CLINICAL HISTORY WRITING

Name of Student: Date:

Davao Medical School Foundation,

Inc. DAVAO MEDICAL HOSPITAL

Date: _

I. PATIENT’S IDENTIFYING DATE

Name: Becky Oliver Age: Gender _ Civil Status: Single_

Address: Chicago??
Religion: Catholic
Source of History Reliability: _

II. CHIEF COMPLAINT

Fatigue

III. HISTORY OF PRESENT ILLNESS (HPI)

Onset 2 months ago?

Location
Duration
Characteristic
Aggravating
Alleviating
Associated symptoms
Radiation
Timing
Severity
History of travel
What did you eat prior
(Diarrhea)
Cough productive or dry?
(Cough)
Character of phlegm
productive or dry? (Cough)

IV. PAST MEDICAL HISTORY

Childhood Illnesses (Chicken pox,

polio, Rheumatic fever, Measles)

Adult Illnesses
 Medical (Maintenance
medications)

 Surgical (Dates, indication,
type of operation,
medication, complication,
where)
 Obstetric (Obstetric history,
menstrual history, methods
of contraception, sexual
function)
 Psychiatric (Illness and
time frame, diagnoses,
hospitalizations,
treatments)
Health Maintenance
 Immunizations
 Screening tests
Allergies
V. FAMILY HISTORY
NAME RELATIONSHIP
Mother
Father
Paternal Grandfather’s
VI. PERSONAL AND SOCIAL HISTORY
Lifestyle habits, exercise and diet
(Frequency of exercise, usual
daily food intake, dietary
supplements or restrictions, use
of coffee, tea and other
caffeinated beverages)
-I've never had any operations or
psychiatric problems. I've occasionally
had trouble donating blood because of
low iron
-Broke wrist playing volleyball when in
high school
Allergy to penicillin she took when she
had mononucleosis
DATE DIED AND/ OR
DISEASE
Overweight
Overweight,
Hypertension
Diabetes
-Had drugs 2 months ago from a party.
Smoked a marijuana & had cocaine. Took
few days to recover.
-one or two cups of coffee in the morning.
have a cup or two at night when I have to
stay up late to study
- at three meals a day. For breakfast, I either
have cereal or a roll and coffee. Because I'm
so busy this semester with school, I usually
have fast food for lunch and then something I
can throw in the microwave, like a frozen
meal, for dinner. When I am under a lot of
stress, I tend to eat more
- walk to school every day
 - If I have a headache I usually take Tylenol
-last trip during spring break last year from
South Padre Island
History of smoking (How long the
patient has been smoking and
how many sticks/ pack per day)

History of alcoholic beverage Occasional. Few beers on Friday/Sat night.

intake (What type of liquor, how In party, had mixed drink or two.
many glass/ bottle and how often)

Alternative health care practices

(yoga, mediation, acupuncture)

Patients Interests

Source of support -have little extra money. I'm pretty much on

my own. money I do have is from a student
loan.
-only child
Coping styles

Strengths and weaknesses

Occupation Junior in Microbiology

Educational Degree

Home situation live alone in a small efficiency apartment

Source of Stress

VII. REVIEW OF SYSTEMS

General Usual weight, recent weight
change, clothing that fits more
tightly or loosely than before;
weakness, fatigue, or fever.
Skin Rashes, lumps, sores, itching,
dryness, changes in color;
changes in hair or nails; changes
in size or color of moles.
Head Headache, head injury, dizziness,
lightheadedness.
Eyes Vision, glasses or contact lenses,
The patient is able to raise the
eyebrows equally well
bilaterally. The forehead is
furrowed symmetrically and
there is good strength when
eyebrows are forcibly pushed
downward. The patient is able
to close both eyes equally
well and the eyelashes are
obliterated to the same
degree on both sides. The
patient's smile, both on
volition and reflexively when
laughing, is seen to be
symmetrical.
get some pretty bad
headaches from time to
time but Tylenol always
seems to take care of it
 last examination, pain, redness,
excessive tearing, double or
blurred vision, spots, specks,
flashing lights, glaucoma,
cataracts.
Ears Hearing, tinnitus, vertigo,
earaches, infection, discharge. If
hearing is decreased, use or
nonuse of hearing aids.
Nose Frequent colds, nasal stuffiness,
discharge, or itching, hay fever,
nosebleeds, sinus trouble.
Throat (or Condition of teeth and gums,
mouth and bleeding gums, dentures, if any,
pharynx) and how they fit, last dental
examination, sore tongue, dry
mouth, frequent sore throats,
hoarseness.
Neck “Swollen glands,” goiter, lumps,
pain, or stiffness in the neck.
Breasts Lumps, pain, or discomfort, nipple -The breasts are
discharge, self-examination symmetric, and skin over
practices. the breasts is smooth with
no thickening and no
alteration in vascular
pattern. Nipples are
everted, with symmetric
areolae which are diffusely
reddish brown; there is no
discharge, irregularity, or
rash, nor any
supernumerary nipples.
Raising the arms over the
head or pressing the hands
against the hips does not
change breast contour nor
produce dimpling.
-On palpation, the
glandular breast has a
lobular consistency which
is homogeneous
throughout both breasts;
there is mild tenderness,
and no discrete nodules or
areas of induration are
present. The mammillary
tail is of the same
consistency and no masses
are palpable in the anterior
or posterior axillary folds.
Respiratory Cough, sputum (color, quantity;
presence of blood or hemoptysis),
shortness of breath (dyspnea),
wheezing, pain with a deep breath
(pleuritic pain), last chest x-ray.
You may wish to include asthma,
bronchitis, emphysema,
pneumonia, and tuberculosis.
Cardiovascular “Heart trouble”; high blood Internal jugular pulses are
pressure; rheumatic fever; heart noted to 2 cm above the
murmurs; chest pain or discomfort; sternal angle with the
palpitations; shortness of breath; patient’s head, neck and
need to use pillows at night to
 ease breathing (orthopnea); need trunk elevated at 30 to 45°
to sit up at night to ease breathing with the head of the patient
(paroxysmal nocturnal dyspnea); in the midline position or
swelling in the hands, ankles, or slightly turned to the
feet (edema); results of past
opposing side.
electrocardiograms or other
cardiovascular tests
Gastrointestinal Trouble swallowing, heartburn, On auscultation, clicks and
appetite, nausea. Bowel gurgles are heard 10 to 15
movements, stool color and size, times per minute and there
change in bowel habits, pain with are occasional borborygmi;
defecation, rectal bleeding or black no hums, bruits or friction
or tarry stools, hemorrhoids,
rubs are heard.
constipation, diarrhea. Abdominal
pain, food intolerance, excessive
belching or passing of gas.
Jaundice, liver, or gallbladder
trouble; hepatitis.
Peripheral Intermittent leg pain with exertion
Vascular (claudication); leg cramps;
varicose veins; past clots in the
veins; swelling in calves, legs, or
feet; color change in fingertips or
toes during cold weather; swelling
with redness or tenderness.
Urinary Frequency of urination, polyuria,
nocturia, urgency, burning or pain
during urination, blood in the urine
(hematuria), urinary infections,
kidney or flank pain, kidney stones,
ureteral colic, suprapubic pain,
incontinence; in males, reduced
caliber or force of the urinary
stream, hesitancy, dribbling.
Genital Male: Hernias, discharge from or On speculum exam, the
sores on the penis, testicular pain vagina easily admits the
or masses, scrotal pain or swelling, speculum; the vaginal walls
history of sexually transmitted are bluish pink, moist and
infections and their treatments.
elastic, with prominent
Sexual habits, interest, function,
satisfaction, birth control methods,
rugae; the cervix is
condom use, and problems. symmetric and closed,
Concerns about HIV infection. without discharge or
Female: Age at menarche, eversion, and appears
regularity, frequency, and duration nulliparous.
of periods, amount of bleeding; Inspection. The patient's
bleeding between periods or after escutcheon is of the female
intercourse, last menstrual period, pattern; there are no
dysmenorrhea, premenstrual rashes or excoriations on
tension. Age at menopause, the external genitalia; the
menopausal symptoms,
labia are symmetric; the
postmenopausal bleeding. If the
patient was born before 1971,
urethral orifice is open and
exposure to diethylstilbestrol without discharge, situated
(DES) from maternal use during just below the clitoris; the
pregnancy (linked to cervical introitus is without
carcinoma). Vaginal discharge, inflammation or visible
itching, sores, lumps, sexually lesions; no cystocele or
transmitted infections and rectocele is noted when the
treatments. Number of patient strains.
pregnancies, number and type of Palpation. There are no
deliveries, number of abortions palpable cysts or nodules
(spontaneous and induced),
in the external genitalia. On
complications of pregnancy, birth-
control methods. Sexual
bimanual examination, the
vagina easily admits two
 preference, interest, function,
satisfaction, any problems,
including dyspareunia. Concerns
about HIV infection.
fingers; the cervix is soft,
mobile and nontender; the
isthmus can be felt through
the posterior fornix; the
uterus is about the size of a
large orange; it is softened
and nontender; adnexae on
both sides are mobile,
palpable and mildly tender.

Musculoskeleta Muscle or joint pain, stiffness, The spine is symmetric;

l arthritis, gout, backache. If there is lumbar lordosis and
present, describe location of thoracic kyphosis; the iliac
affected joints or muscles, any crests are at equal height
swelling, redness, pain, from the floor. Cervical
tenderness, stiffness, weakness,
spine is lordotic and
or limitation of motion or activity;
include timing of symptoms (e.g., symmetric
morning or evening), duration, and
any history of trauma. Neck or low
back pain. Joint pain with systemic
symptoms such as fever, chills,
rash, anorexia, weight loss, or
weakness.
Psychiatric Nervousness, tension, mood,
including depression, memory
change, suicidal ideation, suicide
plans or attempts. Past counseling,
psychotherapy, or psychiatric
admissions.
Neurologic Changes in mood, attention, or
speech; changes in orientation,
memory, insight, or judgment;
headache, dizziness, vertigo,
fainting, blackouts; weakness,
paralysis, numbness or loss of
sensation, tingling or “pins and
needles,” tremors or other
involuntary movements, seizures.
Hematologic Anemia, easy bruising or bleeding,
past transfusions, transfusion
reactions.
Endocrine “Thyroid trouble,” heat or cold
intolerance, excessive sweating,
excessive thirst or hunger,
polyuria, change in glove or shoe
size.

WBC 6,000/mm3
RBC 4.32 m/mm3
Hemoglobin 12.9 g/dL
Hematocrit 39%
MCV 95 fL
MCH 29 pg
MCHC 33%
Platelets 240,000/mm3
Bands 3% WBC count
Neutrophils 61% WBC count
Lymphocytes 28% WBC count
Eosinophils 2% WBC count
Monocytes 5% WBC count
Basophils 1% WBC count

Blood Pressure 112/74 mm Hg

Heart Rate 76
Temperature 98.6° F
Respiration 16
Pulse 76
O2 sat 97%
Rhythm Slight sinus arrhythmia
Height 5'3" (160cm)
Weight 135 lbs (61.2kg)

PT – 12.5

Height: 5'3" (160cm)

Weight: 135 lbs (61.2kg)
BMI: 24

142 mIU/mL – b-hCG

Transvaginal ultrasound - Development of placenta and fetus, consistent with early pregnancy.
VIII. PHYSICAL EXAMINATION
NEURO
- CRANIAL NERVES
- SENSORY
- MOTOR
- CEREBRAL AND CEREBELLAR
- REFLEXE

IMPRESSION

SALIENT FEATURES IN

HISTORY SALIENT FEATURES

IN PE DIFFERENTIAL

DIAGNOSIS FINAL

DIAGNOSIS

DISCUSSION OF THE FINAL DIAGNOSIS