|
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
·
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
·
Intake of
Sedatives/ Other Drugs
·
Sleeping
Habits
·
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 |
|