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    Mcu-Fdt Medical Foundation Hospital Out Patient Services: Chief Complaint: History of Present Illness

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    vinb
    This document contains a template for documenting a patient's outpatient visit to the department of otorhinolaryngology-head & neck surgery. It includes sections for the patient's personal details, chief complaint, history of present illness, medical history, review of systems, vital signs, physical examination findings, clinical impression, management plan, and disposition. The physical exam would involve inspection of the ears, nose, mouth, throat, head and neck.

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    Mcu-Fdt Medical Foundation Hospital Out Patient Services: Chief Complaint: History of Present Illness

    Uploaded by

    vinb
    142 views2 pages
    This document contains a template for documenting a patient's outpatient visit to the department of otorhinolaryngology-head & neck surgery. It includes sections for the patient's personal details, chief complaint, history of present illness, medical history, review of systems, vital signs, physical examination findings, clinical impression, management plan, and disposition. The physical exam would involve inspection of the ears, nose, mouth, throat, head and neck.

    Original Title

    ENT_OPD_CHARTS

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    This document contains a template for documenting a patient's outpatient visit to the department of otorhinolaryngology-head & neck surgery. It includes sections for the patient's personal details, chief complaint, history of present illness, medical history, review of systems, vital signs, physical examination findings, clinical impression, management plan, and disposition. The physical exam would involve inspection of the ears, nose, mouth, throat, head and neck.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    142 views2 pages

    Mcu-Fdt Medical Foundation Hospital Out Patient Services: Chief Complaint: History of Present Illness

    Uploaded by

    vinb
    This document contains a template for documenting a patient's outpatient visit to the department of otorhinolaryngology-head & neck surgery. It includes sections for the patient's personal details, chief complaint, history of present illness, medical history, review of systems, vital signs, physical examination findings, clinical impression, management plan, and disposition. The physical exam would involve inspection of the ears, nose, mouth, throat, head and neck.

    Copyright:

    © All Rights Reserved
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    of 2

    MCU-FDT MEDICAL FOUNDATION HOSPITAL

    OUT PATIENT SERVICES


    DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD & NECK SURGERY

    Family Name Given Name Middle Name Age Date:

    Time:

    CHIEF COMPLAINT:

    HISTORY OF PRESENT ILLNESS:

    OB GYNE HISTORY PAST MEDICAL HISTORY FAMILY HISTORY PERSONAL/SOCIAL HISTORY

    FMP _____ __ ALLERGY __ HPN __ NONE __ HPN SMOKING HISTORY


    LMP _____ __ BRONCHIAL ASTHMA __ DM __ DM __ CANCER ALCOHOL CONSUMPTION
    PMP _____ __ CONVULSION __ TB __ HEART DISEASE DIET
    PMS _____ __ HEART DISEASE __ OTHERS
    G __ P __ ( __,__,__,__) __ OTHERS

    REVIEW OF SYSTEMS
    HEADACHE ___ BLURRING OF VISION ___ DYSPNEA ___ CHEST PAIN ___
    DIZZINESS ___ VISUAL LOSS ___ WHEEZING ___ PALPITATIONS ___
    MIGRAINE ___ DECREASED HEARING ___ TACHYPNEA ___ EASY FATIGABILITY ___
    OTHERS TINNITUS ___ COUGH ___ ORTHOPNEA ___
    NOSE BLEED ___ HEMOPTYSIS ___ PEPTIC ULCER DISEASE ___
    OTHERS OTHERS

    HEMATEMESIS ___ NECK PAIN ___ PARESTHESIA ___ FEVER ___


    CONSTIPATION ___ JOINT PAIN ___ WEAKNESS ___ CHILLS ___
    HEMATOCHEZIA ___ BACK PAIN ___ SYNCOPE ___ JAUNDICE ___
    ABDOMINAL PAIN ___ MUSCLE PAIN ___ CONVULSION ___ MALAISE ___
    DYSPEPSIA ___ OTHERS DEPRESSION ___ OTHERS
    VOMITING ___ HALLUCINATION ___
    DIARRHEA ___ OTHERS
    MELENA
    OTHERS

    VITAL SIGNS ANTHROPOMETRICS


    PR ___ RR ___ BP ___ TEMP ___ PAIN SCALE ___ WEIGHT ___ HEIGHT ___ BMI ___

    PHYSICAL EXAMINATION;

    GENERAL SURVEY:

    OTOSCOPY
    RHINOSCOPY

    ANTERIOR POSTERIOR

    ORAL CAVITY INDIRECT LARYNGOSCOPY

    HEAD AND NECK

    /
    CLINICAL IMPRESSION:

    MANAGEMENT:

    DISPOSITION: History and PE done by: Countersigned by:

    ____ Admitted ______________________ ,MD


    ____ Discharged with prescription Signature over printed name
    and instructions Resident-in charge

    Date of follow-up ______________________ ,MD


    Signature over printed name
    ____ Home against medical advice Consultant on Duty

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