QCGH HISTORY-PHYSICAL EXAM GUIDELINE

MEDICAL HISTORY
COUGH
I. GENERAL DATA- Identifying data/ Information of the patient
 Patient’s name (last, given, middle) C CHEST PAIN MASAKIT PO BA ANG DIBDIB KAPAG UMUUBO?
 Age, sex, civil status H HEMOPTYSIS MAY DUGO BA KASAMA ANG PLEMA? (DESCRIBE IF PRESENT)
 Occupation, nationality, race, religion E EASY FATIGABILITY MADALI PO BA MAPAGOD?
 Birthday and birthplace W WEIGHT LOSS NANGANGAYAYAT KA BA?
 Residence/ Present address F FEVER MAY LAGNAT BA KASAMA ANG PAGUUBO MO?
 Number of times admitted (same hospital) I INSOMNIA NAHIHIRAPAN KA BA MAKATULOG SA GABI?
 Date and time of admission
N NIGHT SWEATS PINAGPAPAWISAN BA SA GABI?
D DYSPNEA NAHIHIRAPAN KA BA SA PAGHINGA?
II. CHIEF COMPLAINT- List of one or more symptoms that causes the patient to seek attention,
Written as words of phrases, not as complete sentences; patient’s own words C COUGH INUUBO KA BA? MAY PLEMA BAO WALA? ( DESCRIBE IF PRESENT)
A ANOREXIA NAWAWALAN KA BA NG GANA SA PAGKAIN?
III. HISTORY OF PRESENT ILLNESS- amplifies the chief complaint, describes how each symptoms develop; patients B BACK PAIN SUMASAKIT BA ANG LIKOD HABANG INUUBO KA?
symptoms should be accurately described
UTI

PQRST OF PAIN W WEAK STREAM MAHINA PO BA ANG PAGLABAS/ PAGDALOY HABANG UMIIHI?
I INCONTINENCE MAY LUMALABAS PO BA NA IHI KAPAG IKAW AY UMUUBO O TUMATAWA/
P Palliative Conditions that relieve or worsens the pain UMAABOT PO BA SA BANYO KAPAG NAKARAMDAM NG KAGUSTUHANG
Q Quality Heavy, Dull, Crushing, Burning, Searing, UMIHI?
throbbing, Colicky, Pins and needles N NOCTURIA ILANG BESES BUMABANGON MULA SA PAGTULOG SA GABI PARA UMIHI?
R Radiation Radiating to the back, left arm, etc. D DYSURIA MASAKIT PO BA ANG IYONG PAG IHI?
S Severity Mild, Moderate, Severe, Tolerable, not S SYMPTOM OF HIRAP PO BA SA PAGSISIMULA NG PAG IHI?
tolerable HESITANCY
T Timing Time of the day when pain occurs U URGENCY MADALAS BA MAKARAMDAM NG KAGUSTUHAN NA UMIHI?
R RETENTION BALISAWSAW? MAY PAKIRAMDAM PO BA NA PARANG MAY NATITIRA
ABDOMINAL PAIN (Also when considering dyspepsia, uninvestigated) PAGTAPOS UMIHI?
F FREQUENCY ILANG BESES UMIIHI SA LOOB NG 1 ARAW?
H HEARTBURN MAY GUMUGUHIT NG MAINIT SA SIKMURA OR DIBDIB?
A ANOREXIA NAWAWALAN KA BA NG KUMAIN? If suspecting PRESENCE OF STONES, assess the following: FLANK PAIN, PUS CELLS 1-3/ HPF, STONE HISTORY, RBC TMTC
V VOMITING NAGSUSUKA PO? Normal urine output: 30 cc/kg/day; Oliguria: <500 cc/day; Anuria: <100 cc/day
E EARLY SATIETY MADALI KA BA MABUSOG? KIDNEY- PUNCH TEST/ GOLD FLAM: (+) if grimace of jarring due to the stretching of the renal capsule
N NAUSEA MAY PAKIRAMDAM KA BA NA GUSTO MO SUMUKA?
B BLOATING PUNO BA NG HANGIN ANG TIYAN MO? NAG UUTOT BA?
FEVER
A ABDOMINAL PAIN SUMASAKIT BA ANG TIYAN? SAAN PARTE?
R REGURGITATION MAY NALALASAHAN KA BA NA MAASIM PAGTAPOS KUMAIN? CONTINOUS FEVER DIURNAL VARIATION OF 0.5- 1.0C
P POST PRANDIAL SUMASAKIT BA ANG TIYAN PAGKATAPOS KUMAIN? REMITTENT FEVER DIURNAL VARIATION OF > 1.1C BUT NO NORMAL READINGS
PAIN
INTERMITTENT FEVER ON AND OFF/ EPISODES OF FEVER SEPARATED BY DAYS OF NORMAL
TEMP.
ABDOMINAL PAIN: ALARM SYMPTOMS
RELAPSING FEVER BOUTS OF FEVER OCCURRING EVERY 5-7 DAYS FROM INFECTION
EPISODIC FEVER FEVER LAST FOR DAYS OR LONGER FOLLOWED BY PROLONGED PERIODS
J JAUNDICE
WITHOUT FEVER (at least 2 weeks) WITH REMISSIONS OF CLINICAL
A AGE 45 Y/O ILLNESS
W 20% WEIGHT LOSS (SIGNIFICANT)
C CHRONIC NSAID USE/ INTAKE
H HEMATOCHEZIA/ MELENA
A ABDOMINAL MASSES/ ODYNOPHAGIA
P PREVIOUS PEPTIC ULCER DISEASE

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 Last sexual contact

 Number of sexual partners and occupation of sexual partners
WITH PREVIOUS ADMISSIONS AND CONSULTATIONS (IF RELATED TO THE PRESENT ILLNESS):  Unusual sexual practices
INCLUDE AN INTERVAL HISTORY (USUALLY FOR CHRONIC CONDITIONS, DETAILS ABOUT THE LAST EPISODES TO THE  Use of contraception (type and duration of use)
PRESENT CONDITION)  Symptoms: dyspareunia, post-coital bleeding, discharge

IV. PAST MEDICAL HISTORY REVIEW OF SYSTEMS

 Childhood illnesses (measles, mumps, chicken pox) General Weight loss, weight gain, fever, chills, fatigue, insomnia, loss of appetite, night sweats
 Previous hospitalizations Skin Color change, sores, rash, itching, scaling, bleeding
 History of surgeries Head/Neck Headache, tauma, stiffness
 History of accidents, trauma, blood transfusions Eyes Corrective lenses, pain, diplopia, itch, blurring of vision, dryness, redness
 History of allergies to food and drugs Ears Hearing, pain, tinnitus
 History of disease such as hypertension, diabetes, asthma, goiter, PTB, arthritis, hepatitis Nose Colds/ nasal stuffiness, bleeding, dryness, discharge, pain, sneezing
 Medications taken for a certain disease condition Mouth Bleeding gums, soreness, ulcers, hoarseness, pain, dryness
Respiratory Cough, chest pain, dyspnea, hemoptysis
V. FAMILY HISTORY- documents presence or absence of specific illness in the family (parents, siblings, children, Cardiac Chest pain, dyspnea, PND, orthopnea, palpitations
grandchildren, grandparents)
Gastro Anorexia, dysphagia, hematemesis, nausea, vomiting, hematochezia. ,Elena, diarrhea
Heredofamilial diseases- HPN, DM, asthma, goiter, malignancies
Genito Dysuria, hematuria, nocturia, retention, incontinence, frequency, urgency, discharge
Communicable diseases- PTB, hepatitis, pneumonia
MusculoS Pain, weakness, tenderness, cramps, trauma, joint pain, backache, stiffness
VI. PERSONAL AND SOCIAL HISTORY Endocrine Polyuria, polydipsia, polyphagia, cold intolerance, heat intolerance
 Family of origin (number of siblings and birth order of the patient) Hema Pallor, easy bruising
 Education and educational attainment Nervous Syncope, seizure, dizziness, tremor
 Occupation history Psychiatric Sleep disturbance, depression, hallucination
 Marital history
 Current household living conditions, sources of water, waste disposal, toilet
 Personal habits, diets, exercise PHYSICAL EXAMINATION
 History of smoking, drinking alcoholic beverages, illicit drug use
Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress
Ventilation: 20% of the total floor area Vital Signs: BP CR RR T
Pack years: # sticks per day x # of year smoking/ 20 Ht Wt BMI
(5-7 pack years (MALE) and 7-10 pack year (FEMALE) BMI Classifications (ASIANS)
Underweight <18.5
VII. OG- GYNE HISTORY Normal 18.5-22.9
Overweight 23-24.9
M MENARCHE AGE AT FIRST MENSTRUATION (NORMAL 10-16 Y/O) Obese1 25-29.9
I INTERVAL REGULAR OR IRREGULAR (NORMAL 28 +/- 7 DAYS) Obese2 30 and above
D DURATION HOW MANY DAYS (NORMAL 4 +/- 2 DAYS) BMI = kg/m2
A AMOUNT NUMBER OF PADS PER DAY, HOW SOAKED? (NORMAL 20-60 ML)
S SYMPTOMS ASSOCIATED SYMPTOMS IF PRESENT (dysmenorrhea)
HEENT Anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge, no tonsillopharyngeal
OBSTETRICAL SCORE congestion, no cervical lymphadenopathy
th
HEART Adynamic precordium, normal rate, regular rhythm, PMI at 5 ICS LMCL, no murmur
G GRAVIDA TOTAL NUMBER OF PREGNACIES REGARDLESS OF OUTCOME CHEST/LUNGS Symmetrical chest expansion, no retraction, no lagging, equal vocal and tactile fremitus, clear
P PARITY NUMBER OF VIABLE BIRTHS (>20 weeks) breath sounds
T TERM 37-42 weeks ABDOMEN Flabby abdomen, normoactive bowel sounds, soft, non-tender to deep and light palpation
P PRETERM Before 37 completed weeks EXTREMITIES Grossly normal extremities, no deformities, no external signs of cyanosis, no pallor, no edema, full
A ABORTION Pregnancy termination prior to 20 weeks AOG or < 500 grams BW equal pulses on brachial, radial and dorsalis pedis
L LIVING Number of alive children
NEUROLOGIC EXMANIATION
SEXUAL HISTORY
I S - Can identify the odor of coffee on both nostrils with eyes closed
 Coitarche – age of first sexual intercourse
II S - Can read the newsprint at a distance of one foot
 Frequency of coitarche
 History of STI II, III Presence of direct and consensual light reflexes on both eyes
III,IV,VI M - Full EOM movements

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V S - Able to feel pinprick, light touch, dull pain, temp nystagmus ensues, the person is brought back to sitting. There is a delay of about 30 seconds again, and then the other
M - Clench teeth and resist pressure applied on the chin side is tested. (BPPV testing)
V, VII Corneal reflex intact
VII M - Raise eyebrows, wrinkle forehead and open/close eyes
M - Pout, purse lip, smile, blow off cheeks
S – taste sensation, anterior 2/3 WITHOUT GLASSES
VIII S - Rubbing of fingers on both sides; or OD OS
Can hear the tick of a watch on both ears No pinhole 20/40 20/80
IX, X Gag reflex, Uvula position, Pharyngeal movement With pinhole 20/20 20/40
X Voice, nasal twang
XI M - Shrug and elevate shoulders with or without resistance WITH GLASSES
M - Move head laterally with or without resistance OD OS
CN XII M - Tongue position, Retract and protrude tongue No pinhole 20/20 20/20
With pinhole 20/20 20/20
MOTOR FUNCTION - No muscle atrophy, no tremors noted
FEVER WITH RASHES
A-appearance
B - borde
C- color
D - distribution
E - elevation
CEREBELLAR FUNCTION - Able to perform finger to nose test, alternating supination and pronation test, heel to sheen test

REFLEXES

SENSORY FUNCTION - Reacts to pain, touch, pressure, position and vibration sense

SPECIAL TEST
DIGITAL RECTAL EXAM (DRE) – no skin tags, no fissures, no external haemorrhoids, full rectal vault, no mass, prostate
gland not enlarged and non-tender, fecal material is non-bloody on tactating finger
INTERNAL EXAM (IE) – vagina accepts 1(virgins)/ 2-3(non-virgins) fingers with ease. No foul smelling discharge. Vaginal
wall is non-tender. Cervix is not dilated, non-tender, firm closed. No mass, no bloody discharge. Uterus not enlarged.
Uterus and ovaries are non-palpable

For patients complaining of headache and dizziness, visual acuity test, otoscopy, neurological examination, tilt test and
dix hall pike test must be performed.

TILT TEST – take the patient’s BP while lying down. Then after 5 min, take it while patient is sitting. Also take note of the
pulse rates (for cardiac problems, syncope)

DIX HALL PIKE TEST – a person is brought from sitting to a supine position, with the head turned 45 degrees to one side
and extended about 20 degrees backward. Once supine, the eyes are typically observed for about 30 seconds. If no

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