5) Right Left

UE (hand grip )

LE (resistance)

 muscle tone ( spaticity, rigidity, flaccidity)

 spontaneous movements (Tics, tremors, twitching, chorea, athetosis)

4. sensory system (both sides,eye closed)

 Sensations of :  position sense/ vibrations
o pain  discrimatory sensation
o touch  sensory dysfunction
o temp.

5. CRANIAL NERVES EXAMINATION:

a. olfactory (check both side one at a time|)

 smell  identify odor (by smelling)

b. optic
 visual acuity  visual field.
 confrontation test  opthalmoscopic exam
 color vision

C. Oculomotor
 Papillary light reflex  Near response (parasympathetic)
o Convergence
o accomodatio
d. trochlear/abducents
 EOM  diplopia

e.Trigeminal
 corneal rxn  pain sensation of face.
 ability to open mouth

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
f. Facial
 symmetry of face  test for taste (ant 2/3)
 wrinkle forehead ,  chovstek sign
 smile, frown, raise eyebrows
.
g. Acoustic
 hearing
o rhinne test (Air > bone conduction)  equilibrium
o weber test (bone conduction)

h. Glossopharyngeal/ vagus
 symmetry of uvula with phonation  elicit gag reflex

i. accessory
 strength of trapezius/  Turn head (up- down, L/R)
 shoulder shrug (strong or week )  Check w/ resistance

j. hypoglossal
 deviation of protruded tongue  impaired swallowing
 tremors and strength

6. REFLEX:

1. DTR – result ranges from 0 - ++++

a. biceps
b. triceps
c.knee jerk
d. Achilles or ankle joints
2.Superficial
a. cremasteric male – whether (+) or (-)
b. abdominal – whether (+) or (-)

3. Pathological
a. ankle clonus + if abn L and R
b. babinski + if abn L nd R
c. karnigs + if abn
d. brudzinski +if abn
report :
Right Left
Biceps ++ ++
Triceps ++ ++
Knee ++ ++
Achilles ++ ++
Ankle clonus ++ ++
Babinski ++ ++

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
REFERENCES :
-Bates physical diagnosis
- Macleod's Clinical Examination

Acknowledgement :
 Dr. Louella Quijano
 kalpana shah, Southwestern University

For suggestions and comments : Deepakghimire101@gmail.com,

Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.