Case Report

Date:

/ 201

PATIENT ID
Name:
Age:
Residency:
Marital Status:
Single Married
Divorced
Widowed
Occupation:
DOA:
/
/ 201
Source of info:

HISTORY OF CURRENT PREGNANCY:

G P A
LMP:
Hb:
EDD:
Gestational age:
Singleton pregnancy
Ultrasound?
Why?

Blood Group:

Last

Twin pregnancy:

Result?
Did you become pregnant while using birth control?
Are you currently experiencing any of the following?
Nausea
Vomiting
Headache
Swelling
CHIEF COMPLAINT

Pain?
HISTORY OF THE

S:
O:
C:
R:
A:
T:

Vomiting?
PRESENT
ILLNESS
-amount :
-color:
-odor:
hematemesis:
mucous:
preceded by
nausea?
w/ pain?
projectile non-

Fatigue

Bleeding?
-amount:
-color:
-odor:
w/ pain
gush of fluid

HPI SUMMARY:

PAST OBSTETRICAL HISTORY:

G

Gende
r

Year

Duratio
n of
preg.

Weig
ht

Type of
deliver
y

Place
of
deliver
y/
abortio
n

1st
2nd
3rd
4th
5th
6th
7th
8th

PAST GYNECOLOGICAL HISTORY:

1st menarche:
years old.
LMP:
/
/
.
Regularity:
Period starts every
day.
Duration of bleeding:
days.
Bleeding or spotting b/w periods.
Contraceptives?
pills
IUD
Pap smear? Why?
Result?
Pain w/ periods?

When?

complications

NSI
/
IVF
*

both

before menses

during menses

PAST MEDICAL HISTORY

Disease

When

Drug(s)

PAST SURGICAL HISTORY

Surgery

When

Where

Complication(s)

DRUG HISTORY
Drug

Dose

Frequency

For (disease)

FAMILY HISTORY
Relationship

Disease(s)

Age diagnosed

SOCIAL HISTORY
Smoking: Yes:
Alcohol: Yes:
House Ventilation:
Well ventilated
ventilated
Pets:
Yes:
Pollution/Factories: Yes:
Travel:
Yes:

No
No
Poorly
No
No
No

ALLERGIES
Drug/Food/Others

Effect(s)

BLOOD TRANSFUSION:

SUMMARY:

REVIEW OF SYSTEMS
GENERAL
Fever

Undocumented
Documented
Sweating

Chills
Fatigue

CARDIOVASCULAR SYSTEM
Chest Pain: Site:
Onset:

Sudden

Gradual

Character:
Heaviness Stabbing Burning
Other:
Radiation/Referral:
Time:
Continuous Severity:
Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:
Dyspnea:

Onset:

Sudden

Gradual

 Continuous Severity:

Time:

Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:
Orthopnea
Dizziness/Syncope
Palpitation
Claudication
Distance:

PND

Edema

RESPIRATORY SYSTEM
Cough:

Painful
Yes
No
Dry/Wet: Dry
Wet
Sound:
Time:
Sputum:
Amount:
Color:
Taste/Odor:
Hemoptysis:Amount:
Appearance: Blood-streaked
Frequency/Duration:
Wheezing

GASTROINTESTINAL SYSTEM

Clots

Mouth ulcers
Dysphagia: Solids
Liquid
Both
Intermittent Continuous
Complete obstruction with regurgitation No
regurgitation
Level food get stuck in:
Odynophagia
Nausea
Vomiting:
Preceded by nausea
Without warning
With abdominal pain
Without pain
Pain relieved after vomiting
Not relieved
Related to meals
Related to times:
Amount:
Color:

Odor:
Projectile

Non-Projectile

Hematemesis:
Amount:
Appearance: Coffee-ground
Fresh
Preceded by retching (make the sound and movement of vomiting).
Blood only appears after the first vomit
Medications (NSAIDs/corticosteroids):

Abdominal Pain: Site:

Onset:
Sudden
Gradual
Character:
Colicky Constant
Twisting
Tearing
Radiation/Referral:
Time:
Continuous Severity:
Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:

Heartburn Relieved by:

Weight loss (significant if >10% of weight in 6 months)
Loss of appetite
Altered bowel habit: Frequency
Increased
Decreased
Consistence
Watery Soft

Hard
Color:
Odor:
Blood:
Melena (tarry-stool)

Fresh
Mucus
Pus
Tenesmus
Urgency
Incontinence

URINARY SYSTEM
Color:

Odor:
Volume: Normal Increased
Decreased
Frequency:
Normal Increased
Decreased
Stream: Normal Thick
Thin
Dysuria
Urgency
Incontinence
Nocturia
Hematuria

NERVOUS SYSTEM

Headache: Site:
Onset:
Sudden
Character:

Gradual

Radiation/Referral:
Time:
Continuous Severity:
Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:
Motor problems:
Sensory problems:
Change in personality/judgment:

Convulsions
Visual changes
Auditory changes
Tinnitus
Dizziness

MUSCULOSKELETAL SYSTEM
Muscle pain
Joint pain

Exacerbated by movement (mechanical)

Relieved by movement (inflammatory)
Morning stiffness (inflammatory)
Limitation in movement
Joint swelling
Deformities

SKIN

Rash

Pain
Redness
Swelling

Itching
Pigment changes
Discharge/Bleeding
Hair changes
Nail changes

ENDOCRINE:
Alimentary changes:
weight loss
weight gain
polydipsia
Integumental changes:
pigmentation
sweating

dryness

Nervous changes:
nervousness
seizures
loss

irritability
Fatigue

loss of appetite

headache
Visual