_______________________–AUP College of Medicine Timing Questions

CP#: When/at what time did the pain start?

Date: __/___/16 Time: ___:___AM/PM Source: _____
Name: ________________________Sr/Jr Gender:M/F
Birthday: _______Age:___Marital Status: S M D/S W LI
Occupation: _______________ Religion: __________
Educational Attainment: ________________________
Address: ____________________________________
_____________________________________________
Date & Time of Admission: __/___/16 ___:___AM/PM
Others: ____________________Philhealth/ HealthCard
How long did it last?
How often does it occur: hourly ? daily? weekly? monthly?
Is it sudden or gradual?
What were you doing when you first experienced it?
When do you usually experience it: daytime? night? early morning?
Are you ever awakened by it?
Does it lead to anything else?
Is it accompanied by other signs and symptoms?
Does it ever occur before, during or after meals?
Does it occur seasonally?
Notes:________________________________________
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Past Medical History

General health: ________________________________

Chief Complaint: _____________________________
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History of Present Illness- OPQRST/OLDCART
Onset:_____________Date:__/__/__Time:__:_AM/PM
Symptom: _______________Sudden/Gradual________
Major Adult Illnesses: Diabetes/Hypertension/ Cancer/Asthma
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Hospitalization/Surgery: Date Hospital Diagnosis Complication
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Location: _____________________________________
Injuries/Disabilities:____________________________
Continuous/ Intermittent Duration:_________________
OB: G__P__ T__ P__ A__ L__ M__ ______________
Radiation: ____________________________________
Quality: ______________________________________ Major Childhood Illnesses: ______________________
Sharp Dull Stabbing Burning Crushing Throbbing Immunizations: _______________________________
Nauseating Shooting Twisting Stretching
Polio M easles TT M eningococcal Hepa A/B
Aggravating: _________________________________ DPT M umps Varicella Influenza Cholera
BCG Typhoid HiB pneumococcal
Food/ Activity/ Rest/ Movement
Alleviating: ___________________________________
Prescribed treatments/ Self-Remedies/ Food/ Rest/ Heat Medications: Past, current, recent, supplement, home
Ice/ Activity/ Position
Severity: _______________________Pain Scale: __/10 Name Dose Route Indication
Exposure: ____________________________________
Timing: ______________________________________
Effect on Pt. Lifestyle: __________________________

Notes:________________________________________
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WRE16
Allergies: Drug/Food/Environment ____________________
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Recent Lab Tests: Glucose,cholesterol,papsmear,mammogram
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Family History
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HPN Ca DM
Cardiac Respi Kidney
Thyroid Stroke Asthma
M ental TB Hepa
Allergy
Deaths/Abortion/Stillbirth
Relative Age Time Cause
Personal/ Social History
Personal Status: Birthplace _______Raised In _______
Parental Divorce/separation_______Living with_______
Socioeconomic class_______Position in family_______
Religious preference_______ ____Marital Status______
Cultural Background & Practices: __________________
General life satisfaction__________________________
Hobbies/Interests_______________________________
_____________________________________________
Sources of strain/stress___________________________
Habits:Nutrition/Diet____________________________
__________________________pattern______________
Sleeping pattern________________________________
Exercise quantity & type_________________________
Coffee, tea, alcohol quantity______________________
_____________________smoking_________________
salt intake____________, weight control____________,
dental hygiene________, Vitamins_________________
Water_____________, BSE/TSE__________________
Drug use_____________________________________
Sexual Activity: Contraception ___________________
Home Conditions: Economic, number in household,
pets __________________________________________
Occupation: work conditions & hours, physical or
mental strain, protective devices used, exposure to
chemicals etc. _________________________________
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Environment: Home, School,Work,Travel,water supply
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Notes: _______________________________________
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Review of Systems
“The next part of the history may feel like a hundred
question but they are important and I want to be
thorough”
General: Fever( ) Chills( ) Malaise( ) Fatigability( ) Night
Sweats( ) Weight(Average, Preferred, Present, Change)_____
Skin, Hair, Nails: Rash( ) Itching( ) pigmentation or texture
change( ) excessive sweating( ) abnormal nail/hair growth( )
Head & Neck:
General: Frequent/unusual headaches( ) location _______
Dizziness( ) Syncope( ) Severe head injuries( ) periods of loss
of consciousness( ) (momentary or prolonged)
Eyes: Visual Acuity L___R___ Blurring( ) Diplopia( )
Photophobia( ) Pain( ) glaucoma( ) Recent change in
appearance or vision( ) use of eyedrops or other meds( ) Hx of
trauma or familial eye disease( )
Ears: Hearing loss( ) Pain( ) Discharge( ) Tinnitus( )Vertigo( )
Nose: Sense of smell( )______ Obstruction( ) Frequency of
colds( )______ epistaxis( ) Postnasal discharge( ) Sinus pain( )
Throat & Mouth: Hoarseness or change in voice( ) frequent
sore throats( )___ Bleeding( ) Swelling of gums( ) recent tooth
abscesses or extraction( ) soreness of tongue or buccal
mucosa( ) ulcers( ) Disturbance of taste( )
Lymph nodes: Enlargement( ) Tenderness( ) Suppuration( )
Chest & Lungs: Pain related to respiration( ) dyspnea( )
cyanosis( ) wheezing( ) cough( ) sputum( ) (character,
quantity) _________ Hemoptysis( ) Night sweats( ) Exposure
to TB( ) Date and result of last chest x-ray________________
Breasts: Pain( ) Tenderness( ) Discharge( ) Lumps( )
Galactorreha( ) Mammograms( ) (screening or diagnostic)
Frequency of self-examination_________________________
Heart & Blood Vessels: Chest Pain or distress( ) precipitating
causes, timing and duration, character, relieving factors
__________________________________________________
Palpitations( ) Dyspnea( ) orthopnea( ) (number of pillows
needed)_____ Edema( ) Claudication( ) Hypertension( )
Previous Myocardial Infarction( )_____ estimate of exercise
tolerance__________ Past ECG or other cardiac tests_______
Notes: ____________________________________________
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WRE16
Peripheral Vasculature: Claudication( ) (Frequency, Psychiatric: Depression( ) Mood changes( ) Difficulty
Severity)___________ Tendency to bruise or bleed( )_______ concentrating( ) Nervousness( ) Tension( ) Suicidal thoughts( )
Thromboses( ) Thrombophlebitis( ) Irritability( ) Sleep Disturbances( )

Hematologic: Any known abnormality of blood cells( ) Concluding Questions

_____________ Transfusions( )____________________
Gastrointestinal: Appetite( ) ________ Digestion( ) _______
Intolerance( )__________ Dysphagia( ) Heartburn( ) Nausea( )
Vomiting( ) Hematemesis( ) Regularity of bowels( )________
Constipation( ) Diarrhea( ) Change in stool color or contents( )
(Clay colored, tarry, fresh blood, mucus, undigested food)
__________________________________________________
Flatulence( ) Hemorroids( ) Hepatitis( ) Jaundice( ) Dark
urine( ) History of ulcer( ) Gallstones( ) Polyps( ) Tumor( )
Previous Xray examinations(where, when, findings)________
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Diet: Appetite_____ Likes & Dislikes___________________
Restrictions( ) ________________ Vitamins/Supplements( )
Use of caffeine-contaning beverages( ) intake diary( )
Endocrine: Thyroid enlargement or tenderness( ) heat or cold
intolerance( ) Unexplained weight change( ) Diabetes( )
Polydipsia( ) Polyuria( ) Changes in facial or body hair( )
increased hat and glove size( ) Skin striae( )
Females:
Menses: Onset _______ Regularity______ Duration _______
Amount of flow_________ LMP_________ Dysmenorrhea( )
Intermenstrual discharge or bleeding( ) itching( ) libido( )
Date of last papsmear( )_____Age at menopause( ) _________
Frequency of intercourse( )_______________
Sexual Difficulties( )_______________ Infertility( )
Pregnancies: Number____ Living Children____
Multiple Births( )____ Miscarriages( )_____ Abortion( )_____
Duration of Pregnancies _____________ Type of delivery for
each ______________________________________________
Complications during any pregnancy or postpartum period or
with neonate________________________________________
Use of oral or other contraceptives( )____________________
Difficulty in getting pregnant( ) ___________
Is there anything else that you think would be important
for me to know?
If there are several problems: Which concerns you the
most?
If the history is vague, complicated or contradictory:
What do you think is the matter with you, or, what
worries you the most?
Notes: ____________________________________________
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Note

Males: Puberty onset______ Difficulty with erections( )

emissions( ) Testicular Pain( ) Libido( ) Infertility( )

Genitourinary: Dysuria( ) Flank or suprapuic pain( )

Urgency( ) Frequency( ) Nocturia( ) Hematuria( ) Polyuria( )
Hesitancy( ) Dribbling( ) Loss in force of stream( ) Passage of
stone( ) Edema of face( ) Stress incontinence( ) Hernias( )
Sexually transmitted disease( ) (type & symptoms & result of
tests)______________________________________________

Musculoskeletal: Joint Stiffness( ) Pain( ) Restriction of

motion( ) Swelling( ) Redness( ) Heat( ) Bony Deformity( )

Neurologic: Syncope( ) Seizures( ) Weakness( ) Paralysis( )

Abnormalities of sensation or coordination( )______________
Tremors( ) Loss of memory( )

WRE16
Physical Examination
General Statement:
Age ___y/o, Race _______, Gender M/F,
General Appearance______________
Nutritional Status____________, Weight____________,
Height_______, Frame size__________, BMI ________
VS: T____ P____ R____ BP______
Mental Status:
Physical Appearance and Behavior
Cognitive: Memory, reasoning, attention span, response
to questions
Speech and Language : Voice quality, articulation,
content, coherence, comprehension
Emotional Stability: Anxiety, depression, disturbance
of thought content
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Skin:
Color, integrity temperature, hydration, tattoos, scars
Presence of edema, excessive perspiration, unusual odor
Presence and description of lesions (size, shape,
location, inflammation, tenderness, induration,
discharge), parasites
Hair texture and distribution
Nail configuration, color, texture, condition, presence of
clubbing, nail plate adherence, firmness
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Head:
Size and countour of head, scalp appearance and
movement
Facial features (characteristics, symmetry)
Presence of edema or puffiness, tenderness
Temporal arteries: Characteristics
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Eyes:
Visual acuity, visual fields
Appearance of orbits, conjunctivae, sclera, eyelids,
eyebrows
Pupillary shape, consensual response to light and
accommodation, extraocular movements, corneal light
reflex, cover-uncover test.
Opthalmoscopic findings of cornea, lens, retina, optic
disc, macula, retinal vessel size, caliber, and
arteriovenous crossings.
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Ears:
Configuration, position and alighment of auricles
Otoscopic findings of canals (cerumen, lesions,
discharge, foreign body) and tympanice membranes
(integrity, color, landmarks, mobility, perforation)
Hearing: Air and bone conduction tests, whispered
voice, conversation
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Nose:
Appearance of external nose, nasal patency, flaring
Nasal mucosa and septum, color, alighment, discharge,
crusting, polyp
Appearance of turbinates
Presence of sinus tenderness or swelling
Discrimination of odors
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Mouth and Throat:
Number, occlusion and condition of teeth; [resemce pf
dental appliances
Lips, tongue, buccal and oral mucosa, floor of moth
(color, moisture, surface characteristics, ulcerations,
induration, symmetry)
Oropharynx, tonsils, palate (color, symmetry, exudate)
WRE16
Symmetry and movement of tongue, soft palate and
uvula; gag reflex
Discrimination of taste
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Neck:
Mobility, suppleness, strength
Position of trachea
Thyroid size,shape, tenderness, nodules
Presence of masses, webbing, skinfolds
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Chest:
Size and shape of chest, anterposterior versus tranverse
diameter, symmetry of movement with respiration
Presence of retractions, use of accessory muscles,
diaphragmatic excursion
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Lungs:
Respiratory rate, depth, regularity, quietness or ease of
respiration
Palpation findings: symmetry and quality of tactile
fremitus, thoracic expansion
Percussion findings: quality and symmetry of
percussion notes, diaphragmatic excursion
Auscultation findings: characteristics of breath sounds
(pitch, duration, intensity, vesicular, bronchial,
bronchovesicular) unexpected breath sounds
Characteristics of cough
Presence of friction rub, egophony, whispered
pectoriloquy
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Breasts:
Size, contour, venous patterns
Symmetry, texture, masses, scars, tenderness,
thickening, nodules, discharge, retraction, or dimpling
Characteristics of nipples and areola
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Heart:
Anatomic location of apical impulse
Heart rate, rhythm, amplitude, contour
Palpation findings: pulsations, thrills, heaves, or lifts
Ausculation findings: characteristics of S1 and S2
(location, intensity, pitch, timing, splitting, systole,
diastole)
Presence of murmurs, clicks, snaps, S3 or S4 (timing,
location, radiation, intensity, pitch, quality)
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Blood Vessels:
Blood pressure: Comparison between extremities with
position change
Jugular vein pulsations and distention, pressure
measurement
Presence of bruits over carotid, temporal, renal, and
femoral arteries, abdominal aorta
Pulses in distal extremities
Temperature, color, hair distribution, skin texture, nail
beds of lower extremities
Presence of edema, swelling, vein distention, Homans
sign, or tenderness of lower extremities
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WRE16
Abdomen:
Shape, contour, visible aorta pulsations, venous patterns,
hernia
Auscultation findings: bowel sounds in all quadrants,
character
Palpation findings: aorta, organs, feces, masses,
location, size, contour, consistency, tenderness, muscle
resistance
Percussion findings: areas of different percussion notes,
costovertebral angle tenderness
Liver span
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Female Genitalia:
Appearance of external genitalia and perineum,
distribution of pubic hair, inflammation, excoriation,
tenderness, scarring, discharge
Internal examination findings: appearance of vaginal
mucosa, cervix, discharge, odor, lesions
Bimanual examination findings : size, position,
tenderness of cervix, vaginal walls, uterus, adnexa,
ovaries
Rectovaginal examinations findings
Urinary incontinence with bearing down
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Male Genitalia:
Appearance of external genitalia, circumcision status,
location and size of urethral opening, discharge, lesions,
distribution of pubic hair
Palpation findings: penis, testes, epididymides, vasa
deferentia, contour, consistency, tenderness
Presence of hernia or scrotal swelling
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Reference: Mosby’s Physical Examination
Handbook, 7th ed.
Anus and Rectum:
Sphincter control, presence of haemorrhoids, fissures,
skin tags, polups
Rectal wall contour, tenderness, sphincter tone
Prostate size, contour consistency, mobility
Color and consistency of stool
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Lymphatic:
Presence of lumph nodes in head, neck, epitrochlear,
axillary, or inguinal areas
Size, shape, consistency, warmth,, tenderness, mobility,
discreteness of nodes
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Musculoskeletal:
Posture: Alignment of extremities and spine, symmetry
of body parts
Symmetry of muscle mass, tone and muscle strength;
grading of strength, fasciculations, spasms
Range of motion, passive and active; presence of pain
with movement
Appearance of joints; presence of deformities, effusions,
warmth, tenderness, or crepitus
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Neurologic:
Cranial nerves: specific findings for each or specify
those tested, if findings are recorded in head and neck
sections
Cerebellar and motor function: gait, balance,
coordination with rapid alternating motions
Sensory function, symmetry (touch, pain, vibration,
temperature, monofilament)
Superficial and deep tendon reflexes: symmetry, grade
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WRE16