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Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
Date: ............................ Historian: .................................... Time:............................ Informant: .................................... Reliability: ..................% GENERAL DATA: Name......................................
Age..........................................
Sex................................ ..........
Status...................................... DOB/POB................................
Occupn.....................................
Religion....................................
Nationality............................... Address....................................
Times of Adm................
Adm. Date......................
Adm. Time...................
CHIEF COMPLAINT: ............................................................................................................................. .............................. HPI (PRESENT ATTACK) :
Site: (where? diffuse/localized? maximal pain?)................................................................................................... Onset – When? Sudden or gradual? Progressive/regressive? ...............................................................................
Character – how? What? (Sharp, dull, crushing, burning, tearing, throbbing, constant, intermittent)………………
Radiation – Does? ..................................................................................................................................................
Associations – other S & sx? ...................................................................................................................................
Time -how long (duration- Y/M/W/D/Hr/Min/S)...................................................................................................
o Episodic (better/worse, frequency, duration)..........................................................................................
o Continuous (any change in severity?)......................................................................................................
Exacerbating/Relieving factors – Circumstances (food, meds, posture, sleep).......................................................
Severity - How bad? pain scale O (min) – 10 (max) .................................................................................................
Previous Lab test (include Pertinent Negatives)...................................................................................................... PAST MEDICAL HISTORY:
Measles/ mumps /chicken pox /recurrent tonsillitis/ respiratory disease like pneumonia.................................... Major injuries- trauma /history of fall or operations (date, effects).....................................................................
Previous hospitalizations/ o Hospital date dx , stay duration attending remarks o Eg. hosp. X 10.25.2014 Diabetes 1 Week Dr. X -
Drug History o Name dose(route) frequency duration remarks (compliance) o EG. Aspirin 75mg once daily 2 month No allergy o o
Food & drug allergy .....................................................................................................................
History of asthma, diabetes, HPN, PTB.................................................................................................
History of similar complaint or present problem in the past (chronic/recurrent)................................................... Surgical History (Procedures)
Tonsillectomy 1952 Hospital X COPD since 1990 General practitioner
PERSONAL AND SOCIAL HISTORY: Educational attainment..........................................................................................................................................
Occupation (past & present)........................................................................................................................... ........
Hx. of travel....................................................................................................................... ......................................
Smoking/ Drinking Age started...............................................................................................................................................
Consumption per day / pack year (No of pack per day X yr smoked)......................................................
Reason of stopping (financial or health)...................................................................................................
Drugs (tranquilizers, laxatives), other................................................................................................................. ..... Sleeping habits........................................................................................................................................................
Married
Duration and health of partner/ Compatibility.........................................................................................
No of living children/age/health............................................................................................................
Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
FAMILY HISTORY:
Grandparents (if dead, age & COD).........................................................................................................................
Parents..................................................................................................................................................................... Brothers /sisters...................................................................................................................... ................................
Heredo-familial disease
Asthma
Diabetes HPN
CA
Psychiatric epilepsy
Migraine,
Allergy
Hematologic disease
other
MENSTRUAL AND OBSTETRICAL HISTORY:
Menarche.............................................................
Duration............................................................... Cycle (monthly or irregular)...............................
Menstrual flow (minimal/moderate/ profuse)....
Associated symptoms (dysmenorrhoea, flow, breast pains & headache).....................................
Date of last menstruation (LNMP)......................
Menopause (age last menstruated).....................
Vaginal bleeding/discharges................................
No. Of pregnancies............................................. Route and No. Deliveries....................................
Complications (HPN, eclampsia, abortions)....... .............................................................................
Procedures (CS, BTL, hysterectomy -dates, surgeon).............................................................
Contraceptives Used............................................
REVIEW OF SYSTEMS: Double check of the HPI Skin :
Cyanosis
pallor
jaundice
moisture (cold)
eruption /lesion
distribution
pruritis,
bruishing
bleedingHair :
loss /growth (bladness) premature graying Nails :
cyanosis Clubbing brittleness Head :
headache o location o character o severity o radiation
Migraine
Hx of trauma,
vertigo
convulsive seizures
Eyes:
visual loss
color blindness,
diplopia,
hemianopsia,
trauma,
inflammation,
photophobia,
pain
blurring,
abnormal lacrimation,
Abn discharges(desrice the color),
use of eyeglasses (date when started to use )
use of contact lens.
Ears :
deafness (L/R)
tinnitus
vertigo
discharges (L/R , color )
Pain
Mastoiditis
previous operations (masoidectomy)
hx of infections (otitis)
Nose :
coryza
rhinitis
sinusitis
discharges
epistaxis
No smell Mouth :
soreness of mouth /tongue
symptoms of teeth
bleeding /swelling of gums
taste ulcers ,
hx of recent tooth extraction
complicationsThroat :
hoarseness
sorethroat,
hx of recurrent tonsillitis,
pharyngitis,
voice charges
Neck :
swelling
suppurative lesions (scrofula)
LN enlargement
Goiter,
stiffness,
limitation of movement.
Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
Breast :
development,
lactation,
hx of trauma,
lumps,
pain
discharges from nipple(color),
changes in nipple
gynecomastia,
hx of surgical procedure (mastectomy/biopsy )
Results
Respiratory system:
Pain
SOB o walking short distance o climbing stairs
Wheezing,
Dyspnea o Exertional o At rest
Nocturnal dyspnea
Orthopnea ( No of pillows used)
Cough o hard o paroxysmal o productive o non productive o occasional
Sputum o scanty o copious
Hemoptysis
Night sweats,
Afternoon or night fever,
Hx of pleurisy,
Bronchitis,
TB
Pneumonia,
Asthma,
Hx of X-ray
Result.
Cardiovascular :
palpitation,
Irregularity of rhythm ,
Pain in the chest ,
Exertional dyspnea,
PND,
Orthopnea(how many pillows used),
Cough,
Cyanosis,
Edema,
Easy fatigability ,
Fainting spells,
Legs cramps,
Hx of HPN,
RHD
Rheumatic fever,
Angina pectoris,
MI,
Hx of EKG done,
Drugs (digitalis,nitroglycerin, diuretic )
GIT:
Appetite
increase or loss
changes in weight o Approx. Loss......... o Approx. Grain...... o highest wt............
Dysphagia
Nausea,
Vomiting o Episodes........... o Vomitus........... o Volume............
Flatulence
Abdominal pain o S o O o C o R o A o T o E o S
Hematemesis
Melena
Diarrhea o episodes o volume
Constipation o Duration o Laxatives use
Changes in color
Change calliber of stool
Change in bowel habits,
jaundice
Haemorrhoids,
Hx of operations( appendectomy)
Hx of procedures (GI series on BA-enema)
GUT:
Color of urine.................................
volume of urine (per void) ............
polyuria
oliguria
nocturia(no.of voids)......................
frequency.....................................
dribbing
hematuria
o initial o terminal o all thoughout
dysuria o initial o terminal o throughout
location of pain o hypogastric/ penis
incontinence
pain or colic (passage of stone )
hx of recurrent infection
history procedures like IVP,
hx of STD,
penile discharges
vaginal discharge
Neuromuscular system:
Disturbances in smell
Disturbances in vision,
Parethesiaises,
Weakness,
Convulsions,
Paralysis,
anethesia,
loss of concoiusness,
Numbness,
Malaise ,
joint pain.
Metabolic :
wt . loss wt. Gain fever Neuro psychiatric:
Hallucinations o Visual
o Auditory
insomnia, nervousness
memory loss
Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
PHYSICAL EXAMINATION: (describe, give No diagnosis) Objective Examination using 4 basic maneuvers; inspection , percussion, palpation and auscultation. Gen survey:
Physical appearance
apparent age
Mental state
Distress
Ambulatory /non
Cooperative/non
Undernourished
state of consciousness o conscious o lethargic o stuporous o comatose
Smells
Ht/wt/WC.
febrile /afebrile
emotional state
Vital signs:
BP
RR
PR,
Temp
wt.
BMI Skin :
complexion
color (don’t state normal)
texture
turgor(lost/ senile/ good)
pigmentation and location ,
lesions,
rashes/ eruptions o location o distribution
pallor
severity
Head:
Shape:
normocephalic
Scars o size o location
fractures
asymmetry ,
abn. Movements ,
amount and texture of hair
facie
color changes of face.
Eyes:
Eye lids edema ,
ptosis
lid lag
sclera jaundice
hge.
Conjunctiva pallor
severity,
petechiae, injection
corneal scars,
ulceration,
arcus senillis
corneal opacity,
corneal reflex
Pupils size/ shape,
equality reactive to light and accommodation
vision
acuity confrontation
convergence
xanthelasma,
strabismus,
nystagmus,
palpate for IOP
exopthalmos
Ears :
ext. Ears-defect
ext. Ears- abnormalities
ext. Ears -lesions
hold pinna,
tophi,
discharges( L/R) ,color
foreign body ,
cerumen ,
mastoid tenderness
test for hearing.
Nose:
shape ,
discharge (color)
congestion of turbinates,
polyps,
foreign body,
epistaxis,
palpable septal deviation
sinus tenderness.
Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
Mouth and throat:
inspect from outside
lips symmetry,
color changes like cyanosis,
ulcerations,
swelling lesions
gums swelling ,
bleeding/ color
teeth caries
no. of dental repair
buccal / mucosal pallor,
ulcerations,
lesions like koplick spots in measles
tongue color,
ulceration,
deviation/tremor
palate deviation
tonsils
pharynx congestion,
enlargement,
presence of exudates ,
odor of breath
Neck :
landmarks,
pulsation,
blood vessels engorgement
position (like 45 angle)
palpate thyroid gland
enlarged or not,
tracheal deviation,
palpate lump node
described size, location, tenderness, no.)
note presence of rigidity
auscultate for bruit,
palpate for cupitus.
Breast :
symmetry ,
dimpling,
nipple discharges,
lymph node (axillary)
mass o location, o size, o mobility, o consistency ,
o tenderness , o borders , o no.
CHEST AND LUNGS: Inspection
contour,
symmetry,
expansion ,
rate and rhythm of breathing
bony abnormalities.
Palpation:
tactile or vocal fremitus o equal
o increase/ decrease
note the location , tenderness in chest area/
sternum, Percussion :
changes in remnance/dullnss
note exact location eg. R basal lung field)
Auscultation :
type of breath sounds, o bronchial o vesicular
abnormal sounds o rales, o rhonchi, o wheeze,
rub
exact location
HEART: Inspection
symmetry PMI
(5th L- MCL)
heave
abn. Pulsation
lesion,
bony abnormality.
Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
Palpation :
PMI
location,
thrill(location and timing),
pulse rate,
tenderness.
Percussion :
cardiac dullness Auscultation:
heart sounds
distinct or faint
rate and rhythm,
friction rub
murmur(TLDIPCTQ)
ABDOMEN: Inspection
contour
shape
scars (size/location)
state surgical procedure
engorged veins
spider nevi
visible masses
Striae
Pulsations
bulging like hernia.
Auscultation:
bowel sounds (normo/ hypohyperactive / absent)
metallic sounds ,
bruit, venour hum,
fetal heart ( pregnant )
special maneuvers o puddle sign –ascites o Succession splash-obstruction
Percussion :
Change in tympany
super liver dullness
fluid wave
shifting dullness
RUQ fist percussion
CVA tenderness. Palpation: (area of pain -last )
muscles guarding (voluntary or involuntary)
muscle spasticity
consistency (soft / rigid)
crepitations
tenderness (location, whether on light or deep palpation)
masses (location , size, shape, consistency, mobility, tenderness, borders)
engorgement of liver , spleen , spleen, kidney
bladder distention
fetal parts (female)
aortic pulsation,
rebound tenderness,
direct tenderness,
lmp nodes,
rovsings sign
Psoas sign
obturator sign
BACK AND SPINE
Mobility
Curvature
vertebral tenderness
bony abnormality. EXTREMITIES: (specify whether upper/ lower, R/L)
Color/ cyanosis
moisture
clubbing
joint swelling /deformity
Mobility
Temperature
equality of pulses
Edema
Varicosity
Atrophy/ Hypertrophy
tenderness of muscles
abn. Movements
range of motion
signs of inflammation
congenital
Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
NEUROLOGIC EXAM: 1.cerebral functions
level of consciousness
appearance
gen. Behaviour
emotional status
thought content
intellectual performance
recognize object (yes/no)
Communicate(yes/no)
carry out skills(yes/no) 2. cereblum functions
gait
posture.
Coordination (romberg’s test)
finger to nose
heel to shin
knee pat
3. motor system :
strength (weakness or paralysis) -ranges ( 0/5-5/5)
Right Left
UE (hand grip )
LE (resistance)
muscle tone ( spaticity, rigidity, flaccidity)
spontaneous movements (Tics, tremors, twitching, chorea, athetosis) 4. sensory system (both sides,eye closed)
Sensations of : o pain o touch o temp.
position sense/ vibrations
discrimatory sensation
sensory dysfunction
5. CRANIAL NERVES EXAMINATION: a. olfactory (check both side one at a time|)
smell identify odor (by smelling) b. optic
visual acuity
confrontation test
color vision
visual field.
opthalmoscopic exam
C. Oculomotor
Papillary light reflex
Near response (parasympathetic) o Convergence o accomodatio
d. trochlear/abducents
EOM diplopia e.Trigeminal
corneal rxn
ability to open mouth
pain sensation of face.
Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
f. Facial
symmetry of face
wrinkle forehead ,
smile, frown, raise eyebrows
test for taste (ant 2/3)
chovstek sign
. g. Acoustic
hearing o rhinne test (Air > bone conduction) o weber test (bone conduction)
equilibrium
h. Glossopharyngeal/ vagus
symmetry of uvula with phonation elicit gag reflex
i. accessory
strength of trapezius/
shoulder shrug (strong or week )
Turn head (up- down, L/R)
Check w/ resistance j. hypoglossal
deviation of protruded tongue
tremors and strength
impaired swallowing
6. REFLEX: 1. DTR – result ranges from 0 - ++++
a. biceps b. triceps c.knee jerk d. Achilles or ankle joints
2.Superficial a. cremasteric male – whether (+) or (-) b. abdominal – whether (+) or (-)
3. Pathological
a. ankle clonus + if abn L and R b. babinski + if abn L nd R c. karnigs + if abn d. brudzinski +if abn
report :
Right Left
Biceps ++ ++
Triceps ++ ++
Knee ++ ++
Achilles ++ ++
Ankle clonus ++ ++ Babinski ++ ++
Complete History & PE Template by Deepak Ghimire, Southwestern University -College of Medicine.
REFERENCES : -Bates physical diagnosis - Macleod's Clinical Examination Acknowledgement :
Dr. Louella Quijano
kalpana shah, Southwestern University
For suggestions and comments : Deepakghimire101@gmail.com,