Original Notes by: “Villtura”

MEDICAL HISTORY
I. General Data – Identifying data/information of the patient
a. Patient’s name (last, given, middle initial) Abdominal Pain – ALARM SYMPTOMS
b. Age, sex, civil status
c. Occupation, nationality, race, religion J Jaundice
d. Birthday and birthplace A Age 45 yo
e. Residence/present address W 20% weight loss (significant)
f. Number of times admitted (same hospital) C Chronic NSAID use/intake
g. Date and time of consultation H Hematochezia/melena
A Abdominal mass/odynophagia
P Previous Peptic ulcer disease
II. Chief Complaint – list of one or more symptoms that caused the patient to
seek consult; written as words or phrases, not as complete sentences;
patient’s own words Cough

III. History of Present Illness - amplifies the chief complaint, describes how C Chest pain Sumasakit po ba dibdib kapag umuubo?
each symptoms develop, symptoms should be accurately described H Hemoptysis May kasama bang dugo ang plema? (describe if
present)
PQRST of Pain E Easy fatigability Mabilis po bang mapagod?
W Weight loss Nangangayayat ka ba?
P Palliative Conditions that relieve or worsen the pain F Fever Nilalagnat ba kasaby ng ubo?
Q Quality Heavy, Dull, Crushing, Burning, Searng, Throbbing, I Insomnia Nahihirapan bang matulog sa gabi?
Colicky, Pins and Needles N Night sweats Pinagpapawisan bas a gabi?
R Radiation Radiating to the back, left arm, etc D Dyspnea Nahihirapan ka ba huminga?
S Severity Mild, moderate, severe C Cough Inuubo k aba? May plema ba o wala? (describe if
T Timing Time of the day when pain occurs present)
A Anorexia Nwawalan ba ng gana sa pagkain?
B Back pain Sumasakit ba ng likod kapag inuubo?
ABDOMINAL PAIN

H Heartburn May gumuguhit na mainit paakyat mula sa UTI

sikmura o sa dibdb?
A Anorexia Nawawalan ba ng ganang kumain? W WEAK STREAM MAHINA PO BA ANG PAGLABAS/ PAGDALOY HABANG UMIIHI?

V Vomiting Nagsusuka? I INCONTINENCE MAY LUMALABAS PO BA NA IHI KAPAG IKAW AY UMUUBO O

E Early Satiety
N Nausea
B Bloating/Bloatedness
A Abdominal pain
TUMATAWA/
Mabilis ka bang mabusog? UMAABOT PO BA SA BANYO KAPAG NAKARAMDAM NG
May pakiramdam ban a gusto mo sumuka? KAGUSTUHANG UMIHI?
Puno ba ng hangin ang tiyan mo? Naguutot ba N NOCTURIA ILANG BESES BUMABANGON MULA SA PAGTULOG SA GABI PARA
madalas? UMIHI?
Sumasakit baa ng tiyan? Saang parte? D DYSURIA MASAKIT PO BA ANG IYONG PAG IHI?

R Regurgitation May nalalasahan ka bang maasim pagkatapos S SYMPTOM OFHESITANCY HIRAP PO BA SA PAGSISIMULA NG PAG IHI?

kumain? May pakiramdam bang bumabalik ang U URGENCY MADALAS BA MAKARAMDAM NG KAGUSTUHAN NA UMIHI?

kinain mo? R RETENTION BALISAWSAW? MAY PAKIRAMDAM PO BA NA PARANG MAY NATITIRA

PAGTAPOS UMIHI?
P Post Prandial Pain Sumasakit baa ng tiyan pagkatapos kumain?
F FREQUENCY ILANG BESES UMIIHI SA LOOB NG 1 ARAW?

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 Original Notes by: “Villtura”

If suspecting the PRESENCE OF STONES, assess the following: c) Occupation history

d) Marital history
FLANK PAIN, PUS CELLS 1-3/HPF, STONE HISTORY RBC TMTC e) Current household living conditions, sources of water,
waste disposal, toilet
Normal Urine Output: 30cc/kg/day Personal habits, diets, exercise
Oliguria: <500cc/day f) History of smoking, drinking alcoholic beverages, illicit drug use
Anuria: <100cc/day Ventilation: 20% of the total floor area
Pack years: # sticks per day x # of year smoking/ 20
Kidney punch test: (+) grimace due to stretching of renal capsule (5-7 pack years (MALE) and 7-10 pack year (FEMALE)

Fever

Continuous Diurnal variation of 0.5-1.0 C VII. OB- GYNE HISTORY

Remittent Diurnal Variation of >1.1 C but no normal readings
Intermittent On and off/episodes of fever separated by normal temperature
M MENARCHE AGE AT FIRST MENSTRUATION (NORMAL 10-16 Y/O)
Relapsing Bouts of fever occurring every 5-7 days from infection
Episodic Fever last for days or longer followed by prolonged periods without
fever (at least 2 weeks) with remissions of clinical illness I INTERVAL REGULAR OR IRREGULAR (NORMAL 28 +/- 7 DAYS)

D DURATION HOW MANY DAYS (NORMAL 4 +/- 2 DAYS)

A AMOUNT NUMBER OF PADS PER DAY, HOW SOAKED? (NORMAL 20-
WITH PREVIOUS ADMISSIONS AND CONSULTATIONS (IF RELATED TO THE
60 ML)
PRESENT ILLNESS):
INCLUDE AN INTERVAL HISTORY (USUALLY FOR CHRONIC CONDITIONS, DETAILS S SYMPTOMS ASSOCIATED SYMPTOMS IF PRESENT (dysmenorrhea)
ABOUT THE LAST EPISODES TO THE
PRESENT CONDITION)
OBSTETRICAL SCORE
IV. PAST MEDICAL HISTORY
a) Childhood illnesses (measles, mumps, chicken pox) G GRAVIDA TOTAL NUMBER OF PREGNACIES REGARDLESS OF
b) Previous hospitalizations OUTCOME
c) History of surgeries P PARITY NUMBER OF VIABLE BIRTHS (>20 weeks)
d) History of accidents, trauma, blood transfusions T TERM 37-42 weeks
e) History of allergies to food and drugs P PRETERM Before 37 completed weeks
f) History of disease such as hypertension, diabetes, asthma, goiter, PTB, arthritis, A ABORTION Pregnancy termination prior to 20 weeks AOG or < 500 grams
hepatitis BW
g) Medications taken for a certain disease condition L LIVING Number of alive children

V. FAMILY HISTORY- documents presence or absence of specific illness in the family

(parents, siblings, children, grandchildren, grandparents) L SEXUAL HISTORY (For STI only)
Heredofamilial diseases- HPN, DM, asthma, goiter, malignancies a) Coitarche – age of first sexual intercourse
Communicable diseases- PTB, hepatitis, pneumonia b) Frequency of coitarche
c) History of STI
VI. PERSONAL AND SOCIAL HISTORY d) Last sexual contact
a) Family of origin (number of siblings and birth order of the patient) e) Number of sexual partners and occupation of sexual partners
b) Eucation and educational attainment f) Unusual sexual practices

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 Original Notes by: “Villtura”

g) Use of contraception (type and duration of use)

h) Symptoms: dyspareunia, post-coital bleeding, discharge

REVIEW OF SYSTEMS
General Weight loss, weight gain, fever, chills, fatigue, insomnia, loss of
CHEST AND Symmetrical chest expansion, no retraction, no lagging, equal vocal
appetite, night sweats
LUNGS and tactile fremitus, clear breath sounds
Skin Color change, sores, rash, itching, scaling, bleeding HEART Adynamic precordium, normal rate, regular rhythm, PMI at 5th ICS
Head Headache, trauma, stiffness LMCL, no murmur
Eyes Corrective lenses, pain, diplopia, itch, blurring of vision, dryness, ABDOMEN Flabby abdomen, normoactive bowel sounds, soft, tympanitic, non-
redness tender to deep and light palpation
Ears pain, tinnitus EXTREMITIES Grossly normal extremities, no deformities, no external signs of
Nose Colds/ nasal stuffiness, bleeding, dryness, discharge, pain, sneezing cyanosis, no pallor, no edema, full
Mouth Bleeding gums, soreness, ulcers, hoarseness, pain, dryness equal pulses on brachial, radial and dorsalis pedis
Respiratory Cough, chest pain, dyspnea, hemoptysis
Cardiovascular Chest pain, dyspnea, PND, orthopnea, palpitations
Gastrointestinal Anorexia, dysphagia, hematemesis, nausea, vomiting, NEUROLOGIC EXAMINATION
hematochezia. mlena, diarrhea
Genitourinary Dysuria, hematuria, nocturia, retention, incontinence, frequency, I S Can identify the odor of coffee on both nostrils with eyes closed
urgency, discharge II S Can read the newsprint at a distance of one foot
Musculoskeletal Pain, weakness, tenderness, cramps, trauma, joint pain, backache, II, III Presence of direct and consensual light reflexes on both eyes
stiffness III, M Full EOM movements, (-) nystagmus
Endocrine Polyuria, polydipsia, polyphagia, cold intolerance, heat intolerance IV,
Hematologic Pallor, easy bruising VI
Nervous Syncope, seizure, dizziness, tremor V S Able to feel pinprick, light touch, dull pain, temp
Psychiatric Sleep disturbance, depression, hallucination M Clench teeth and resist pressure applied on the chin
V, Corneal reflex intact
VII
PHYSICAL EXAMINATION VII M Raise eyebrows, wrinkle forehead and open/close eyes, Pout, purse lip,
Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress smile, blow off cheeks
Vital Signs: BP CR RR T
Ht Wt BMI S taste sensation, anterior 2/3
BMI Classifications (ASIANS) VIII S Rubbing of fingers on both sides; or
Underweight <18.5 Can hear the tick of a watch on both earS
Normal 18.5-22.9 IX, X Gag reflex, Uvula position, Pharyngeal movement,
Overweight 23-24.9 X Voice, nasal twang
Obese1 25-29.9 XI M Shrug and elevate shoulders with or without resistance, Move head
Obese2 30 and above laterally with or without resistance
XII M Tongue position, Retract and protrude tongue
BMI = kg/m2
MOTOR FUNCTION - No muscle atrophy, no tremors noted
SKIN Brown, No lesions, no masses, soft, warm to touch CEREBELLAR FUNCTION - Able to perform finger to nose test, alternating supination
HEENT Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge, and pronation test, heel to sheen test
no tonsillopharyngeal congestion, no cervical lymphadenopathy REFLEXES
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 Original Notes by: “Villtura”

SENSORY FUNCTION - Reacts to pain, touch, pressure, position and vibration sense GRADING MUSCLE STRENGTH

CEREBRUM: alert, relaxed, cooperative, coherent, oriented to time, place and person
CEREBELLAR: can do rapid, alternating movement, finger to nose and heel to shin
0 No muscular contraction detected
SPECIAL TEST
1 A barely detectable trace of contraction
2 Active movement, gravity eliminated
 DIGITAL RECTAL EXAM (DRE) – no skin tags, no fissures, no external
haemorrhoids, full rectal vault, no mass, prostate gland not enlarged and non- 3 Active movement against gravity
tender, fecal material is non-bloody on tactating finger 4 Active movement against gravity and some resistance
5 Active movement against gravity with full resistance
 INTERNAL EXAM (IE) – vagina accepts 1(virgins)/ 2-3(non-virgins) fingers
with ease. No foul smelling discharge. Vaginal wall is non-tender. Cervix is not
dilated, non-tender, firm closed. No mass, no bloody discharge. Uterus not
enlarged. Uterus and ovaries are non-palpable ROMBERG’S TEST/ SENSORY TEST OF BALANCE
Ask patient to stand with feet together and eyes open, then ask patient to close eyes for
20-30 seconds  mild swaying may occur (stand close to the px to prevent falls)
For patients complaining of headache and dizziness, visual acuity test, otoscopy,
neurological examination, tilt test and dix hall pike test must be performed. (+) Loss of balance wen eyes are closed  poor position sense
 TILT TEST – take the patient’s BP while lying down. Then after 5 min, take it
while patient is sitting. Also take note of the pulse rates (for cardiac problems,
REFLEXES
syncope)
4+ HYPERACTIVE (WITH CLONUS)
 DIX HALL PIKE TEST – a person is brought from sitting to a supine position,
with the head turned 45 degrees to one side and extended about 20 degrees 3+ BRISKER THAN AVERAGE
backward. Once supine, the eyes are typically observed for about 30 seconds. If 2+ AVERAGE, NORMAL
no nystagmus ensues, the person is brought back to sitting. There is a delay of 1+ DIMINISHED, LOW NORMAL
about 30 seconds again, and then the other side is tested. (BPPV testing) 0 NO RESPONSE

WITHOUT GLASSES
OD Os
NO PINHOLE 20/40 20/80
WITH PINHOLE 20/20 20/40

WITH GLASSES
OD Os
NO PINHOLE 20/20 20/20
WITH PINHOLE 20/20 20/20

FEVER WITH RASHES

A - appearance
B - border
C - color
D - distribution
E - elevation

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 Original Notes by: “Villtura”

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