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Complete Medical History

DATE :Tuesday, October 25, 2005

GENERAL DATA: Name of patient, age, sex, civil status, nationality, occupation, religion, birth place, presently residing, sought consult to our clinic on date

CHIEF COMPLAINT: Cough, Cold, and Fever for 2 days

HISTORY OF PRESENT ILLNESS:

“Chronological recording of Data”

· Date, time of onset of chief complaint

· mode of onset

· precipitating factors

· exact anatomical location (if applicable)

· severity

· character

· number of times

· method/agent of relief

Four days PTA	Periorbital edema, (-) hematuria, (-) dysuria, nor change in pattern of urination (-) no Consult done
Three days PTA	non- productive cough, watery nasal discharge generalized muscle pain, intermittent fever, undocumented Med. Paracetamol—temporary relief
Two days PTA	Consult : Private M.D. Dx. URTI Meds Cefaclor QID Bromhexine SCMC
Day of Admission	Headache, nausea and vomiting, tea colored urine Decrease frequency of urination No Dysuria, flank pain, no fever

Admission

BIRTH HISTORY: (pedia)

Borne; 24 y/o G1P1 (1001) NSD, Home, (+) spontaneous cry and respiration, uncomplicated

Birth weight; unknown

Maternal History: (pedia)

Irregular PNCU

(-) Maternal Illness

(-) Intake of meds. Nor X-ray exposure.

FEEDING HISTORY: (pedia)

Breast feeding birth-------- 4 months then shifted to milk feed

Weaning 4 months

IMMUNIZATION: (pedia)

Complete

GROWTH and DEVELOPMENTAL HISTORY: (pedia)

Rolled over -4 months sat alone- 8 months

crawled- 5 months walk- 1 year

PAST MEDICAL HISTORY:

· During birth

() congenital defects:____________________

() malnutrition

() low birth weight

· Childhood/ Adult Diseases

() TB	() typhoid	() bronchitis	() dysentery	() rheumatism
() HPN	() diabetes	() hepatitis	() freq. Coughs	() influenza
() RHD	() measles	() parasitism	() freq. Colds	() heart disease
() cancer	() malaria	() small pox	() diphtheria	() scarlet fever
() mumps	() migraine	() chicken pox	() pneumonia	() GIT problem
() asthma	() tonsillitis	() arthritis	() amoebiasis	() renal disease
() freq. Sore throat

· Immunizations

Name	Age	Date

· Allergen and Drug Sensitivities

Substance	Reaction	Desensitization/ serum injection/vaccination: if any

· Trauma/ Major Injuries/ Accidents

Time	Condition	Injury	Treatment/Management

· Previous Hospitalizations/ Operations

Date	Name of Hospital/ Clinic	Diagnosis

· History of Transfusion

Date	Name of Hospital/ Clinic	Reason for Transfusion

· Current Medication

Name of Medicine	Dosage	When Started

· General Past State of Health

() excellent () good () poor

FAMILY HISTORY:

· Members of the Family

Name	Age	Disease and Cause of Death

· Diseases within the Family and Immediate Family

() TB	() anemia	() arthritis	() renal disease	() mental disorder
() HPN	() cancer	() gout	() hemophilia	() blood dyscracias
() ulcers	() asthma	() epilepsy	() heart disease	() neurologic disorder
() strokes	() diabetes	() GIT problems	() nervous disorder	() similar Sx as Pt.

SOCIAL HISTORY:

· Marital Status;

Duration of Marriage	Occupation of Partner	Health of Partner	Number of Children

· Habits

· Alcohol

Type	Amount	Frequency	When Started	When Ended

· Cigarettes

Pack Years	Duration

· Intake of Sedatives/ Other Drugs

Name	Dose	Duration

· Sleeping Habits

Length/Time	Position

· Dietary Habits

# of Meals/ day	Preferences

· Exercise

· Forms of Recreation

· Sex Life/ Problems

· Educational Attainment

· Occupation

Present Work	Previous Work/ Job	Exposure to Occupational Hazards	Work Habits

(Example: Patient is married with three children. He works as mason.

(+) alcohol intake (gin) x 10 years, about 3x/ week, stopped 7 months ago

(+) Five pack years of smoking, stopped 7 months ago

(-) history OF IV drug abuse

OBSTETRICAL AND MENSTRUAL HISTORY:

· Menarche

Age of Onset	Duration	Amount of Discharge	Associated Sx.

· Subsequent Menstruation

Cycle	Duration	Amount of Flow	Date of Last Period	Mtd. Of Contraceptives	Date of last Gyne exam/pap s./serology

Associated Sx.

() Unusual vaginal discharges	() Bleeding b/w Periods	() Gonorrhea	() STD
() Changes in cycle/ freq.	() Abdominal pains	() Sterility	() Dysmenorrhea
() Bleeding after sex	() Premens. Pain	() Itching	() Infertility

· Menopause

Age Of Onset	Post menstrual bleeding	Associated Sx.

· Pregnancies

Gravida	Para	Obst. Score (term-premature-abortion-living)	Manner of Deliveries	Attending personnel	Place of Deliveries	Complications

(Example: Menarche 13 y/o. Successive Menses: regular 4-5 days 28-30 days cycle

G5P3 - LMP - 7/13/97

EDC- 4/40/98

AOG- 39-40 weeks

G1- 1979, NSD

G2- 1980, NSD

G3- 1989, NSD

G4- 1991, Curettage; Abortion incomplete

G5- present pregnancy

Regular pre-natal check-ups with Quezon City Gen. Hospital since 4 months pregnancy

(+) History of URTI 5-6 months AOG.

REVIEW SYSTEMS:

Note: JUST PUT THE POSITIVE AND THE RELEVANT NEGATIVE

· Integument:

· Skin

() color	() pigmentation	() temperature
() moisture	() eruptions	() pruritus
() scaling	() bruising	() bleeding

· Hair

() color	() texture
() abnormal loss or growth	() distribution

· Nails

() color changes	() brittleness	() ridging
() pitting	() curvature

· Lymph Nodes.

() enlargement

() pain

() suppuration

() draining sinuses

· Bones, Joints, and Muscles.

()Fractures	() dislocations	() sprains	() arthritis	() myositis
() pain	() swelling	() stiffness	() migratory	() distribution
() muscular weakness	() wasting	() atrophy	() Night cramps

· Hematopoetic System.

() Anemia

() lymphadenopathy

() bleeding

· Endocrine System.

() Skin pigmentation	() Weakness	() exophthalmos	() dryness of skin and hair	() intolerance to heat or cold	() tremor
() Polyphagia	() polydipsia	() polyuria	() glycosuria	() impotence	() sterility

· Allergic and Immunologic History.

() Dermatitis	() urticaria	() asthma	() eczema	() hay fever
() vasomotor rhinitis	() angioneurotic edema	() vernal conjunctivitis	() sensitivity to pollens	() sensitivity to foods	() sensitivity to drugs

· Head.

() Headaches	() trauma	() syncope
() migraine	() vertigo	() convulsive seizures

· Eyes.

() Visual loss	() diplopia	() trauma	() glasses
() color blindness	() hemianopsia	() inflammation

· Ears.

() Deafness	() vertigo	() pain
() tinnitus	() discharge from the ears	() mastoiditis

· Nose.

() Coryza	() sinusitis	() obstruction
() rhinitis	() discharge	() epistaxis

· Mouth

() Soreness of mouth or tonque

() symptoms referable to teeth

· Throat.

() Hoarseness

() sore throats

() tonsillitis

() voice changes

· Neck.

() Swelling	() suppurative lesions	() enlargement of lymph nodes
() goiter	() stiffness	() limitation of motion

· Breasts.

() lactation	() trauma	() lumps	() pains
() discharge from nipples	() gynecomastia	()changes in nipples

· Respiratory System.

() Pain shortness of breath	() dyspnea	() cough	() hemoptysis	() pleurisy
() wheezing	() orthopnea	() sputum	() night sweats

· Cardiovascular System.

() Palpitation	() irregularities of rhythm	() pain in the chest	() cough	() ascites
() tachycardia	() exertional dyspnea	() orthopnea	() cyanosis	() edema

· Gastrointestinal System.

() Change in appetite	() changes in weight	() dysphagia	() nausea	() hemorrhoids
() flatulence	() abdominal pain or colic	() vomiting	() hematemesis	() jaundice

· Genitourinary System.

() Color of urine	() polyuria	() oliguria	() nocturia
() dysuria	() hematuria	() pyuria	() urinary retention
() urinary frequency	() incontinence	() pain or colic	() passage of stones or gravel

· Nervous System.

· Cranial Nerves.

() Disturbances of smell (1^st)	() visual disturbances (2^nd, 3^rd, 4^th, 6^th)	() orofacial paresthesias (5^th)	() difficulty in chewing (5^th)
() facial weakness (7^th)	() taste disturbances (7^th)	() disturbance in hearing (8^th)	() disturbances in equilibrium (8^th)
() difficulties in speech (9^th, 10^th, 12^th)	() difficulties in swallowing (9^th, 10^th, 12^th)	() difficulties in taste (9^th, 10^th, 12^th)	() limitation in motion of neck (11^th)

· Motor System.

() Paralyses	() involuntary movements	() gait
() atrophy	() convulsions	() incoordination

· Sensory System.

() Pain	() lightning pain	() girdle pain
() paresthesia	() hypesthesia	() anesthesia

· Autonomic System.

() Control of urination and defecation	() erythema	() pallor
() sweating	() cyanosis	() reaction to heat and cold

(Example),

HEENT	() Blurring of vision
CNS	() Seizures
RESP	() Shortness of breath, (-) cough
CVS	() Easy fatigability
GIT	() Constipation, nor diarrhea
GUT	()Urgency,frequency, incontinence,urinary retention
MUSK	() lower nor upper extremity weakness
HEMA	() bleeding tendencies

PHYSICAL EXAMINATION:

Fairly nourished, fairly develop, conscious, coherent, oriented to three spheres, afebrile, and ambulatory, not in cardio-respiratory distress with the following vital signs.

BP= PR= RR= T=

· HEENT-

1. Head. Normocephalic, symmetrical, no abnormal masses, no tenderness, no scalp lesions, coarse thick black well- distributed hair, symmetrical face, no skin lesions, no abnormal facies.

2. Eye. Eyebrows well- distributed, eyelashes well distributed, normal direction of growth, no lid edema, no ptosis, normal intraocular pressure, normal extraocular eye movements, no lid lag, pinkish palpebral conjunctiva, no lesions, anicteric sclerae, clear cornea, black iris, pupils 3mm in diameter, pupil both reactive to light, converge at ___ cm, normal visual fields.

3. Nose. Symmetrical, no deformities, no lesions, septum not deviated, no congestion in paranasal sinuses.

4. Ear. No deformities, no lesions, nomal position, no abnormalities in cartilage, no swelling and tenderness pre auricular and post auricular, no lesions and discharge in external canal.

5. Oral Cavity. Pinkish lips, no lesions, pinkish gums, no lesions, pinkish buccal mucosa, no lesions, ___ carries in _____ tooth, tongue moist, papilla present, no lesions, no tremors, tongue not deviated on protrusion, no abnormalities in palate, no swelling/hyperemia in posterior pharynx, tonsils not inflamed, uvula at midline, no congestion

6. Neck. Symmetrical, no lesions, no visible masses/ swelling/edema, no prominent lymph node, thyroid gland not palpable, trachea at midline, no abnormalities in neck movement.

(shortcut - normocephalic, pink palpebral conjunctiva, anicteric sclerae, no nasal nor ear discharge, no TPC, no cervical lymphadenopathies, no neck vein engorgement.)

· CHEST AND LUNGS- Symmetrical expansion, resonance/dull on percussion, clear breath sounds, equal vocal and tactile fremitus, no rales, no wheezes.

· HEART- adynamic precordium, PMI at 5^th intercostal space, no heaves, no thrill, cardiac dullness _______, normal rate, regular rhythm, no murmur, no splitting, no friction rub, no clicks.

Note: Heart sounds; (note character, intensity, murmurs, location, pitch, transmission, timing, duration,

intensity ). Aortic area: Pulmonic area: Tricuspid area: Mitral area:

· ABDOMEN-Flat , not distended, no dilated superficial veins(spider angioma), no scars, no visible peristalsis, no bruit, no succussion splash, NABS normoactive bowel sounds, no palpable mass, (+) tenderness on palpation (direct [S superficial, or D deep], rebound [Sor D], (+) organomegaly (liver, colon, spleen, gall bladder, pancreas, kidney, uterus), liver edge (smooth, irregular, nodular), liver consistency (firm, hard, stony hard), extent of liver dullness, extent of spleen dullness, no fluid wave nor shifting dullness, () Murphy’s sign, () CVA tenderness on percussion.

· EXTREMITIES- pink nail beds, no edema, no congenital deformities, no tremors, pulses full and equal.

· NEURO- (SHORTCUT)

Cerebrum -----------------	oriented to time, person, and place
Cerebellum ---------------	can do finger to nose test
Cranial nerves -----------	no deficits
Motor ----------------------	upper ext.- 5/5 lower ext.- 5/5
Sensory --------------------	can distinguish two point discrimination
Reflexes -------------------	normal 2/4
Pathological Reflexes ---	(-) babinski

Complete-

· Cerebral- oriented to time, person, and place.

· Cranial Nerves-

Cerebrum		oriented to time, place, and person
Cerebellum		finger to nose test, finger to finger test, Knee heel test, romberg test
Cranial Nerves	1^st Olfactory	() anosmia R,L
	2^nd Optic	Visual acuity 20/20 (Snellin’s test) Opthalmoscopy Visual field (Confrontation test)
	3^rd Oculomotor	() nystagmus normal pupillary size (3mm), reactive to light both direct and consensual can follow movement of examiners finger as they moved in all directions, cannot look up down or medially.
	4^th Trochlear	Supply the superior oblique muscles With involvement patient cannot look downward and laterally
	6^th Abducens	Lateral rectus muscle patient cannot look laterally
	5^th Trigeminal	Motor- temporalis muscle: (good/weak/paralyzed) masseter: Sensory- () intact corneal reflex () sensory deficit (pain, touch, temp. of forehead, cheeks, jaws)
	7^th Facial	Motor- frontalis muscle: (good/weak/paralyzed) orbicularis oculi muscle: platysma: orbicularis oris: risorius: bucinator: Sensory- () intact taste
	8^th Vestibulo-cochleal	() abn. Rinne’s test () abn. Webster’s test () can’t hear whisper words and rubbed hair
	9^th Glossopharyngeal 10^th Vagus	() poor gag reflex () unequal palatal elevation
	11^th Spinal Accessory	normal upward movement of shoulders good strength of sternocleidomastoid
	12^th Hypoglossal	tonque: () assymmetry () deviation () atrophy () fasciculations
· Sensory		() deficit light touch sense at: () deficit pain sense at: () deficit temperature at: () abn. Proprioception () deficit point localization sense () agraphesthesia () asteriognosia () deficit two- point discrimination
· Motor	Upper Extremities	-muscle tone(smoothly/resistance) -() latent paralysis -strength of muscles		grade 0 grade 1 grade 2 grade 3 grade 4 grade 5	0% 10% 25% 50% 75% 100%		-no evidence of contractility -slight contractility but no joint motion -complete motion with gravity eliminated -complete motion against gravity -complete motion with gravity and some resistance. - complete motion with gravity and full resistance
		() fasciculation () atrophy
	Lower Extremities	() latent paralysis - strength of muscles (5/5) () fasciculations () atrophy muscle tone (good/weak/paralyze)
· Reflex	bicep reflex triceps reflex knee jerk reflex achilles tendon reflex	grade 0 grade 1 grade 2 grade 3 grade 4		0 # ## ### ####		-absent - diminished but present - normal - hyperactive - hyperactive with clonus
	superficial reflexes		upper abdominal lower abdominal plantar cremasteric reflex superficial anal reflex
· Pathological Reflexes	() babinski () chaddock’s sign () oppenheim’s sign () gordon sign () ankle clonus () meningeal signs - Brudzinski’s, Kernig’s sign () oculocephalic reflex (doll’s eye movement)