UNIVERSITY OF BALAMAND

FACULTY OF MEDICINE AND MEDICAL SCIENCES

CLINICAL SKILLS I
PROBLEM ORIENTED MEDICAL RECORD
1
To Be Completed By Medical Studet! " Not #a$t O% O%%icial Medical Reco$d
Date: ____________________
1. Introductory Statement
Introductory Statement is a brief one-sentence description introducing
the patient to the reader. It may include the patient's age, sex,
occupation, marital status, children, ethnicity, religion, living
arrangement, and any other salient identifying characteristics.
Name: _________________________________________________________________________
Medical Record No.: ___________________ Bed No.: __________________
Date o Admi!!ion: _______________________
A"e: _________________________________ Se#: ____________________________
$. Source!
This is a statement of whether the history was obtained from the
patient, relatives, or other sources (old medical records, ambulance
driver, etc. and an expression of opinion concerning the reliability of
the history obtained. !or example" #The reliability of the patient's
history is uncertain having been obtained from his next-door neighbor
$r. x% &nd the ambulance driver ...#
Source o Inormation: _______________________________
Do you t%in& t%e !ource i! relia'le: Yes No not sure
1
*Original Source: Printed Matter From The Faculty Of Medicine merican !ni"ersity Of #eirut $ Mc%ill !ni"ersity &ase 'e(ort Format
Name of Patient: Medical 'ecord No):
#ed No): _______________________________
Name o Attendin" P%y!ician:
Contacted( Yes * + No * +
T%e )i!tory
*. C%ie Com+laint
This is the ma'or reason for which the patient comes to see a physician
at a given time. It is expressed succinctly in a single sentence, often in
the patient's own words, and includes the duration over which the
complaint has lasted.
&hief com(laint:
,. )i!tory o Pre!ent Illne!!
This is the most important part of the history and, if properly obtained,
the diagnosis of a patient's problem can be made from the history in
approximately seventy percent of cases. (nfortunately, this is also the
most difficult portion and the area where most omissions and errors in
diagnosis are made.
The )resent Illness refers to the recent change in a patient's health
which caused him*her to see+ medical attention. It starts with the
event or occasion which the patient notes as a change from his*her
#usual# health (which may in fact be a low level of health and
function and proceeds to the time of presentation for medical
attention. The ,)I may begin as follows" #This -- year old male with
longstanding ischemic heart disease and two previous $I's was in his
usual state of health until - days prior to admission when ...#. !rom
this point the )resent Illness is written in an orderly chronological
manner including all symptoms, feelings and events that are pertinent
to the patient's current illness. It is important to remember that the
order in which the )resent Illness is written does not necessarily
mirror the order in which the information was obtained.
The description of the symptoms in the )resent Illness should be very
specific and the following features of each symptom delineated"
PHYSICIAN PATIENT RELATIONSHIP
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
Bodily loc!io"#
T$e %i!e& or %i!e%& o' !$e com(li"! %$ould )e ide"!i'ied*
C$ro"olo+y#
T$e !ime o' o"%e!& !$e dur!io"& !$e (eriodici!y "d
're,ue"cy& "d !$e cour%e o' !$e %ym(!om% %$ould )e
%(eci'ied* T$e 'i"l e-e"!.%/ 0$ic$ (rom(!ed !$e (!ie"! !o
%ee1 medicl !!e"!io" %$ould )e %(eci'ied*
2uli!y#
A de%cri(!io" o' !$e ,uli!y o' !$e %ym(!om& u%ully )e%!
re(or!ed i" !$e (!ie"!3% o0" 0ord%& %$ould )e i"cluded*
2u"!i!y#
T$e -olume& i"!e"%i!y& %i4e& "um)er or "y o!$er
((ro(ri!e ,u"!i'ic!io" o' !$e (!ie"!3% %ym(!om %$ould
)e recorded * * *
Se!!i"+# T$i% i% de%cri(!io" o'#
1* $o0 !$e (!ie"!5% li'e circum%!"ce% $-e ''ec!ed
!$e de-elo(me"! o' %ym(!om%& "d
2* $o0 !$e %ym(!om% $-e ''ec!ed !$e (!ie"!3%
li'e%!yle*
A++r-!i"+ or
lle-i!i"+ 'c!or%# T$e u!ili4!io" "d e''ec! o' dru+%& c$"+e% i" (o%i!io"&
re%!& e!c*& o" !$e %ym(!om %$ould )e de%cri)ed*
A%%oci!ed
m"i'e%!!io"%# T$i% i"clude% 'ull e",uiry o' !$e or+" %y%!em.%/ !$ou+$!
!o )e i"-ol-ed % 0ell % re-ie0 o' co"%!i!u!io"l
%ym(!om%*
The ,istory of )resent Illness ends with the hospital admission. It
should be clearly stated why the patient sought medical advice at the
particular time when he/she came to see a physician.
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
The concluding paragraph of the present illness should contain
pertinent positive and negative information to answer any anticipated
.uestions regarding the patient's differential diagnosis. This typically
includes a functional en.uiry of the system thought to be involved in
the patient's illness. It should also include comments on general well-
being, changes in weight or color, changes in lifestyle, and functional
capacity secondary to the illness, recent medications and any other
information deemed important to the present illness (i.e. family
history in the case of genetic disease.
Present lllness:
PHYSICIAN PATIENT RELATIONSHIP
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________

-. Pa!t Medical )i!tory
The )ast $edical ,istory is a record of all previous illnesses including
medical and psychiatric illnesses, surgical procedures and an
obstetrical history if appropriate. These are all listed chronologically
beginning with the most remote and proceeding to the most recent.
They should include the date, the hospital (if an admission was
re.uired, the diagnosis, the treatment, the complications and the
se.uelae.
Medical +ro'lem!
Sur"ical +rocedure!
O'!tetrical %i!tory i a++ro+riate
P!yc%iatric illne!!e!

1os(itali2ations
3ate 4ocation 'eason

________________ ________________ ________________
________________ ________________ ________________
________________ ________________ ________________
________________ ________________ ________________
ccidents5 trauma:
6mmuni2ations
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
-. Medication! and Aller"ie!
com(lete list of all medications ta8en (re,hos(itali2ation as 9ell as 8no9n drug5 food and other
allergies should :e listed)
&urrent; (ast medications:
3rug 3ose 3uration 3rug 3ose 3uration
Of inta8e of
inta8e
1) <)
-) =)
/) >)
0) .)
7) 1?)
llergies: drug5 food5 other)
.. /amily )i!tory
This provides data concerning hereditary disease and familial illness.
It should contain information about all the patient's blood relatives,
the illnesses they have, and if they are dead, their age at death, and
the illnesses they had at the time of death.
& convenient format for this is as follows"
Family history: consanguinity5 dia:etes5 thyroid disease5 hy(erli(idemias5 malignancies
*s(ecify ty(e and location+5 renal disease5 allergies5 hy(ertension5 heart
disease5 neurologic disease5 (sychiatric disease5 musculos8eletal5 sic8le
cell5 thalassemia5 :leeding tendency5 %6 disease
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
0. Per!onal )i!tory
This section provides a profile of the patient as a person including"
Erly
6e-elo(me"!# Plce o' )ir!$& c$ild$ood de-elo(me"!& $el!$ c!i-i!ie%&
%ocil "d eco"omic e"-iro"me"!
Educ!io"#
Sc$ool $i%!ory& -oc!io"l !ri"i"+
Socil
Ac!i-i!ie%# Recre!io"%& reli+iou% "d commu"i!y %u((or! +rou(%
7or1 Record#
A+e )e+u"& !y(e& "um)er o' 8o)%& %ucce%% "d 'ilure&
i"du%!ril $4rd% "d e9(o%ure%& (re%e"! 0or1
H)i!%#
Li-i"+ co"di!io"%& die!& lco$ol& dru+%& !o)cco
:ri!l S!!u%#
;mily %!ruc!ure& curre"! li-i"+ rr"+eme"!% e!c*
Patient (rofile:
#irth (lace___________________ @ducation _______________ Marital status_______________
Occu(ation______________________ @n"ironmental eA(osure_____________________
&ountries "isited recently__________________________
Food intolerance and food fads_______________________
dditional historical data
dditional &omments
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
1. /unctional En2uiry
The functional en.uiry is an integral part of the case report. It is
designed to give an overview of those systems not covered in the
)resent Illness. In recording the functional en.uiry in the case report
it is unnecessary to repeat those portions previously recorded in the
Present Illness or Past Medical History. /ot all this information is
desirable in case reports although at the beginning of one's clinical
training it is appropriate to practice using these .uestions in a
systematic way so as to gain necessary experience with them.
$any of the following symptoms are formal medical terminology and
need to be communicated in layman's language to your patients.
Instructions: Circle positive or abnormal responses and comment appropriately.
Underline negative or normal responses. Leave unaltered if information
not available.
Sy!tem! Re3ie4:
1+ %eneral: Bea8ness5 Fatigue5 a((etite5 change in 9t) _________________5 slee(ing
ha:its5 chills5 fe"er5 night s9eats
-+ 6ntegument: &olor changes5 (ruritus5 infections5 tumor *:enign ;malignant+5 hair changes
nail changes5 s8in disease5 change in moles5 rash5 alo(ecia5 (igmentation)
/+ @yes "ision5 date of last eAamination5 ____________________ scotomata5 (ain5
di(lo(ia5 (hoto(ho:ia5 glaucoma5 refraction errors)
0+ @ars: tinnitus5 hearing loss5 discharge5 other)
7+ Nose5 throat and sinuses: e(istaAis5 discharge5 sinusitis5 hoarseness5 recurrent sore throat)
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
<+ &entral Ner"ous: headache5 di22iness5 synco(e5 sei2ures5 "ertigo5 di(lo(ia5 (aralysis ; (aresis5
tremor5 muscle 9ea8ness5 ataAia5 sensory a:normalities5 head trauma5 history
of meningitis5 other)
=+ #reasts: Masses5 discharge5 (ain
>+ @ndocrine: %oiter5 heat intolerance5 cold intolerance5 family history of dia:etes5 (olyuria5
(olydi(sia5 (oly(hagia5 inta8e of hormones
.+ 1ematological: nemia5 a:normal :leeding5 :ruising5 adeno(athy5 family history of
hematologic disease5 other)
1?+ &ardio"ascular: &hest (ain5 ty(ical angina (ectoris5 dys(nea on eAertion5 ortho(nea5
(aroAysmal nocturnal dys(nea5 (eri(heral edema5 murmur5 (al(itations5
"aricosities5 throm:o(hle:itis5 claudication5 'aynaudCs (henomenon5
synco(e5 near synco(e5 (ast heart disease5 rheumatic fe"er5 hy(ertension5
inta8e of cardio"ascular drugs5 other)
11+ Pulmonary: &ough *(roducti"e ; non (roducti"e+5 change in cough5 amount and
characteristics of s(utum (roduction5 ______________________5 (ac8 years
of to:acco usage ________________9hee2ing5 hemo(tysis5 recurrent
res(iratory tract infections5 (ositi"e tu:erculin test5 shortness of :reath5
(re"ious chest radiogra(h5 family history of chest disease)
1-+ %astrointestinal: 3ys(hagia5 indigestion5 heart:urn5 nausea5 "omiting5 diarrhea5 consti(ation5
melena5 hematemesis5 rectal :leeding5 change in :o9el ha:its5 a:dominal
(ain5 a:dominal s9elling5 Daundice5 dar8 urine5 clay colored stools5 food
intolerances5 eAcessi"e gas5 use of antacids5 use of laAati"es5 hernia5
hemorrhoids5 (arasites5 (e(tic ulcer disease5 gall :ladder disease5
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
(ancreatitis5 gastrointestinal surgery5 alcohol inta8e5 family history of %l
malignancy5 other)
1/+ !rinary tract: Nocturia5 freEuency5 urgency5 dysuria5 hematuria5 difficulty in starting urinary
stream5 urinary stream a:normalities5 incontinence5 (olyuria5 renal calculi5
infections5 flan8 (ain5 (re"ious urine eAamination5 (re"ious radiogra(hy of
urinary tract5 family history of renal disease5 other)

PHYSICIAN PATIENT RELATIONSHIP
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
10+ %enitore (roducti"e system:
a+ Male: Penile discharge5 lesion5 history of "enereal disease5 serology5 testicular mass5
infertility5 im(otence5 li:ido5 history of undescended testicules)
:+ Female: %ynecologic history:
age of menarche________________5 last menstrual (eriod______________5
age at meno(ause_____________5 (ost meno(ausal :leeding5 a:normal
menses5 amount of :leeding5 intermenstrual :leeding5 (ostcoital :leeding5
leucorrhea5 (ruritis5 history of "enereal disease5 serology5 last
PPs____________5 results__________5 (el"ic (ain5 (el"ic mass5 other)
c+ O:stetric history: Full term deli"eries_______________5 (regnancies_____________
a:ortions_____________5 li"ing
children_______________ com(lications of (regnancies5 infertility5
li:ido)
d+ Methods of contrace(tion:
17+ Musculos8eletal system:
a+ Foints: (ain5 s9elling5 heat5 redness5 stiffness5 deformity5 family history of Doint
disease)
:+ Myalgias5 family history of muscle disease
1<+ Psychiatric: 1y(er"entilation5 ner"ousness5 de(ression5 insomnia5 nightmares5
memory loss5 drug a:use)
ny suggestion of (sychotic sym(tomsG Yes_______No_______
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
5. P%y!ical E#amination
The art of medicine includes a thorough history and a thoughtful
physical examination followed by the interpretation of this data.
Information recorded in the physical examination section should be
the findings made during the patient's exam and not the interpretation
of these observations. This is at times difficult to do and re.uires
practice to fully master.
The following outline will serve as a guide in performing and recording
a physical examination.
P%y!ical E#amination
Hital signs:
Pulse reg; irreg) 'es(irations_____________Tem(______________oral ; rectal
#lood (ressure:
Su(ine ' arm__________________su(ine 4 arm______________4eg_____________
Standing ' arm________________standing 4 arm_____________________________
Beight______________________1eight________________________
%eneral:
6ntegument: Turgor5 teAture5 (igmentation5 cyanosis5 telangiectasia5 (etechiae5 (ur(ura5
ecchymosis5 infection5 lesions5 hair5 nails5 mucous mem:ranes)
4ym(h nodes: &er"ical5 (ostauricular5 su(racla"icular5 aAillary5 inguinal5 other)
S8ull: Trauma5 :ruits5 other
@yes: 4acrymal glands5 cornea5 lids5 sclerae5 conDuncti"ae5 eAo(htalmus5 lid,lag
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
Fundi: 3iscs5 arteries5 "eins5 hemorrhages5 eAsudates5 microaneurysms
@ars: To(hi5 tym(anic mem:ranes5 eAternal canal5 hearing5 air conduction5 :one
conduction5 laterali2ation
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
Mouth5 nose and throat: 3entition5 gingi"al tongue5 tonsils5 (harynA5 nasal mucosa5 nasal
se(tum5 sinuses
Nec8: Mo:ility5 scars5 masses5 thyroid5 sali"ary glands5 tracheal shift5 :ruits
#reasts: Masses5 discharge5 ni((les5 asymmetry5 gynecomastia5 s8in
&hest:
'es(iratory rate ___________ ;min) m(litude: shallo95 dee(5 normal
'es(iratory rhythm: regular5 irregular5 (eriodic5 (rolonged eA(iration
&hest 9all: 3eformities5 eAcursion: good5 fair5 a:sent5 use of accessory muscles
uscultation: Bhee2es5 rhonchi5 crac8les5 ru:s5 :reath sounds: increased5 decreased5 normal5
other
*3iagram location of a:normal :reath sounds5 transmitted "oice5 or a:normal (ercussion+
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
&ardio"ascular system:
, @Aternal Dugular "eins distended ; Not distended
, 1e(atoDugular refluA
, &arotid: thrill5 :ruit5 u(stro8e_______________
, Precordium: acti"e5 Euiet
Point of maAimum im(ulse: ____________________
1ea"e *4H;'H+5 thrill *Systolic; diastolic+5 location:
Pal(a:le ecto(ic (ulsation
S1: S-: S/: *heard5 not heard+ S0: *heard5 not heard+
%allo(s: &lic8s: other:
Systolic murmurs grade5 location5 radiation:
3iastolic murmurs grade5 location5 radiation:
3iastolic murmurs and grades:
Other:
3iagram
&lu::ing5 cyanosis5 edema5 throm:o(hle:itis5 (aradoAical (ulse5 stasis5 ulceration
&arotid #rachial 'adial orta Femoral Po(liteal PT 3P
_'__6_________6_________6_________6________6_________6________6_____6______6
_4 __6_________6_________6_________6________6_________6________6_____6______6
Scales ?,0 @Aaggerated / ) Normal 0) 3iminished -) Fust (al(a:le) :sent ?)
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
:domen: O:esity5 contour5 scars5 "enous collaterals5 hernias5 (ulsations5 tenderness5
&H tenderness5 masses5 re:ound5 rigidity5 fluid 9a"e5 shifting dullness5 fran8
ascites5 :ruits)
#o9el sounds: Normal5 a:sent5 hy(eracti"e5 hy(oacti"e
Organomegaly: 4i"er5 s(leen5 8idneys5 :ladder5 gall :ladder5 *descri:e fully (ositi"e
findings use diagram if necessary+
Male: %enitalia: (enis5 scrotum5 testes5 e(ididymis5 masses5 other)
'ectal: (erineum5 hemorroids5 s(hincter tone5 (rostate5 masses5 :leeding5 stool
Female: @Aternal genitalia5 la:ia5 clitoris5 introitus5 urethra5 (erineum5 other
6nternal genitalia: "agina5 cer"iA5 adneAa5 cul,de,sac5 discharge
Pa(s: done5 omitted
'ectal: hemorroids5 s(hincter tone5 :leeding5 masses5 stool
Foints: 'ange of motion: fingers5 9rist5 el:o95 shoulder5 hi(5 8nee5 an8le
3eformity5 redness5 heat5 edema5 tenderness)
S(ine: deformity *8y(hosis5 lordosis5 scoliosis+5 range of motion5 muscle s(asm5
tenderness5 others)
Neurological: ((earance5 affect5 motor :eha"ior5 memory5 general attention s(an5 Dudgment5
a:straction5 delusions5 hallucinations5 mental state5 orientation to time5 (erson5
and (lace
4e"el of consciousness: alert 9a8efulness5 lethargic5 o:tunded5 stu(orous5 semi,
comatose5 comatose)
4aterali2ing cortical functions: s(eech and other dominant hemis(here
functions5 non dominant hemis(here functions5 handedness ' ; 4
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
&ranial ner"es:
6: Not tested5 tested *list test materials+
66: 3iscs5 (a(illedema5 "enous (ulses5 o(tic atro(hy5 "isual fields5 acuity)
6665 6H5 H6: Ptosis5 (al(e:ral fissure
Pu(ils: eEual5 uneEual5 dilated5 constricted5 normal)
'eaction to light: ' 4
&onsensual reaction: ' to 4 4 to '
'eaction to near "ision: ' 4
@Atra ocular mo"ements: dolls,eyes5 cold calories5 ga"e (reference5 nystagmus5
others)
H: Sensory: 1
st
di"ision -
nd
di"ision /
rd
di"ision
' corneal 4 corneal
Motor: masseters5 (terygoids5 tem(oralis
H66: 6ntact ' ; 4 central ' ; 4 (eri(heral
H666: 6ntact
6I5 I: 3ysarthria5 gag5 (honation5 u"ula5 soft,(alate5 s9allo9ing
I6: Sternocleidomastoids5 tra(e2ii
I66: Tongue in midline5 de"iation to ' ; 45 atro(hy5 fasiculations5 ra(id alternating
Mo"ements
%ait and station *not tested+:
Bal8ing: normal5 a:normal5 heel 9al8ing5 toe 9al8ing5 tandem 9al8ing
Truncal ataAia
'om:erg: ' ; 4
6n"oluntary mo"ements
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
&ere:ellum: 'a(id alternating mo"ements5 finger,nose5 heel,shin5 (ast,(ointing5 (osturing
Sensory: Pain5 tem(erature5 light touch5 Doint (osition5 "i:ratory t9o (oint discrimination5
Stereogenesis
ssociati"e functions: S(eech5 9riting5 reading5 a(raAia5 agnosia5 other
Motor: Tone5 mass5 fasciculations5 tremor5 hemi(aresis5 hemi(legia
'efleAes:
#i Tri #r J Plantar :domen
? K a:sent5 tr K trace5 1L decreased5 - L K normal5 / L K hy(eracti"e5 0L K sustained clonus
16. Summary
The Summary is a brief recapitulation of the pertinent symptoms and
signs elicited during the patient interview and physical examination. It
is fre.uently divided into two parts"
0. Sub'ective - The significant historical findings (i.e. ,)I, )ast
$edical ,istory, )ersonal and !amily ,istory.
1. 2b'ective - The significant positive physical findings. (& 3ab 4ata
section usually follows the )hysical 5xamination and the
pertinent lab results are then summari6ed here.
It should be remembered that the role of the Summary is chiefly as a
teaching tool to help clarify what portions of the history, physical
examination and laboratory results are important for formulation of a
problem list and diagnostic impression.
PHYSICIAN PATIENT RELATIONSHIP
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Name of Patient: Medical 'ecord No):
#ed No): _______________________________
________________________
Student
Signatures indicate agreement 9ith 3ata #ase content)
@Ace(tions and additions should :e noted and dated)
__________________________________________
'esident ; ttending Physician
PHYSICIAN PATIENT RELATIONSHIP
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