DEPARTMENT OF SURGERY

HISTORY

Informant: Relationship to Patient: Reliability: ____%

GENERAL DATA:
PHYSICAL EXAMINATION
This is a case of ______________________, _____ years of age,
______, ______________, born on __________________ in General Survey:
_______________, presently residing at __________________ and was ( ) Awake ( ) Asleep ( ) Afebrile ( ) Cardiorespiratory
admitted at our institution last August ____, 2017. distress

CHIEF COMPLAINT: Vital Signs:

Temp: _____ C RR: ____ cpm HR: ____
HISTORY OF PRESENT ILLNESS: bpm BP: ________ mmHg

NOI:
SKIN: Color: _________ with _______ turgor and mobility
POI:
TOI: HEENT:
DOI:
Head: ( ) normocephalic
GCS: E___V____M____ Eyes: _______ sclerae, __________ palpebral conjunctiva. _______ eyeballs
( ) LOC Ears: ( ) mass or lesions. ( ) Tympanic membrane with good cone of light.
( ) Headache Nose: ( ) Septum midline. ( ) Discharge
( ) Vomiting - ____ times Throat/mouth: ( ) Exudates
Neck: ( ) Cervical lymphadenopathy
Lypmh Nodes: ( ) lymphadenopathy
PAST MEDICAL HISTORY:

Past diseases: CHEST AND LUNGS:

Immunization status:
Past hospitalizations ( ) Symmetric chest expansion ( ) Retractions
Past Surgeries: Breath sounds: ____________

FAMILY HISTORY: CARDIOVASCULAR SYSTEM:

( ) Adyanmic precordium ( ) Normal rate ( ) Tachycardic

Maternal side:
( ) regular rhythm ( ) thrills and murmurs.
Paternal side:

PERSONAL AND SOCIAL HISTORY: ABDOMEN:

Abdomen is _________ with __________active bowel sounds. ( ) soft

Diet: ( ) firm ( ) palpable mass Liver span: __________
Alcohol consumption:
Smoking: ____ No _____ Yes Pack Years: _____ PERIPHERAL VASCULAR SYSTEM:

( ) Pale ( ) Warm ( ) Cold ( ) Edema

REVIEW OF SYSTEMS:
( ) Full Pulses ( ) Good capillary refill
General: ( ) Weight loss
SKIN: ( ) dryness skin ( ) jaundice ( ) pallor
NEURO: ( ) altered sensorium in behavior GENITALIA, ANUS, RECTUM:
HEENT: ( ) lightheadedness ( ) dryness of lips MUSCULOSKELETAL SYSTEM:
RESPI: ( ) difficulty breathing
CVS: ( ) chest pain ( ) palpitation ( ) easy fatigability __________ range of motion in arms, wrist, fingers, hip, knee, and
GI: ( ) loss of appetite ( ) nausea ( ) ankle.
vomiting ( ) difficulty eating ( ) difficulty in passing stool
GUT: ( ) dysuria ( ) oliguria ( ) anuria
MS: ( ) body pains MENTAL STATUS:
NERVOUS SYSTEM:

Cranial Nerves:

II

III, IV, VI

VII

VIII

IX, X

XI

XII

Reflexes:

MOTOR SENSORY

ADMITTING DIAGNOSIS: