Medicine HistoryPatient Profile

Name: _________________________

Age: _______________________

History given by: __________________

Gender: Male/Female

Date: __________________________Address: ____________________MR#: _______________________History taken in: OPD / IPD

Presenting Complaint:____________________________________________________________________________________________

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____________________________________________________________________________________________History of Presenting Complaint

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General: change in weight0, loss of appetite0, weakness0, fever0Endo: neck swelling0, hand tremors0, heat/cold intolerance0, sweating0, fatigue0, hair change0, skin change0, voice change0, polydipsia0 GIT: dysphagia0, regurgitation0, flatulence0, heartburn0, nausea0, vomiting0, hematemasis0, abdominal pain0, abdominal distention0, abnormal bowel habit0, constipation0, diarrhea0, rectal bleeding0, fecal incontinence0, jaundice0Resp: hemoptysis0, hoarseness0, wheezing0, chest pain0, shortness of breath0, night sweats0CVS: dyspnea0, paroxysmal nocturnal dyspnea0, orthopnea0, cyanosis0, chest pain0, dizziness0, ankle swelling0, palpitations0, syncope0, pain in legs on walking0UGS: loin pain0, poor stream0, dribbling0, hesitancy0, dysuria0, urgency0, hematuria0, oligouria0, polyuria0, incontinence0, nocturia0, bedwetting0, urine colour change0CNS: behavioral changes0, depression0, memory loss0, anxiety0, tremor0, loss of consciousness0, fits0, muscle weakness0, sensory disturbances0, parasthesias0, dizziness0, change of smell0, vision0 or hearing0, headaches0, seizures0, hyperactivity0MSS: muscle aches0, bone pain0, joint swelling0, limitation of joint movement0, disturbance of gait0Skin: rash0, unusual marks0_______________________________________________________________________________________________________________Past Medical HistoryMedical: HTN, DM, IHD, epilepsy, TB, hepatitis, asthma, cancer, allergies, _______________________________________________________________________________________________________________________________________________________________________Surgical: trauma, blood transfusion, surgery, previous hospitalization, ______________________________________________________________________________________________________________________________________________________________________________Medication History: ___________________________________________________________________________________________________________________________________

Family History HTN, DM, IHD, epilepsy, TB, hepatitis, asthma, cancer, allergies, ________________________________________________________Social History

Smoking, any other addictions: _________________________________ Water: ____________________________________________Sanitary condition: __________________________________________ Socioeconomic class: ________________________________

ExaminationGENERAL AND PHYSICAL EXAMINATIONAppearance: _________________________________________________________________________________________________

Vitals

Pulse: ______ bpm, rhythm: ________, volume: ________, character: ________, vessel wall: _________, peripheral pulses: _________

Respiratory rate: __________ /min Blood pressure: ______ / ______ mmHg

Temperature: _________ GCS: _________

Weight: _________ kg

Height: ____________________

BMI: _________

Hands: leukonychia0, koilonychia0, thenar0 or hypothenar0 atrophy, sweatiness0, splinter hemorrhages0, Oslers nodes0, Heberdens nodes0, Bouchards nodes0, tremors0, prominent palmar creases0, blue nails0, red nails0, clubbing0, Beaus lines0, Mees lines0, half and half nails0Skin: pallor0, rash0, petechiae0, bruises0, decreased capillary refill0, skin turgor0 Eyes: both pupils round, regular and reactive, pallor0, jaundice0, ptosis0 Face: jaundice0, periorbital edema0, proptosis0, drooping of mouth0 Neck:, tracheal deviation0, goiter0, engorged neck veins0 Lymph nodes: submental0, submandibular0, anterior cervical0, posterior cervical0, preauricular0, postauricular0, occipital0, supraclavicular0, axillary0, inguinal0 Extremities: ankle edema0, cyanosis0, erythema0, varicose veins0CARDIOVASCULAR EXAMINATIONInspection Abnormal pigmentation, scar marks, visible veins, visible pulsations____________________________________________________________________________________________________________Palpation Apex Beat: ________ intercostal space Heaves, thrills

____________________________________________________________________________________________________________Auscultation S1+S2: ________________________________________________________________________________________________________________________RESPIRATORY EXAMINATIONInspection Chest shape: ____________________________________ Chest movements: ________________________________

Scar marks, pigmentation, visible veins, use of accessory muscles, nasal flaring

Palpation Trachea: ________________________________________

Chest expansion: _________________________________ Chest wall movements: ____________________________

Vocal fremitus: __________________________________

Percussion Resonance: __________________________________________________________________________________________Auscultation Breath sounds: _______________________________________________________________________________________ABDOMINAL EXAMINATIONInspection Scar marks pigmentation, abdominal distension, visible veins Umbilicus: ______________________________________

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Palpation Hepatomegaly, splenomegaly, kidneys palpable, guarding, abdominal rigidity Tenderness: _________________________________________________________________________________________________Percussion Liver span: ______________ Shifting dullness: ______________

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Auscultation Bowel sounds: increased/decreased/normal Renal bruit, splenic rub, aortic bruit

CNS EXAMINATION Cranial nerves: _______________________________________________________________________________________________

Motor examination: ___________________________________________________________________________________________

Sensory Examination: __________________________________________________________________________________________

Reflexes: ____________________________________________________________________________________________________

Cerebellar function: ___________________________________________________________________________________________

OTHER EXAMINATION (_____________________________________________________________)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Investigations_______________________________________________________________________________________________________

Differential Diagnosis____________________________________________________________________________________________________

Plan/Treatment________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________