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Clinical History I. General Data
Clinical History I. General Data
CLINICAL HISTORY
I. GENERAL DATA
A.S., 3 years old, Filipino, female, Catholic, was born on April 12, 2013 in Dasmariñas, and still resides in
Dasmariñas, was admitted
Name: ______________________ Age: _______________________
Civil Status: _________________ Nationality: _________________
Sex: _______________________ Religion: ___________________
Birth Place: _________________ Birth Date: _________________
Address: ____________________ Handedness: _______________
Nth visit: ___________________ Date and Time of admission: ___________
Risk habits:
Smoking age started:____ age stopped: ____ cig/day: _____ pack/yrs: _______
Alcohol drinking: age started:____ age stopped: ____ frequency: ______ bottles: _______
Drugs:
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
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: _____/_____
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
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
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
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)
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