MEDICAL HISTORY AND PHYSICAL EXAM GUIDE

NAME OF STUDENT: SECTION: DATE:

NAME OF PATIENT: AGE: SEX: WARD:

PATIENT PROFILE
Life History Name: Sex: Age:
Birth Date: Birthplace:
Place of Residence:
Race: Religion: Educational Attainment:
SES of Family: Family Composition:
Living Environment:
Hobbies and Interests:
Marital History Marital Status: Compatibility: Adjustment:
Occupation & Employment Present Work:
Previous Work:
Occupational Hazards: Adjustment:
Financial Status  Sufficient  Insufficient Specify:
Personality Type  High Strung  Chronic Worrier  Easy Going  Others:
Habits, Average Day Dietary and Eating Habits:
Sleeping Habits:
Exercise:
Tobacco Use (Pack Years): Alcohol Intake:
Caffeine Intake: Drug Intake:
Current Medications
(Dose, Frequency, Duration)

CHIEF COMPLAINT
Complaint + Duration

HISTORY Detailed restatement of the CC:

OF PRESENT ILLNESS
Onset + CLITAA + Course

Present Problem from Onset:

Current Status of Patient:

tonifeliciano
 Significant Positives and Negatives:

Temporal Profile

PAST HEALTH
MAINTENANCE
Childhood Diseases  Mumps  Measles  Chicken Pox  Polio  Diphtheria
 Pneumonia  Helminthiasis  Hepatitis  Others:
Allergies
Surgeries
Immunizations VACCINE DOSES AND DATES VACCINE DOSES AND DATES
BCG
DPT
OPV
MMR
Measles
 Fully Immunized  Completely Immunized  Incomplete
Adverse Vaccine Reactions: ____________________________________________
Tuberculin Tests: _____________________________________________________

Hospitalizations
Major Illnesses
Accidents
Pregnancies, Deliveries

FAMILY HISTORY Present Status of Parents and Siblings

HEALTH STATUS/
NAME AGE/SEX RELATIONSHIP
AGE & CAUSE OF DEATH

Heredofamilial Diseases
 Cancer:
 Diabetes:
 Hypertension:
 Cerebrovascular Disease:
 Cardiovascular Disease:
 Mental Illness:
 Others, specify:

tonifeliciano
 Pedigree

REVIEW OF SYSTEMS
General  Fever  Fatigue  Sweating  Weight Loss  Weakness

Skin Color: Texture:

 Itching  Rashes  Changes in Hair/Nails

Eyes  Visual Impairment  Redness  Tearing  Pain

 Double Vision  Discharge  Trauma

Ears  Hearing Loss  Otalgia  Discharge  Tinnitus

Nose, Throat, Mouth  Nasal Obstruction  Discharge  Anosmia  Epistaxis

 Frequent Colds/Cough  Dysphagia  Odynophagia  Change in Voice
 Neck Mass  Toothache  Dental Caries  Gum Bleeding
 Ulcerations  Congenital Deformities

Respiratory  Cough/Sputum  Difficulty of Breathing  Wheezing/Asthma

 PTB Exposure  Hemoptysis

Cardiovascular  Palpitations  Syncope  Chest pain  Edema

 Hypertension  Orthopnea  Dyspnea

Gastrointestinal  Dysphagia  Nausea  Vomiting  Appetite

 Abdominal Pain  Melena  Jaundice  Bleeding
 Indigestion  Heartburn  Hematemesis  Fatty Food Intolerance
 Change in Stool Frequency/Character:
 Hemorrhoids  Abdominal Distention  Hernia

Urinary  Pain  Change in Color/Volume/Frequency/Stream:

 Retention  Bleeding  Polyuria  Anuria  Nocturia
 Stones  Infection  Hesitancy  Urge  Dribbling

Genitoreproductive Male:  Discharge  Pain  Change in Libido  Sexual Difficulties

Female: Menarche: LMP: PMP:
Menses:  Regular  Irregular Duration: Amount:
 Abnormal Vaginal Bleeding  Discharge  Dysmenorrhea/Pelvic Pain
 Post-Coital Bleeding  Contraceptive use:
Pregnancies: Live Births: Heaviest Baby: lbs  PID
Menopause Age:  Postmenopausal Bleeding

Breast  Nipple Changes  Lumps  Pain  Discharge

Extremities  Cyanosis  Clubbing  Edema  Varicosities  Ulcers  Claudication

Hematopoeitc System  Excessive Bleeding/Bruising  Anemia  PICA

Nervous System  Headache  Tremors  Fainting Spells  Seizures

 Dizziness/Vertigo  Head Trauma  Sensory Perversions

tonifeliciano
 Musculoskeletal  Joint Stiffness  Pain  Swelling  Muscle Weakness

Endocrine System  Heat/Cold Intolerance  Thyroid Problems  Neck Surgery/Irradiation  DM Indicators

Psychiatric  Mood Swings  Behavioral Changes  Anxiety  Depression

PHYSICAL EXAMINATION
General Survey LOC:  Conscious  Drowsy  Stuporous  Comatose  _______________
Coherence:  Coherent  Incoherent
General Appearance:  Cardio respiratory distress  Pain  Anxiety
 Chronically ill  Acutely ill
Grooming:  Well  Fairly  Poorly
Development:  Endomorph  Mesomorph  Ectomorph
 Well  Fairly  Poorly
 Looks according to age  Looks younger/older
Nutrition:  Well nourished  Obese  Cachexic
Emotional State:  Calm  Restless  Tense  Worried
Gait:  Coordinated  Uncoordinated  Staggering
 Shuffling  Stumbling  Unable to walk alone
 Walks with assistive devices
Vital Signs T = ____________°C, (Oral, Axillary, Rectal)
HR = ___________ breaths/min
PR = ___________ beats/min
BP = ___________ mmHg, (Sitting, Lying, Standing)
Anthropometrics Height = ___________cm Weight = __________kg BMI = ____________
Skin General Color:  Pallor  Jaundice  Flushing  Cyanosis
Moisture:  Dry  Wet/Clammy  Oily
Turgor:  Good  Fair  Poor
Texture:  Smooth  Rough  Others: _________________________
Temperature:  Warm  Cool  Others: _________________________
Lesions/Rashes (Distribution, Color, Pruritus, Etc.): ________________________________________
Hemorrhages:  Petecchiae  Ecchymoses  Hematoma
Hair:  Fine  Coarse  Dry
 Normal distribution  Alopecia
 Clean  With dandruff  With lice
Nails:  Pink  Pale  Cyanotic  Inflamed  Clubbed
 Edema, grade: _________  Non-pitting  Pitting  Pedal R L
Eyes Lids:  Symmetrical  Edema R L  Ptosis R L
Periorbital region:  Edema  Sunken  W/discoloration
Conjunctiva:  Pinkish  Pale  Discharge
 Lesions: _______________________________________________________
Sclera:  Anicteric  Icteric  Hemorrhages
Cornea & Lens:  Smooth  Clear  Lesions
 Opacity  Arcus Senilis
 Signs of inflammation  Exophthalmos  Tension
Head  Symmetrical  Asymmetrical  Masses: _____________________________________
Ears  Normoset  Symmetrical  Asymmetrical  Tender
 Gross abnormalities/lesions: ________________________________________________________
 Discharge:  Foul smelling  Serous  Purulent  Mucoid
Gross Hearing:  Symmetrical  Deafness R L
 Impacted cerumen Tympanic membranes:  Intact  Infiltrated
Nose Patency:  Both Patent  Obstructed R L
 Masses/Lesions: ____________________________________________________
Septum:  Midline  Deviated  Perforated
Mucosa:  Pinkish  Pale  Reddish
 Discharge:  Serous  Purulent  Mucoid  Bloody
Sinuses:  Non-tender  Tender: ____________________________________________

tonifeliciano
 Mouth Lips:  Pallor  Cyanosis  Dryness/Cracks  Lesions
Tongue:  Midline  Deviation R L  Atrophy
 Fasciculations  Lesions: _______________________________________________
Teeth:  Complete  Missing: ______________________________________________
 Caries  Dentures  Braces/Retainers

Upper Lower

Gums:  Pinkish  Pale  Bleeding  Tender

Mucosa:  Pinkish  Pale  Cyanotic
Throat Uvula:  Midline  Deviation to R L
Mucosa:  Pinkish  Pale  Reddish
Tonsils:  Not inflamed  Inflamed  Exudates
Neck Trachea:  Midline  Deviation to R L
Lymph nodes:  Nonpalpable  Palpable/enlarged  Tender
Thyroid:  Nonpalpable  Enlarged
 Normal ROM  Neck Rigidity  NVE at _______° Angle R L
 Masses: _________________________________________________________________________
Breast  Masses: _____________________________  Discharge: _______________________________
 Inverted nipple  Others: _________________________________
Chest and lungs Shape:  Barrel  Funnel  Pigeon
APL ratio: ________ : ________ IE Ratio: ________ : ________
Breathing Pattern:  Eupnea  Hyperpnea  Tachypnea
 Dyspnea  Alar flaring  Retractions
 Use of accessory muscles
Chest surface:  Tenderness  Deformities  Masses
Chest expansion:  Symmetrical  Decreased/Lag R L
Tactile Fremitus:  Symmetrical  Dec/Inc at ___________________________ lung field
Percussion:  Resonant  Dullness at __________________________________
 Hyper resonant at _______________________________________________
Breathe sounds:  Vesicular at ____________________________________________________
 Bronchovesicular at _____________________________________________
 Bronchial at ___________________________________________________
Consolidation:  Egophony  Bronchophony  Whispered petriloquy
Abnormal BS:  Wheezes  Ronchi  Rales  Friction rub
Cardiovascular Configuration: Symmetrical  Pectus excavatum  Pectus carinatum
Precordial Area:  Flat  Bulging  Scars
 Normodynamic  Hyperdynamic  Heaves/thrills
 JVP at ____________ cm, with HOB at ____________ °angle  Hepatojugular reflex
PMI at ______________ Apex beat at ______________
Heart Sounds:  Distinct  Faint S1 ______ S2 at base S1 ______ S2 at apex  S3  S4
 Murmur, grade ________ best heard at _______________________________________________
 Pericardial friction rub  Other sounds: ____________________________________

PULSE GRADE PULSE GRADE PULSE GRADE

Radial Femoral Posterior Tibial
Brachial Dorsalis Pedis Carotid

tonifeliciano
 Abdomen Configuration:  Symmetrical  Asymmetrical
 Flat  Flabby  Globular  Protuberant  Scaphoid
Skin:  Dilated veins  Striae  Scars  Rashes
 Lesions at __________________________________________________________
Umbilicus:  Sunken  Bulging
Bowel Sounds: ________/min  Normoactive  Hyperactive  Hypoactive  Absent
Bruit:  Absent  Present at ___________________________________________
Percussion:  Tympanitic  Hypertympanitic  Dullness at ______________________
 Fluid wave  Shifting dullness
Traube’s Space:  Intact  Obliterated
Palpation:  Muscle guarding  Tenderness (Direct, Rebound)
 Rigidity  Masses: _______________________
Kidneys:  Palpable (size, contour): _____________________________
 Nonpalpable  Tenderness  CVA tenderness
Urinary Bladder:  Smooth, round  Tenderness
Genitalia Pubic hair:  None  Sparse  More adult-like, at base of penis
 Adult type, smaller area Adult type, up to medial thigh surface
Male
Penis:  Circumcised  Uncircumcised
 Tenderness  Discharge: ______________________________________
 Nodules/lesions at ______________________________________________________
Scrotum:  Equal  Tenderness  Enlargement R L
 Undescended R L  Nodules/lesions at _______________________________
 Hernia  Hydrocele  Tortuous veins
Female
Labia:  Symmetrical  Asymmetrical, lesions at __________________________
 Pinkish  Discoloration  Edema
 Discharge:  Purulent  Bloody  Foul-smelling
Others:  Swelling  Lumps/Nodules at _______________________________
Neurologic
Mental Status Exam
(Temporal & Occipital) Oriented to:  Time (Time of day, d, m, y)  Place (Country, region, city, brgy, bldg)  Person
 Object* naming (at least three)  Color naming (at least three)
Memory:  Immediate*  Recent  Remote
Attentiveness:  Good  Fair  Poor
Conccentration:  Good  Fair  Poor
(Frontal) Expressive Language:  Normal rate  Normal rhythm  Normal pitch
 Normal loudness  Spontaneous
Insight:  Able to interpret proverb
Judgement:  Good  Fair  Poor
Planning:  Good  Fair  Poor
Calculation (Note educational attainment):  Able to do serial 7s
 Intact left and right orientation Finger naming: ________/10 fingers
(Parietal Dominant) Graphesthesia: ________/3 letters/numbers Stereognosis: _________/3 objects
Apraxia:  Able to dress self  Able to button up
Drawing:  Circle  Triangle  Square  Intersecting pentagons
(Parietal Nondominant)
Cranial Nerve I Gross Smell:  Symmetrical  Olfactory Deficiency R L
II Visual Acuity:  _____/_____  Wears eyeglasses/contact lenses
Fundoscopy Findings: ________________________________________________________________
Pupil Size:  Equal = ______ mm
 Unequal R=______ mm L=______ mm
Light Reaction: R  Brisk  Sluggish  Fixed
L  Brisk  Sluggish  Fixed
Reaction to Accommodation:  Uniform  Unequal
III, IV, VI Convergence:  Uniform  Unequal
EOMS:  Intact  Dysconjugate Gaze  Nystagmus
V Facial Sensation:  Symmetrical  Inc/Dec at ______________________

tonifeliciano
  Normal masseter tone  Normal temporalis tone
VII Facial Expressions:  Symmetrical  Lag at __________________________
Anterior 2/3 Taste:  Intact  Absent
Nasolabial Fold:  Symmetrical  Shallowing
VIII Gross Hearing:  Intact Decreased R L
Weber:  Symmetrical  Lateralizes R L  Rinne
IX, X  Able to swallow  Uvula deviation R L  Gag reflex
XI  Shrug (Trapezius)  SCM test
XII Tongue:  Midline  Deviation R L  Atrophy
Speech:  Intact  Slurred  Aphasic
Motor  Symmetrical  Asymmetrical  Atrophic
Muscle Tone:  Normal  Flaccid  Spastic
Muscle Strength: R Upper extremity _______________ R Lower extremity ______________
L Upper extremity _______________ L Lower extremity _______________
ROM:  Full  Decreased at ___________________________________________________
Sensory  Touch  Pain/Dullness  Temperature  Vibration  Proprioception
Cerebellar Gait:  Natural  On heels  On toes  Tandem
 Finger to nose  Heel to sheen  Tibial tapping  Pro/supination
Deep Tendon Reflexes REFLEX GRADE REFLEX GRADE REFLEX GRADE
Biceps Brachioradialis Ankle
Triceps Patellar
 Babinski  Clonus  Others: _______________________________
Meninges  Nuchal rigidity  Kernig’s sign  Brudzinski sign

tonifeliciano