Date

Name:
Age/Sex:
Birthday:
Civil status:
HPI:

ROS:

Ward:
Attending Physician/s:
Admitting Resident/s:
CC:

headache
dizziness
loc
vomiting
fever
dysuria
PMHx:
Disease

dysphagia
body malaise
weight loss
dob
bm changes
melena

HPN
DM
BA
PTB
CVD
MI
Kidney
Thyroid
Malignancy
Allergies:
Hospitalization
Operation

Year
Diagnosed/Dur
ation

OB-Gyne Hx
OB Score: G _ P _ ( _ - _ - _ - _ )
LMP: __________
Menopause:
M: ____

Maintenance Medications

I: ____
D: ____
A: ____
S: ____________ Meds: ____________

 Coitarche:

FMHx:

OCPs:

Disease

HPN
DM
BA
PTB
CVD
MI
Kidney
Thyroid
Malignancy
Allergies:

SIDERelationship to
Patient

P/SHx:
Occupation:_________________
Active Smoker/Passive Smoker/Non Smoker/ Packed years: __________
Alcoholic/Non Alcoholic Beverage Drinker/ Frequency: ______________
PE:
Vital Signs:
BP
T
P
R
CBG
O2 Sat

Gen Survey:
Ambulatory/wheelchairborne/stretcher
borne
Conscious/Semiconscious/unconscious
In CPD/not in CPD

HEENT:
Icteric/Anicteric Sclerae/Pale/Pinkish
Conjunctivae
Dry/Moist Lips/ Dry/Moist
Tongue/Buccal Mucosa
Enlarged/Non Enlarged
/Hyperemic/Nonhyperemic

MAP
Wt
Ht
BMI
IBW -

Non Exudative/Exudative Tonsils

__Cervical Lymphadenopathies

o
o
o

Chest/Lungs:
Symmetrical/Asymmetrical Chest
Expansion
Breath sounds: _______ ___________
Wheeze ______
Rales ________
Rhonchi_______

 Heart: Adynamic/Dynamic Precordium;

PMI: _____
Murmur_______
Regular/Irregular Rate;
Regular/Irregular Rhythm

Abdomen:
Flat/Globular/Flabby/ ____bowel
sounds; Soft/Rigid; Tender/Non tender;
Mass ____

Neuro Exam:

Orientation:
o Person
o Place
o
o GCS ____ ( E ___ V ___ M___)
o
o
o
o
o
o
o
o
o
o

Cranial nerve
CN 1 OLFACTORY
CN 2 OPTIC
CN 3
OCULOMOTOR
CN 4 TROCHLEAR
CN 5 TRIGEMINAL
CN 6 ABDUCENS
CN 7 FACIAL
CN 8 ACOUSTIC
CN 9
GLOSSOPHARYNGE
AL
CN 10 VAGUS

Extremities: __ Edema: grade ___,

varicosities: ___
Full/faint peripheral pulses/ ______
range of motion

Skin:
Lesions_________ Rashes_______

o Time

o Situation

o Response
o
o
o
o
o
o
o
o
o

o CN 11 SPINAL
ACCESSORY

o CN 12
HYPOGLOSSAL
o
o Cerebellar:
o
o
o Meningeal:
o
o
o Babinski:
o
o

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Working Diagnosis/Admitting Impression:

CBG:

ECG:

XRAY:

CT SCAN:

ABG
Ph:
PCO2
PO2
HCO3:
O2 at ____ LPM
DIET:
IVF:
LABS:

o tCO2
o FiO2
o O2 Sat:

o
o
o
o MEDS:
o
o
o
o
o
o
o
o
o
o
o
o
o
o PLANS:
o
o
o
o
o
o
o
o
o
o
o
o
o

o
o M
I
O
o I
n
p
u
t
o I
V
F
o O
u
t
p
u
t
o B
M
o

o o o
7 8 9

o
1

o
1

o o o o o o o o o o
1 1 2 3 4 5 6 7 8 9

o
1

o
1

o o o o o o o
1 1 2 3 4 5 6

o
T

o o o

o o o o o o o o o o

o o o o o o o

o o o

o o o o o o o o o o

o o o o o o o

o o o

o o o o o o o o o o

o o o o o o o

o o o

o o o o o o o o o o

o o o o o o o

o _edajosiemonserate/cpumed2016_