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University of Northern PhilippinesTamag, Vigan City, Ilocos Sur

College of Medicine

DATE & TIME._________________

I.GENERAL DATA.Name: _________________________

Age: __________Sex: [M] [F]Marital Status: [S] [M] Oters:__________________

A!!ress: ________________________________________________________________________________"eligion: ________________________________________________________________________________"ace #$tnicity#Citi%ensi&: _________________________________________________________________Num'er an! (ate o) *os&ital A!missions: _____________________________________

_____________________________________Source o) In)ormation: _____________________________________________________"e)erral: ________________________________________________________________"elia'ility: _____________

II.CHIEF COMPLAINT._____________________________

III.HISTORY OF PRESENT ILLNESS.

+NOT$- . State in cronological or!er )rom te start o) te illness/. 0se s&eci)ic num'er o) ours or !ays1 )or cronic illness, state !ate an! age o) onset/. I) ne2'orn, an!#or &resent &ro'lem is relate! to &renatal 3 &erinatal &erio!, inclu!e maternal an! 'irt istory/

. $la'orate O45"ST +onset, &reci&itating )actors, 6uality1 locali%ation1 !uration1 )re6uency, relie7ing#aggra7ating )actors, associate! signs an! sym&toms3 its O45"ST-1 in!icate mg#8g !ose )or me!ications an! s&eci)ic !ilution )or mil8 )ormula/

. Inclu!e 4ast *istory i) rele7ant to &resent illness +e/g/ &re7iously !iagnose! 2it a !isease relate! to current com&laint#illness-

*istory Ta8ing an! 4ysical $xaminatio+4e!iatrics- Version 9/

Create! 'y Ste&en A/ 0;an

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IV. PAST HISTORY.

A. Childhood Illnesses:

=/ Measles

>/ Mum&s9/ "u'ella

?/ 4oliomyelitis@/ Varicella/ 4ertussisB/ "eumatic )e7er / Scarlet )e7erD/ Oters:

_____________________

B. Medical:+tu'erculosis, e&atitis, astma, or allergies, in;uries#acci!ents, os&itali%ations [!ate1 &lace1 !iagnosis1 treatment]-

C. Surgical:+!ate1 &lace1 in!ication1 ty&e o) o&eration-

D. !stetric"#ynecologic: +inclu!e caesarian sections an! reason1 &regnancy com&lications-

OE *istory: [ ] 4[ ] T[ ] 4[ ] A[ ] G[ ] M[ ] Menstrual *istory: ____________________________

Age o) Menarce: _______________ GM4: ______________

$. Psychiatric:+Illness, time )rame, !iagnosis, os&itali%ations, treatments-

V. IMMUNIZATION HISTORY AND TUBERCULIN TEST.

I%%uni&ation Age #iven"Date Place Unto'ard (eactions

)st *nd +rd ,th -th" Boosters

BC#

epatitis B

P/

DP0

MM(

0etanus 0o1oidPentavalent

D0aP 23y"o"0Dap 4 3y"o

/aricella

Pneu%ococcal

Influen&a

(otavirus

thers:

0u!erculin 0est:

ther Screening 0ests:

Age Co%plications

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VI. FAMILY HISTORY.

Me%!er Age ccupation ealth Status Age of Death Cause of Death4aternal ran!moter

4aternal ran!)ater

Fater:

Maternal ran!moterMaternal ran!)ater

Moter:

Si'lings:

5a%ilial Illnesses:+tu'erculosis, (M, sy&ilis, cancer, e&ile&sy, "*F, mental#&syciatric, congetinal-

+NOT$- Ma8e a genogram o) te )amily i) rele7ant an! note )or consanguinity/

VII. PERSONAL HISTORY.

+NOT$- For H> y#o &atient or > y#o 2it relation to current illness/

A. #estational istory: +NOT$- Age o) moter !uring &regnancy1 &arity1 ealt, nutrition1 in)ection1 !rug#alcool use1 ra!iation ex&osure1 !uration o)gestation i) &ertinent es&ecially in in)ants/

B. Birth istory: +NOT$- Term, &remature or &ostmature1 manner o) !eli7er an! reason i) C.section1 atten!ing &ersons1 'irt2eigt i) &ertinent es&ecially inin)ants/

C. Neonatal istory: +NOT$- A4A" Score1 s&ontaneous res&iration or re6uire! resuscitation1 cyanosis1 &allor1 cry1 ;aun!ice -inclu!e onset-1 emorrage1con7ulsions1 res&iratory o) )ee!ing !i))iculties1 congenital 'irt in;ury i) &ertinent es&ecially in in)ants-

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D. 5eeding istory

Infancy 62* y"o7:

A. 0ype of 5eeding: Ereast)ee!ing1 exclusi7e or mixe!1 )re6uency1 !uration &er 'reast1 i) not 'reast )ee!ing: gi7e reason, )ormula use! 3 !ilution,amount &er !ay, 'ottle or cu& )ee!ing1 in!icate s&eci)ic !ilution )or mil8 )ormula

B. Co%ple%entary 5oods:Age intro!uce!1 initial an! su'se6uent )oo!s intro!uce!1 consistency o) )oo!1 )re6uency o) )ee!ing#!ay

C. Usual 5ood Inta8e:Erea8)ast1 lunc1 !inner1 snac8s1 assess )i7e 'asic )oo! grou&s1 &re)erre! )oo!s

D. Co%pute for Caloric Inta8e9 Co%parison 'ith ($NI or food inta8e to 5ood #uide Pyra%id+See re)erence )or com&utation1 See A&&en!ix A )or te "$NI-

$. 5ood Intolerance:

5. Multivita%ins"Supple%ents:(ose1 )re6uency

#. Caregiver:Moter1 ouseol! el&, gran!&arents1 si'lings

Childhood and Adolescents 6**; y"o7: +NOT$- Omit early )ee!ing istory unless it is &ertinent to &resent illness/

A. Descri!e Appetite:

B. Usual 5ood Inta8e: Meals an! snac8s &er !ay1 amount

C. Assess 5ive Basic 5ood #roups:

D.Co%pute for Caloric Inta8e9 Co%parison 'ith ($NI or food inta8e to 5ood #uide Pyra%id +See re)erence )or com&utation1 See A&&en!ix A )or te "$NI-

$. Multivita%ins"Supple%ents:(ose1 )re6uency

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$. Develop%ental " Behavioral istory /

A. Infancy 62) y"o7:

+NOT$- Jou can use ($NV$" II )or H= y#o as a gui!e !uring te inter7ie2

B.

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D. Adolescence 6);*; y"o7

I. $ADS"S"5I(S0

o%e: S&ace#measurement1 &ri7acy1 )re6uent geogra&ic mo7es1 neig'oroo!

$ducation"School: Fre6uent scool canges, re&etition o) su';ect, teacerKs re&orts, 7ocational goals, e!ucational clu's# grou&s, learning !isa'ilities,acie7ements, a'sences1$ating a!its"Behaviors/

A!use:4ysical, sexual, emotional, 7er'al a'use, &arental !isci&line

Drugs:to'acco, alcool, mari;uana, inalants, clu' !rugs, ra7e &arties, !rug o) coice, age o) initiation, )re6uency1 mo!e o) inta8e1 rituals, alone#2it &eers, 6uitmeto!s an! num'er o) attem&ts

Safety:Seat 'elt, &rotecti7e gears, s&orts sa)ety measures, a%ar!ous acti7ities1 !ri7ing 2ile intoxicate!1SuicidalAtte%pts" Ideation.

Se1uality" Se1ual Identity: "e&ro!ucti7e ealt, use o) contrace&ti7es, &resence o) STI, )eelings, &regnancy1 sexual &ractices, sexual &artners/

5a%ily" 5riends:Family constellation, genogram, ci7il status#relationsi&s, ty&e o) )amily, )amily occu&ations, istory o) a!!iction = stan! >n!!egreerelati7es, &arental attitu!e on !rugs, &arental rules, &eer cli6ues, gangs, &re)erre! )rien!s

I%age:*eigt an! 2eigt &erce&tions, 'o!y musculature an! &ysi6ue, a&&earance, sel).image

(ecreation:Slee&, exercise, s&orts1 acti7ities, total ours s&ent )or recreations/

Spirituality @ Connectedness:*o&e or security )or )uture1 religion1 &ersonal s&irituality &ractices, e))ects o) me!ical care an! li)e issue in7ol7ement

0hreats" /iolence: Sel).arm, arm to oters, running a2ay, cruelty to animals, guns, )igts, arrest, stealing, )igt in scool

II. 5or 5e%ale:

Age o) Menarce: ____________

Menstrual *istory +cycle, regularity, )re6uency, !uration, &ain-:_______________________________________________________

GM4: _____________

Sel). Ereast $xamination 4ractices:

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VIII. SOCIOECONOMIC HISTORY

+NOT$- ?iving circu%stances:&lace an! nature o) !2elling, num'er o) &ersons li7ing in te ouse1 $cono%ic circu%stances:mem'ers o) )amily 2o 2or81

source o) income#)un!s

IX. ENVIRONMENTAL HISTORY:

+NOT$- $nviron%ental circu%stances:ex&osure to cigarette smo8e an! oter &ollutants +s&eci)y an! !uration o) ex&osure-1 #ar!age disposal9 Se'agedisposal9 ater source for drin8ing and 'ashing.

X. REVIEW OF SYSTEMS

#eneralL eigt loss or gainL FatigueL Fe7er or cillsL ea8nessL Trou'le slee&ingL Acti7ity le7elL (elay in gro2t

S8inL "asesL Gum&sL ItcingL (ryness

L AcneL Color cangesL *air an! nail canges

eadL *ea!aceL *ea! in;uryL Nec8 4ain

$arsL (ecrease! earingL "inging in earsL $araceL (rainage

$yes

L Vision Goss#CangesL lasses or contactsL 4ainL "e!nessL Elurry or !ou'le 7isionL Flasing ligtsL S&ec8sL laucomaL CataractsL (rynessL GacrimationL Gast eye exam 3result:_________________

NoseL Stu))inessL (iscargeL ItcingL *ay )e7erL Nose'lee!sL Sinus &ain

0hroat"MouthL Elee!ingL (enturesL Sore tongueL (ry moutL Sore troatL *oarsenessL TrusL Non.ealing soresL Tootace

Nec8L Gum&sL S2ollen glan!sL 4ainL Sti))ness

BreastsL Gum&sL 4ainL (iscargeL Sel).exams

(espiratoryL CougL S&utumL *emo&tysisL SOE#(OEL ee%ingL 4ain)ul 'reating

CardiovascularL Cest &ain or !iscom)ortL TigtnessL 4al&itations

L $asy )atiga'ilityL Orto&neaL Fainting s&ellsL Cyanosis

#astrointestinalL S2allo2ing !i))icultiesL *eart'urnL Cange in a&&etiteL Nausea#VomitingL Cange in 'o2el a'itsL "ectal 'lee!ingL Consti&ationL (iarrea

L Foo! intoleranceL A'!ominal &ainL 4ica

#enitourinaryL Fre6uencyL 0rgencyL Eurning or &ainL Eloo! in urineL IncontinenceL Cange in urinary strengtL Cange in urine colorL $nuresisL(iscargeL $!ema o) an!s an! )eetL 4re&u'ertal: !iscarge an!

itcingL *istory o) Menstrual 4erio!:+onset, )re6uency, regularity,&ain an! GM4-__________________________________________

Peripheral /ascularL Cal) &ain 2it 2al8ingL Geg cram&ingL Varicose 7eins

Musculos8eletalL Muscle or ;oint &ainL Sti))nessL Eac8 &ainL "e!ness o) ;ointsL S2elling o) ;ointsL TraumaL Gim&ingL Gimitation o) motion

Neurologic"BehavioralL Ner7ousnessL Stress

L (e&ressionL Memory lossL (i%%inessL FaintingL Sei%uresL ea8nessL Num'nessL TinglingL TremorL 4aralysisL $ating &ro'lemsL 4ersonality or 'ea7ioralcangesL Tem&er out'urstsL *allucinations

e%atologicL $ase o) 'ruisingL $ase o) 'lee!ingL 4ast trans)usions an!reactions: ______________

$ndocrineL *eat or col! intoleranceL S2eatingL Fre6uent urinationL 4oly!i&siaL 4oly&agiaL 4al&itations

PHYSICAL EXAMINATION

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GENERAL SURVEY

+NOT$- Mental state#sensorium1 le7el o) acti7ity1 eigt1 grooming, !ress an! &ersonal ygiene1 &resence o) C4 !istress or color1 am'ulatory or 'e!ri!!en1 nutritionalstate +2ell, un!er, or o7er nourise!-, state o) y!ration, ill.loo8ing +2ell, mil!, or se7ere: re)er to In!ex A )or Acute Illness O'ser7ational Scale-

VITAL SIGNS

Blood Pressure:R-Arm____________ mm*gL-Arm____________ mm*gCardiac"Pulse (ate:________ '&m(espiratory (ate:_________ c&m1ygen Saturation:________

0e%perature:Rectal:__________Oral:__________

Axillary:___________Tympanic:_________Temporal Artery:__________

Pain Scale:________________

+NOT$- . O'tain E4 i) 9 y#o/ . Correlate C"#4" an! "" to cil!Ks con!ition 2ere it is clinically signi)icant, +i/e/ 2as te cil! aslee&, acti7e, a)e'rile + @.B c&m # C 9B C-, crying, struggling etc/

. "" to C" ration is a'out =:?/

ANTHROPOMETRIC MEASUREMENTS

eigt: ___________ 8g (Percentile: ___)Gengt +H> y#o-: __________cm (Percentile: ___)*eigt +P > y#o-: __________cm (Percentile: ___)

*ea! Circum/ +H9 y#o-: _______ cm (Percentile: ___)Cest Circum/: _________ cm

A'!ominal Circum/: _________ cm

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EMI: _____________ (Percentile: ___)

5or children 'ith gro'th disorders:Arm S&an:___________cm0#G "atio:__________

+NOT$- Q See A&&en!ix A )or te &ercentiles/

HEAD TO TOE PHYSICAL EXAMINATION:

SIN:A)ter )irst year o) li)e, tecni6ues are te same 2it a!ults/ Goo8 )or color, tissue#s8in turgor, ras or eru&tions, emorrages, scars, e!ema, ;aun!ice/ Note

)or milia, erytema toxium, lanugo, $&stein &earls, Mongolian s&ots etc/

$AD: Assess )or air, sa&e, contour, scal&, )ontanels, sutures1 *air is !escri'e! 'ase! on 6uantity, color, texture, sur)ace caracteristics, an! strengt/1 Goo8)or s2elling, ca&ut succe!aneum, ce&alematoma/

5AC$: Ins&ect )or symmetry, ex&ression, unusual )acies, !e)ormities, lum&s, 'um&s1 an! a!enoi! )acies/

$

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C$S0 AND ?UN#S: Ins&ect si%e an! sa&e, mo7ement 2it res&irations, cest retractions, cest ex&ansion, 7ocal )remitus, cec8 'reast contour an!!iscarge +re)er to Tanner Staging-/ 4ercuss, an! auscultate )or 'reat soun!s/

$A(0 AND P$(IP$(A? /ASCU?A(: O'ser7e &recor!ium, 7isi'le &ulsations, a&ex 'eat, trills, eart soun!s an! &ulses/

ABDM$N:Ins&ect si%e, sa&e, &rominent 7essels, striae, &ulsations, &eristaltic mo7ements, mo7ement in relation to res&iration, um'ilical ernia, a'!ominal!istention, a'!ominal circum)erence, auscultation o) 'o2el soun!s, &ercussion, &al&ation o) li7er s&an, s&leen, ten!erness, masses/ Assess )or 8i!neys an!costro7erte'ral angle ten!erness/ Cec8 inguinal regions )or y!rocele, lym& no!es an! ernias/

MA?$ #$NI0A?IA: Ins&ect &enis, &re&uce an! glans, !iscarges, s8in lesions, uretral ori)ice, &al&ate )or te testes/

5$MA?$ #$NI0A?IA:Ins&ect 7ul7o7aginal area )or lesions an! cec8 )or !iscarges, 7aginal introitus, lacerations an! !iscarges, an! sa&e o) ymen/

ANUS AND ($C0UM:Gocation, &atency, )issures, lesions, tags, emorroi!s, &in2orms or &rola&se/ In rectal exam, assess )or s&incter tone, mass,im&acte! )eces an! ten!erness/

UPP$( AND ?$( $0($MI0I$S:Cec8 )or clu''ing, cyanosis, signs o) in)lammation, range o) motion an! ;oint !e)ormities1 i& !islocations inne2'orn an! 7erte'ral s&ine/ Assess )or &eri&eral &ulses, lym& no!es1 an! e!ema/

Musculos8eletal:

Peripheral /ascular:

(adial 5e%oral Popliteal Dorsalis Pedis Posterior 0i!ial

(ight

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?eft

N$(/US: Assess )or sensations1 gait1 strengt an! coor!ination1 !ee& ten!on re)lexes1 !e7elo&ment1 cere'ellar )unction an! cranial ner7es/

Mental Status: +See also Mini.Mental Status $xamination at APP$NDI A-

Cere!ellar: +4er)orm ra&i! alternating mo7ement1 Finger.to.nose1 *eel.to.seen-

#ait"Stance"Balance: +ait#Stance: as8 te &atient to 2al8 across te room1 Ealance: Test )or "om'erg an! 4ronator (ri)t-

Motor and Strength: +ra!e o) muscle strengt 'ilaterally1 see APP$NDI A-

Sensory: +Test )or sensations 'ilaterally1 see APP$NDI A-

Cranial Nerves:

Cranial Nerves"5unction (e%ar8s

I . Ol)action

II . Visual Acuity

III, IV, VI Q $xtraocular Mo7ements

V . Motor an! Sensation

VII . Facial

VIII . *earing

IR, R Q S2allo2ing an! ag "e)lexRI Q S&inal Accessory

RII . *y&oglossal

(efle1es:

Biceps 0riceps Brachioradiali

s

Patellar Achilles Plantar

(ight

?eft

Develop%ent: +For cil!ren 9 y#o-/ As8 to !ra2 a &icture or co&y o';ects, an! !iscuss teir &ictures to test also )or )ine motor coor!ination, cognitionan! language or 0S$ ($NV$" II1 S$$ APP$NDI A-

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APP$NDI A

MiniMental Status $1a%ination

Points Patient>s Score

Orientation

Name: season#!ate#!ay#mont#year +=&t/ )or eac name- +@-

Name: os&ital#)loor#to2n#state#country +=&t/ )or eac name- +@-(egistration

I!enti)y tree o';ects 'y name an! as8 &atient to re&eat +9-

Attention and calculation

Serial Bs1 su'tract )rom = +e/g/, D9QQBDQB>Q@- += &t/ )or eac su'traction- +@-

(ecall

"ecall te tree o';ects &resente! earlier +9-

?anguage

Name &encil an! 2atc +=&t/ )or eac o';ect- +>-

"e&eat No i)s, an!s, or 'uts +=-

Follo2 a 9.ste& comman! +e/g/, Ta8e tis &a&er, )ol! it in al), an! &lace it on te ta'le-+=&t/ )or eac comman!-

+9-

rite close your eyes an! as8 &atient to o'ey 2ritten comman! +=-

As8 &atient to 2rite a sentence +=-

As8 &atient to co&y a !esign +e/g/, intersecting &entagons- +=-

0otal +9-

Muscle Strength $1a%ination

Maor Muscle #roups: (ight ?eft

$l'o2)lexion +C@, C'ice&s-extension +C, CB, Ctrice&s-

rist extension +C, CB, C, ra!ial ner7eextensor car&i ra!ialis longus an! 're7is-

ri& +CB, C, T=-

Finger a'!uction +C, T=, ulnar ner7e-

O&&osition o) te tum' +C, T=, me!ian ner7e-

Flexion at te i& +G>, G9, G? ilio&soas-A!!uction at te i&s +G>, G9, G?a!!uctors-

A'!uction at te i&s +G?, G@, S=gluteus me!ius an! minimus-

$xtension at te i&s +S=gluteus maximus-

Flexion at te 8nee +G?, G@, S=, S>amstrings-

(orsi)lexion +mainly G?, G@ti'ialis anterior-

4lantar )lexion +mainly S=gastrocnemius, soleus- at te an8le

Sensory $1a%ination

Sensory Syste% (ight ?eft

A. Spinothala%ic:&in&ric8, tem&erature, ligt touc (Rate !"# $%$$'

Soul!ers +C?-

Inner an! outer as&ects o) te )orearms +C an! T=-

Tum's an! little )ingers +C an! C-Fronts o) 'ot tigs +G>-

Me!ial an! lateral as&ects o) 'ot cal7es +G? an! G@-

Gittle toes +S=-

Me!ial as&ect o) eac 'uttoc8 +S9-

B. Posterior Colu%n: (I)ta*t "! N"t

4osition sense

Vi'ration

C. Sensory Corte1 +(iscrimination- (I)ta*t "! N"t

Stereognosis

ra&estesia

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