Case Report

Date: / / 201

P ATIENT ID
Name: Age:
Gender:  Male  Female Residency:
Marital Status:  Single  Married  Divorced  Widowed
Job: Date of Admission: / / 201
Source of info: Reliability:

C HIEF C OMPLAINT

H ISTORY OF THE P RESENT I LLNESS

P AST S URGICAL HISTORY
Surgery When Complication(s)

P AST M EDICAL HISTORY

Disease When Drug(s)

 HTN  IHD  Heart Failure  DM  Dyslipidemia

 COPD  Asthma  Interstitial Lung Disease  TB
 Bowel Disease  Liver Disease  Kidney Disease
 Rheumatologic  Endocrine Disease  Stroke
 Cancer

Notes:

D RUG H ISTORY
Drug Dose For (disease) Duration
F AMILY H ISTORY
Relationship Disease(s) Age diagnosed

S OCIAL HISTORY
Smoking:  Yes:  No
Alcohol:  Yes:  No
House Ventilation:  Well ventilated  Poorly ventilated
Pets:  Yes:  No
Pollution/Factories:  Yes:  No
Travel:  Yes:  No

A LLERGIES
Drug/Food Effect(s)

R EVIEW OF S YSTEMS
G ENERAL
 Fever  Undocumented
 Documented
 Chills
 Sweating
 Fatigue
C ARDIOVASCULAR 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
Time:  Continuous Severity:
 Intermittent Frequency:
Duration:
Severity:
Exacerbating Factors:
Relieving Factors:
 Orthopnea
 PND
 Dizziness/Syncope
 Palpitation:  Fast  Slow
 Regular  Irregular
 Edema
 Claudication: Part of leg: Distance:

R ESPIRATORY SYSTEM
 Cough: Dry/Wet:  Dry  Wet
 Sound:
Time:
 Sputum: Amount:
Color:
Taste/Odor:
 Hemoptysis: Amount:
Appearance:  Blood-streaked  Fresh/clots
Frequency/Duration:
 Wheezing

G ASTROINTESTINAL SYSTEM
 Mouth ulcers
 Dysphagia:  Solids and liquids simultaneously  Solids then both
 Intermittent  Continuous and progressive
 Food stuck in pharynx  Food stuck in esophagus
 Regurgitation After:
 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
 Blood only appears after the first vomit
 Medications (NSAIDs/corticosteroids):
 Abdominal Pain: Site:
Onset:  Sudden  Gradual
Character:  Colicky  Constant  Burning  Other
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:
 Pain  Constant flank  Colicky flank  Constant suprapubic
 Dysuria
 Urgency
 Nocturia
Frequency/Volume:  Normal frequency and volume
 Increased frequency with normal volume – Frequency
 Increased frequency and volume – Polyuria
 Decreased frequency and volume – Oliguria/Anuria
 Hesitancy
 Poor stream
 Post-micturition dribbling
 Sense of incomplete voiding
 Incontinence  Urge  Overflow  Stress
 Hematuria

NERVOUS SYSTEM
 Headache: Site:
Onset:  Sudden  Gradual
Character:
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

M USCULOSKELETAL S YSTEM
 Joint pain  Monoarticular  Oligoarticular (2-4)  Polyarticular (>4)
Joints:
 Symmetrical  Asymmetrical
 Migratory
 Inflammatory:  Morning stiffness > 1 hr.
 Stiffness decreases as the day goes by
 Pain decreases with movement
 Swelling
 Mechanical:  Morning stiffness < 30 min
(OA)  Pain increases as the day goes by
 Pain increases with movement
 Deformities
 Limitation in movement
 Muscle pain
S KIN
 Rash
 Pain
 Redness
 Swelling
 Itching
 Pigment changes
 Discharge/Bleeding
 Hair/Nail changes

E NDOCRINE