Case Report

Date: / / 201

PATIENT ID
•Name: •Age:
•Residency:
•Marital Status:  Single  Married  Divorced 
Widowed
•Occupation:
•DOA: / / 201 •Source of info:

HISTORY OF CURRENT PREGNANCY:

•G P A
•LMP: •Blood Group: •Last
Hb:
•EDD:
•Gestational age:
 Singleton pregnancy  Twin pregnancy:
•Ultrasound?
Why?

Result?

•Did you become pregnant while using birth control?

•Are you currently experiencing any of the following?
Nausea Vomiting Headache Fatigue
Swelling
CHIEF COMPLAINT

Pain?
HISTORY OF THE Vomiting?
PRESENT ILLNESS Bleeding?
-amount :
-amount:
-color:
-color:
S: -odor:
-odor:
O: hematemesis:
w/ pain
C: mucous:
gush of fluid
preceded by
R:
nausea?
A:
w/ pain?
T: projectile non-
HPI SUMMARY:

PAST OBSTETRICAL HISTORY:

•G P A .

Place
of NSI
Duratio Type of
Gende Weig deliver /
# Year n of deliver complications
r ht y/ IVF
preg. y
abortio *
n
1st
2nd
3rd
4th
5th
6th
7th
8th

PAST GYNECOLOGICAL HISTORY:

•1st menarche: years old.
•LMP: / / .
•Regularity:
•Period starts every day.
•Duration of bleeding: days.
 Bleeding or spotting b/w periods.
Contraceptives? pills
IUD
Pap smear? Why? When?
Result?
Pain w/ periods?
 before menses during menses
both

PAST MEDICAL HISTORY

Disease When Drug(s)

PAST SURGICAL HISTORY

Surgery When Where Complication(s)

DRUG HISTORY
Drug Dose Frequency For (disease)

FAMILY HISTORY
Relationship Disease(s) Age diagnosed

SOCIAL HISTORY
Smoking:  Yes:  No
Alcohol:  Yes:  No
House Ventilation:  Well ventilated  Poorly
ventilated
Pets:  Yes:  No
Pollution/Factories:  Yes:  No
Travel:  Yes:  No
ALLERGIES
Drug/Food/Others Effect(s)

BLOOD TRANSFUSION:

SUMMARY:

REVIEW OF SYSTEMS
GENERAL
 Fever  Undocumented
 Documented
 Chills  Sweating
 Fatigue

CARDIOVASCULAR SYSTEM
 Chest Pain: Site:
Onset:  Sudden  Gradual

Character:  Heaviness Stabbing  Burning

 Other:
Radiation/Referral:
Time:  Continuous Severity:

 Intermittent Frequency:

Duration:
Severity:
Exacerbating Factors:

Relieving Factors:

 Dyspnea: Onset:  Sudden  Gradual

 Time:  Continuous Severity:

 Intermittent Frequency:

Duration:
Severity:
Exacerbating Factors:

Relieving Factors:

 Orthopnea  PND 
Dizziness/Syncope
 Palpitation  Edema
 Claudication Distance:

RESPIRATORY SYSTEM
 Cough: Painful  Yes  No
Dry/Wet:  Dry  Wet
Sound:
Time:
 Sputum: Amount:
Color:
Taste/Odor:
 Hemoptysis:Amount:
Appearance:  Blood-streaked  Clots
Frequency/Duration:
 Wheezing

GASTROINTESTINAL SYSTEM
 Mouth ulcers
 Dysphagia:  Solids  Liquid  Both
 Intermittent  Continuous
 Complete obstruction with regurgitation  No
regurgitation
Level food get stuck in:
 Odynophagia
 Nausea
 Vomiting:  Preceded by nausea  Without warning
 With abdominal pain  Without pain
 Pain relieved after vomiting  Not relieved
 Related to meals
 Related to times:
Amount:
Color:
 Odor:
 Projectile  Non-Projectile

 Hematemesis: Amount:
Appearance:  Coffee-ground  Fresh
 Preceded by retching (make the sound and movement of vomiting).
 Blood only appears after the first vomit
 Medications (NSAIDs/corticosteroids):

 Abdominal Pain: Site:

Onset:  Sudden  Gradual
Character:  Colicky  Constant  Twisting
 Tearing
Radiation/Referral:
Time:  Continuous Severity:

 Intermittent Frequency:

Duration:
Severity:
Exacerbating Factors:

Relieving Factors:

 Heartburn Relieved by:

 Weight loss (significant if >10% of weight in 6 months)
 Loss of appetite
 Altered bowel habit: Frequency  Increased
 Decreased
Consistence  Watery  Soft 
Hard
Color:
Odor:
Blood:  Melena (tarry-stool) 
Fresh
 Mucus  Pus  Tenesmus
 Urgency  Incontinence

URINARY SYSTEM
Color:
Odor:
Volume:  Normal  Increased  Decreased
Frequency:  Normal  Increased  Decreased
Stream:  Normal  Thick  Thin
 Dysuria
 Urgency
 Incontinence
 Nocturia
 Hematuria

NERVOUS SYSTEM
 Headache: Site:
Onset:  Sudden  Gradual
Character:

Radiation/Referral:
Time:  Continuous Severity:

 Intermittent Frequency:

Duration:
Severity:
Exacerbating Factors:

Relieving Factors:

 Motor problems:
 Sensory problems:
 Change in personality/judgment:

 Convulsions
 Visual changes
 Auditory changes
 Tinnitus
 Dizziness

MUSCULOSKELETAL SYSTEM
 Muscle pain
 Joint pain
 Exacerbated by movement (mechanical)
 Relieved by movement (inflammatory)
 Morning stiffness (inflammatory)
 Limitation in movement
 Joint swelling
 Deformities
SKIN
 Rash
 Pain
 Redness
 Swelling
 Itching
 Pigment changes
 Discharge/Bleeding
 Hair changes
 Nail changes

ENDOCRINE:
•Alimentary changes:
weight loss weight gain loss of appetite
polydipsia
•Integumental changes:
pigmentation dryness
sweating
•Nervous changes:
nervousness irritability headache
seizures Fatigue Visual
loss