Past Medical History:

a. Allergies and/or Drug reactions

b. Medications
1. Current/recent prescription medications
2. Current/recent over the counter medications
3. Current/recent herbal/alternative medications
c. Medical History
1. Major diseases
2. Major treatments
3. Toxins and/or industrial exposures
4. Doctors visits in the last year
d. Surgical history
1. Surgical procedures inpatient and date
2. Surgical procedures outpatient and date
e. Hospitalization and date
f. Gynecologic/Obstetric (add OB SCORE)
1. Menstrual history (onset of menses, cycle length, and # of pads daily)
2. Pregnancy/Childbearing
3. Complication of pregnancy
4. Menopause (onset)
5. Contraception (birth control pills and/or other means)
6. History of STD
7. Mammogram
8. Last Pap smear
g. Immunization (tetanus-diptheria in all patients)
h. Diet
(e.g. What did the patient eat the day before including meals and snacks? Salt intake?
Fiber intake? Caffeine intake? Sugar intake in patients who have diabetes?)
i. Trauma history (prior history of injury and how the injury was treated)
j. Growth and development and childhood disease
Family Medical History:

a. Summary of ages of immediate family members (include those who are alive and dead with

cause of death
b. Summary of and state of physical and mental health of immediate family members (include 

depression or substance abuse)
c. Family members with similar symptoms and signs
d. Presence of chronic and/or infectious diseases within the family members
e. Family relationship ( family interaction pattern)
Personal/ Social History:

a. Marriage/other relationships and outcomes ( e.g. alone or with others, relationship, caregiving)
b. Ethnicity
c. Source of social support
d. Personal background (education, occupation, travel, religion, dwelling, financial stress)
Preventive/Risk Factors:

a. Preventive (any three of recreation, exercise, current stressors, periodic health examination)
b. Tobacco current / past use
c. Alcohol current/ past use
d. Recreational drug use current/ past
e. Sexual history
f. Sexually active
1. Partners (male/female/both)
2. Practice safe sex
3. Male: History of STD (female is found at Gyne/OB PMH)
g. Occupational hazard / environmental exposure
f. Violence risk: (e.g. Do you feel safe? Are you afraid of anyone? Has everyone hurt you?)
Review of Systems

A. General F. Breast
• change in weight? • Pain?
• change in appetite? • Masses?
• Overall weakness? • Discharge?
• Lack of energy?
• Fever chills, sweat? G. Respiratory?
• Lack of enjoyment in life? (anhedonia) • Cough?
• SOB? (dyspnea)
B. Skin • Wheezing or tightness in your chest?
• Sores?
• Itching or rashes? H. Coughing up a substance such as sputum/
• Color or texture changes? phlegm or blood (hemoptysis)
• Hair or nail changes?
• Changes in mole(s)? I. Chest Pain with coughing or breathing?
(pleurisy)
C. Head and Neck
• Headaches?
• Head injury? (Trauma) Cardiovascular:
• Neck Stiffness? • Chest pain?
• SOB when lying down or need to sit up to
D. Eyes breathe? (othropnea)
• Bright flashes of light? • Waking up at night with SOB? (paroxysmal
• Changes in vision? nocturnal dyspnea)
• Blind spot bordered by shimmering light? • Swelling? (edema)
(scintillating scotoma) • Irregular heartbeats or sensation that your
• Spots in visual fields (floaters) heart is racing or skipping beats?
• Double vision (Diplopia) (palpitation)
• Pain

E. Ears, Nose Sinuses, Mouth and Throat

• Sore throat?
• Painful tooth?
• Changes in the sense of taste?
• Difficulty in speech?
• Hoarseness?
• Nasal drainage or nose bleed (epistaxis)
• Changes of loss of hearing?
• Ringing in ears? (tinnitus)
Review of Systems (cont.)

Gastrointestinal:
• Difficulty swallowing? (Dysphagia)
• Heartburn? (reflux)
• Feeling like throwing up or vomiting?
(nausea)
• Vomiting?
• Throwing up of blood? (Hematemesis)
• Excessive belching/burping? (eructation)
• Excessive gas? (flatulence)
• Difficulty or infrequent bowel movements
(constipation)
• Loose or frequent bowel movements?
(diarrhea)
• Bloody or black tarry stool? (melena)
• Abdominal pain?
• Yellowish discoloration of the skin/whites of
the eyes with dark urine (tea colored)?
Jaundice?
• Rectal pain (proctalgia), rectal discharge or
rectal itching (pruritus ani)?
Urinary:
• Urinating often? (frequency)
• Need to urinate suddenly? (urgency)
• Burning when you urinate? (dysuria)
• Urinating blood? (hematuria)
• Getting up more than once a night to
urinate? (nocturia)
• Loss of control of urinating? (urinary
incontinence)
• Pebbles or gravel in your urine? (renal
stones)
• Slow to start urinating? (hesitancy)
Neurologic:
• Fainting or passing out? (syncope)
• Seizure?
• Weakness on one side of the body?
(hemiparesis)
• Shaking that you can’t stop? (tremors)
• Loss of feeling? (anesthesia) or numbness
(parathesia) in part of your body?
• Dizziness
• Loss of balance or lack of coordination?
(incoordination)
• Alteration in consciousness?
• Sleep disorder?
• Memory disorder?
• Migraine headaches?
Psychiatric:
• Nervousness? (anxiety)
• Being sad or blue (depression)
• Having a really up mood? (mania)
• Unwelcome thoughts you can’t get out of
your head (instrusive thoughts)
• Loss of good judgement and/or insight?
• Seeing or hearing things that don’t exist?
(hallucinations)

Female Reproductive:
• Vaginal Pain?
• Vaginal discharge?
• Sores or lesions on your vagina?
• Heavy periods?
• Lack of period? (amenorrhea)
• Hot flashes?

Male Reproductive:
• Lump or swelling of your scrotum? (scrotal
swelling or mass/hernia)
• Scrotal pain?
• Discharge from your penis? (uretheral
discharge)
• Sores on your penis?
• Changes in ejaculation? (bloody, retrograde,
premature)
• Difficulty in getting an erection? (impotence
or erectile dysfunction)
 CBC

Name Definition Normal Range

Hb or Hbg (hemoglobin) Protein in the blood that holds oxygen, lower than normal (M): 13-16 gm/dL (%)
signifies low RBC count (anemia) (F): 12-14 gm/dL (%)

White blood cells (WBC) a.k.a leukocytes

4.5-11T/cumm
cells of the immune system

Differential Count: 55-70%

Neutrophil Seg Neutrophilia -Bacterial infection, inflammation, hemorrhage,

hemolysis, stress

Neutropenia - Acute infection, antibodies, drugs, chemical,

radiation

BAND BAND - Presence of immature granulocytes in peripheral blood

0-10%

Lymphocyte Lymphocytosis - IM, CMV, whooping cough, acute infectious 25-35%

lymphocytosis
Basophil
Basophilia - Chronic myelogenous leukemia, polycythemia vera 0.05%
Eosinophil

Monocyte Eosinophilia - Allergies, skin diseases, parasitic infections, CML 1-4%

Monocytosis - Convalescence from viral infections, chronic 1-6%

infections, TB, subacute bacterial endocarditis, parasitic
infections, rickettsial infection

RBC Carry oxygen through the body.

(M): 4.3-5.9 M/mm3
Help filter CO2.
14-17 gm/dL
LOW = indicates vitamin b6, b12 or folate deficiency, can signify
internal bleeding, kidney dse, or malnutrition.
(F): 3.5-5.5 M/ mm3
HIGH = smoking, CHD, dehydration, hypoxia, pulmonary fibrosis 12-15 gm/dL

Hct (hematocrit) Volume % of red blood cells, disturbance in level indicates blood (M): 42-50%
d/o, dehydration or other medical conditions (F): 37-44%

Reticulocyte Count >2% = ↑ erythropoiesis

0.5-1.5%
<0.1% = ↓erythropoiesis

Hemolytic anemia, blood loss, following treatment of iron

deficiency or megaloblastic anemia
RBC indices:

MCV (mean corpuscular Average size of red blood cells; used to classify anemia
80-96 fL
volume) Normal MCV = normocytic

>100 = macrocytic

<80 = microcytic

*combination of microcytes and macrocytes may result to

normal MCV

MCH (mean corpuscular Average weight of hgb in individual RBC

27-31 pg
hgb)

MCHC (mean corpuscular RBCs with Normal MCHC = normochromic (area of central pallor 32-36 %
hgb concentration) 1/3 diameter of cells).

MCHC ↓ in hypochromic cells (↑ central pallor)

50% of hereditary spherocytosis patients have MCHC ‡ 36

MCHC >37 may indicate specimen problem (hyperlipidemia,

cold agglutinins) or instrument

Platelets a.k.a thrombocytes

150-400T/cumm
component of the blood that stops bleeding by clumping and
clotting blood vessels.

Thrombocytopenia (<150 ・109/L)

-secondary or reactive thrombocytosis ↓ production (e.g.
aplastic anemia, myelodysplastic syndromes),↑ destruction (e.g
immune thrombocytopenic purpura, drugs, DIC, mechanical
destruction by artificial heart valves), splenic sequestration,
massive transfusion (dilution effect)

Primary thrombocytosis (>1,000・109/L) platelet aggregation

may be abnormal
-unregulated production of megakaryocytes in bone marrow
(e.g. essential thrombocythemia, other myeloproliferative
disorders)

-manifestations: Thrombosis or hemorrhage

Secondary or reactive thrombocytosis (>450 ・109/L but

usually <1,000 ・109/L)
-↑ in PLT due to another condition (e.g. hemorrhage, surgery,
splenectomy)

-manifestations: Thrombosis or hemorrhage infrequent

 Liver Function Test

Name Definition Normal Range

Bilirubin Total Bilirubin - reddish yellow pigment product from normal (adult) 0.2-1.3 mg/dl
breakdown of RBC (neonate) 1.0-10.5 mg/dl

Conjugated (D. Bilirubin) Direct Bilirubin is more soluble, less toxic and conjugated 0-0.35 mg/dl
with glucuronic acid

Unconjugated (I.D. Bilirubin) Bilirubin bound to albumin in the blood 0.2-0.65 mg/dl

SGOT (AST) Serum glutamic oxaloacetic transminase, an ezyme (M) 17-59 U/L
that is normally present in the liver and heart cells
(F) 14-36 U/L
↑ with liver disease (marked ↑ with viral hepatitis), acute
myocardial infarction, muscular dystrophy
SGPT (ALT) Serum glutamic pyruvic transminase, an ezyme (M) 21-72 U/L
normally present in the liver and heart cells. more specific (F) 9-52 U/L
for liver disease than AST. Marked ↑ with viral hepatitis

Alkaline phosphate an enzyme found throughout the body, most concentrated 38-126 U/L
in the liver, bile duct, bones and placenta.

↑ liver and bone disease, level higher in biliary tract

obstruction than in hepatocellular disorders (hepatitis,
cirrhosis)

Total Protein biochemical test for measuring total amount of protein in 6.2-8.4 g/dL
serum, made up of albumin and globulin

↑ = dehydration, chronic inflammation, multiple myeloma

↓ = nephrotic syndrome, malabsorption, overhydration,

heaptic insufficiency, malnutrition, agammaglobulinemia

Albumin produced by the liver and forms large proportion of all 3.5-5.0 g/dL
plasma protein.

↑ = dehydration

↓ = malnutrition, liver disease, nephrotic syndrome,

chronic inflammation.

Globulin group of proteins in blood, important role in liver function, 2.3-3.5 g/dL
blood clotting, and fighting infections
 Kidney Function Test

Name Definition Normal Range

Blood urea Urea - terminal product of protein metabolism, and 10-50 mg/dl
1g of protein can produce apprx 0.3g of urea

Serum Creatinine Creatinine - chemical waste product in the blood that (M) 07-1.3 mg/dl
passes through the kidney to be filtered and (F) 0.6 - 1.1 mg/dl
eliminated in urine

Serum Uric Acid Uric Acid - product of metabolic breakdown of (M) 3.4-7.0 mg/dl
purinenucleotide, and it is a normal component of (F) 2.4-6.0 mg/dl
urine

Serum Sodium Sodium - key in controlling amount of fluid in the 135-145 mmol/L
body.

Needed by the brain and muscle tissue in order to

function properly

Serum Potassium Potassium - electrolyte that is essential for muscle Adult: 3.5-5.1 mEq/
and nerve function L or mmol/L

Children: 3.4-4.7
mEq/L or mmol/L

Chloride Chloride - electrolyte that helps keep proper balance 98-106 mmol/L
of fluid and acid-base in the body

Total protein measurement of albumin and globulin in the body 6-8.3 g/dL

Lipid Profile: (cholesterol and triglycerides)

Name Definition Normal Range

Total Cholesterol Total amount of cholesterol in the blood <200 mg/dl

Triglycerides Type of fat that causing hardening of the arteries 10 - 150 mg/dl

HDL (high-density lipoprotein) “good” cholesterol ; helps removes LDL from the >40 - 60 mg/dl
blood

LDL (low-density lipoprotein) “bad” cholesterol ; elevated results raises risk for MI, 70-130 mg/dL
Stroke and atherosclerosis

VLDL (very low-density lipoprotein) VLDL is a type of blood fat. Considered one of the < or = 2-30 mg/dL
“bad” forms of cholesterol, along with LDL and
triglycerides
 Blood Sugar Test

Plasma glucose Test Definition Normal Range Prediabetes

Random Random blood sugar, checks blood 79-160 mg/dL N/A

glucose at a random time of a day

Fasting Used to test for diabetes.

90 - 110 mg/dL 110 - 125 mg/dL
Test refrains from eating or drinking any
liquids other than water for 8 hrs.

2 hour post-prandial Postprandial blood glucose, measures < 140 mg/dL 140 -199 mg/dL
blood glucose exactly 2 hrs after eating a
meal

Glucose tolerance test measures how well the body’s cells are Fasting 60-100 mg/dL
able to absorb glucose (75gm), or sugar
after ingesting a given amount of sugar 1 hr <200 mg/dL

2 hrs <140 mg/dL

HbA1c a marker that can determine your average HbA1c (%) Reading
(hemoglobin) blood sugar (glucose) levels over the
previous 3-months 4.5 - 6.4 Excellent

6.5 - 7.0 Good

7.1 - 8.0 Acceptable

> 8.0 Poor

 Urine Test

Measurement Reference range

Color Yellow cloudy, dark, or blood colored

Appearance Clear Cloudy urine may be caused by crystals, deposits, white cells, red
cells, epithelial cells or fat globules

Specific gravity (g/ml) 1.005-1.030 Indication of kidney’s concentrating ability and state of hydration.

Increase in specific gravity - dehydration, diarrhea, emesis,

excessive sweating, urinary tract/bladder infection, glucosuria,
renal artery stenosis.

↑ in DM = glucose

↓ in DM = ↓ ADH

pH First am: 5.0-6.0

a high (alkaline) pH can be caused by severe vomiting, a kidney
Randome: 4.5-8.0 disease, urinary tract infection, and asthma.

Protein (mg/dL) Negative-trace Protein may be present due to acute inflammation or kidney stone
disease, or as a sign of kidney damage.

Buffered to pH3, most sensitive to albumin.

Glucose (mg/dL) Negative Increase in blood sugar level above a target range-which can occur
in type 1 and type 2 diabetes-the kidneys often release some of the
excess sugar from the blood into the urine.

Ketones (mg/dL) Negative High ketone levels in urine may indicate diabetic ketoacidosis
(DKA), a complication of diabetes.

Bilirubin Negative Only conjugated bilirubin is excreted in urine, (excess bilirubin in

the blood)

Liver disease or biliary obstruction or hepatitis

Nitrite Negative This test is commonly used in diagnosing urinary tract infection.
A positive nitrite testing indicates that the cause of the UTI is a
gram negative organism, Escherichia coli. Some bacteria
reduces nitrates to nitrites. 1st specimen best. ↑ sensitivity when
urine in bladder at least 4hr

Blood Negative Painful blood in the urine can be caused by number of disorders,
including infections and stones in the urinary tract.

Painless blood in the urine can also be due to many causes, e.g.
cancer.

Uniform color = hgb or myoglobin

Speckled = RBCs

Urobilinogen 0.2 - 1.0 Too much urobilinogen in urine can indicate liver disease such as
hepatitis or cirrhosis

Leukocyte esterase Negative is a screening test used to detect substance that suggest there are
white blood cells in the urine. may suggest UTI

WBC/HPF (WBCs per 0-4 to determine if someone has UTI, if both WBC and leukoesterase
high power field) are elevated strongly suggest UTI

Squamous epithelium 0-4 presence of squamous epith. indicate contamination of the urine
specimen.
 Cardiac Blood Test

Name Definition Normal Range

Creatine phosphokinase - CPK-MB test is a cardiac marker used 5-25 IU/L.

MB assist diagnosis of an acute myocardial
(CPK-MB) infarction.

Troponin I
 A troponin test measures the levels troponin Trop I= <0.3 ng/mL
Troponin T T or troponin I proteins in the blood. These Trop T= <50 ng/mL
proteins are released when the heart muscle
has been damaged, occurs with a heart
attack.

Troponin I = more specific marker of risk of

composite cardiovascular disease and
coronary heart disease

Troponin T = associated with risk of non-

cardiovascular disease death

C-Reactive Protein and CRP predicts the chance of having TEST Results Risk
Heart disease risk cardiovascular problems at least as well as
cholesterol levels. <1.0 mg Low

1.0 - 2.9 mg Intermediate

> 3.0 mg High

Thyroid Function Test

Name Definition Normal Range

Triodothyronine (T3) Abnormally high levels most commonly indicate for 75 - 200 ng/dL
Grave’s disease, an autoimmune disorder associated
with hyperthyroidism

Thyroxine (T4) High levels of T4 indicates an overactive thyroid 4.5 - 11.5 ug/dL
(hyperthyroidism). Signs and symptoms: anxiety,
unplanned, weight loss, tremors, and diarrhea

Thyroid-Stimulating Hormone TSH a pituitary hormone that stimulated the thyroid 0.3 -5.0 U/mL
(TSH) gland to produce T4 and then T33 which stimulates
metabolism of most tissue in the body.
 Blood Test for Infertility

Name Definition Normal Range

FSH (Follicular-stimulating helps control woman’s menstrual cycle and 5-20 IU/L (3rd day of menstrual
hormone) production of eggs period)

LH (Luteinizing hormone LH is linked to ovarian hormone production 5-20 mIU/ml

level) and egg maturation 25-40 mIU/ml (24-36 hours before
ovulation)

Prolactin Prolactin test is done to examine amenorrhea Non pregnant: 2-29 ng/mL
or infertility problems or nipple discharge Pregnant: 10-209 ng/mL

Ovarian Reserve (AMH) Test Level of AMH in the blood is generally a good High (often PCOS) >4.0 ng/ml
(Anti-mullerian hormone) indicator for ovarian reserve

Normal 1.5-4.0 ng/ml

Low normal 1.0-1.5 ng/ml

Low 0.5-1.0 ng/ml

Blood test Vitamins and Minerals

Name Definition Normal Range

Vit. b12 Vit. 12 (cobalamin), a water soluble vitamin 300-900 pg/ml

that has key role in the synthesis of myelin
(myelinogenesis) for the brain and nervous
system, and formation of RBC.

Vit. D Vit. D is essential for proper growth and 20-50 ng/ milliliter
formation of teeth and bones. Vit. D test
measures the level of 25-hydroxyvitamin D
and/or 1,25-dihydroxyvitamin D in the blood
to detect a deficiency or excess

Serum Calcium All cells need calcium in order to work, Ca 8.5 - 10.2 mg/dL
helps build strong bones and teeth. It’s key
roles involve heart function, muscle
contraction, nerve signaling and blood
clotting

Bone Density Test test to diagnose osteoporosis before a Normal > (-) 1.0
fracture occurs.
Osteopenia (-) 1.0 - (-) 2.5

Osteoperosis < (-) 2.5

 Tumor martkers

Tumor marker Associated tumor types

Neuron-specific enolass A substance detected in patients with neuroblastoma, small cell lung cancer,
(NSE) medullary thyroid cancer, carcinoid tumors, endocrine tumors of the pancreas and
melanoma.

CEA: Carcinoembryonic a protein found in many types of cells but associated with tumors and the developing
antigen fetus. CEA is tested in blood, most often used in colorectal cancer

Prostate-specific antigen test measures the amount of prostate-specific Age Range (years) Asian American
(PSA) test antigen in the blood. PSA is released into the
blood by the prostate gland.
40-49 0-2.0 ng/mL

50-59 0-3.0 ng/mL

60-69 0-4.0 ng/mL

70-79 0-5.0 ng/mL

Blood Test for Arthritis

Name Definition Normal Range

Rheumatoid Factor (RF) RF are proteins produced by the immune system that < 15 IU/mL
attach healthy tissue in the body

Antinuclear antibody (ANA) Detects ANA in the blood. antibodies are produced to Positive or negative
fight against infections

Anti-cyclic citrullinated peptide anti-CCP is an antibody present in most rheumatoid < 20 u/ml
arthritis patients

HLA-B27 a major histocompatibility complex class 1 molecule that Positive or negative

is strongly associated with ankylosing spondylitis

C-reactive protein Test measures body-wide inflammation. Measures below 3.0 mg/dL
substance produced by the liver that increases in the
presence of inflammation

Antistreptolysin O titer (ASO)

Positive titre: > 200 IU/mL Detects antibody to the antigen streptolysin O produced by group A
streptococci.

Titer rises to a peak at 4-6 weeks and may remain elevated for 1 year.

Positive in: • Streptococcal infection (e.g. upper airway infection, scarlet fever)

• Post-streptococcal infection complication (e.g glomerulonephritis and

rheumatic fever)

False positive in: some bacterial infection

 Widal Test
- measures the capacity of antibodies against LPS and flagella in the serum of individuals with suspected typhoid
fever to agglutinate cells of S. Typhi.

Stage Examination Results (%)

1st week Blood culture

95
Blood picture Leukopenia with relative lymphocytosis

2nd week Blood culture

40-50

Widal Test low titre antibody

3rd week Widal Test

100
Blood culture
15-20
Stool and urine culture 80

4th week Widal test

100
Stool and urine culture
90
Blood culture 5-10