history and pe sheet excel
Post on 07-Aug-2018
233 Views
Preview:
TRANSCRIPT
-
8/20/2019 History and Pe Sheet Excel
1/12
ROTATION
DATE AND TIME
PLACE OF INTERVIEW
I. GENERAL INFORMATION
NAME
MARITAL STATUS
DATE OF ADMISSIONADDRESS
SOURCE OF INFORMATION
II. CHIEF COMPLAINT
P Precipatating?
Q Qualit?
R Relie!?
S Acc"#paning $#pt"#$?
T Ti#ing?
III. HISTORY OF PRESENT ILLNESS
DAYS/WEEKS PTA COMPLAINTS
IV. PAST MEDICAL HISTORY
C%ILD%OOD ILLNESSES
IMMUNI&ATIONS
ADULTILLNESSES
MEDICATIONS 'DRU() DOSA(E) PURPOSE*
ALLER(IES
SRU(ERIES
V. PERSONAL AND SOCIAL HISTORY
SMO+ER? Age $tarte,? Pac- ear$?
ALCO%OLIC DRIN+ER? Age $tarte,? %". "!ten? N"/ 0"ttle$ per ,a? +in, "! alc"1"l?
ILLICIT DRU( USE Age $tarte,? W1at -in, "! ,rug? %". "!ten?OCCUPATION
EDUCATIONAL ATTAINMENT
%OUSE ENVIRONMENT li2ing .it1? %". #an r""#$? Ventilati"n?
WATER SOURCE
(RA3A(E COLLECTION
FOOD SOURCE
DIET tpical #eal? !a2"rite !"",?
%A3ITS c"!!ee?
VI. FAMILY HISTORY
-
8/20/2019 History and Pe Sheet Excel
2/12
FAMIL4 MEM3ER CAD
VII. OBSTETRIC AND GYNECOLOGICAL HISTORYO3 SCORE G P ( F P A L )
PRE(NANC4 4EAR
MENARC%
MENSTRUATION Regular? N"/ ,a$ per #"nt1l ccle? N"/ 0lee,ing ,a$? N"/ pa,$5,a) pre
SE6UAL %ISTOR4 %a, STD 0e!"re? Se7 .it1 ,"#e$tic $e7 ."r-er$?
A(E FIRST SE6
CONTRACEPTION Met1",? %". #an ear$? Rea$"n !"r c1anging5$t"pping?
NO/ OF SE6UAL PARTNERS At pre$ent? Entire li!e?
VIII. REVIEW OF SYSTEMS
(ENERAL
Weig1t L"$$5(ain Napan$ing pag0a0ag" $a ti#0ang
Fatigue palaging pag",
Fe2er lagnat
C1ill$
Tr"u0le Sleeping 1irap $a pagtul"g
S+IN
Ra$1e$
Lu#p$
Itc1ing
Drne$$
C"l"r C1ange$
%air an, nail c1ange$
%EENT
%ea,ac1e
%ea, In8ur
Nec- Pain
Decrea$e, 1earing
Ear Di$c1arge
Ringing in ear$
Earac1e
Vi$i"n L"$$5C1ange$
Ee pain
Ee re,ne$$
3lurr5,"u0le 2i$i"n
Fla$1ing lig1t$
Spec-$
N"$e Stu!!ine$$
-
8/20/2019 History and Pe Sheet Excel
3/12
N"$e Di$c1arge
N"$e0lee,$
Sinu$ pain
Denture$
S"re t"ngue
S"re t1r"at
Dr #"ut1
%"ar$ene$$
T1ru$1
N"n91ealing $"re$
Nec- Lu#p$
S."llen glan,$
Nec- pain
Nec- $ti!!ne$$
IX. PHYSICAL EXAMINATION
A/ (ENERAL SURVE4
APPARENT STATE OF %EALT%
LEVEL OF CONSCIOUSNESS
SI(NS OF DISTRESS
3UILT) 3OD4 S4MMETR4 AND POSTURE
%EI(%T
3MI
3/ VITAL SI(NS
3P
%R
C/ %EENT
%EAD
E4ES VISUAL ACUIT4
VISUAL FIELD 'CONFRONTATION*
POSITION ALI(NMENT OF E4ESE4E3ROWS
E4ELIDS
LACRIMAL APPARATUS
CON:UNCTIVA ; SCLERA
CORNEA ; LENS
IRIS
PUPILS
E6TRAOCULAR MUSCLES
OP%T%ALMOSCOPIC E6AM
EARS AURICLE
EAR CANAL AND DRUM
-
8/20/2019 History and Pe Sheet Excel
4/12
AUDITOR4 ACUIT4
AIR AND 3ONE CONDUCTION
LATERALI&ATION
NOSE AND PARANASAL SINUSES I< Anteri"r an, In!eri"r $ur!ace$ "! t1e n"$e
Te$t !"r Na$al "0$tructi"n
I< in$i,e "! n"$e
NASAL SEPTUM
A0n"r#alitie$< ulcer$ an, p"lp$
Sinu$ Ten,erne$$
MOUT% AND P%AR4N6 LIPS
ORAL MUCOSA
(UMS AND TEET%
ROOF OF MOUT%
TON(UE AND FLOOR OF MOUT%
P%AR4N6
-
8/20/2019 History and Pe Sheet Excel
5/12
A(E
(ENDER
RELI(IONDATE OF 3IRT%
RELIA3ILIT4
CHARACTER
-
8/20/2019 History and Pe Sheet Excel
6/12
%TN AST%MA
LMP
A(E MANNER OF DELIVER4
MENOPAUSE
ence "! $#pt"#$?
3REAST
Lu#p$
Pain
Di$c1arge
Di#pling
C1ange in c"l"r
RESPIRATOR4
C"ug1
Sputu#
C"ug1ing up 0l"",
S1"rtne$$ "! 3reat1
W1ee=ing
Pain!ul 0reat1ing
CARDIOVASCULAR
C1e$t pain5,i$c"#!"rt
C1e$t tig1tne$$
Palpitati"n$
Di!!icult "! 0reat1ing
S.elling
PND
SO3 .it1 acti2it
DO3 .1ile ling ,".n
(ASTROINTESTINAL
S.all".ing ,i!icultie$
%eart0urn
C1ang in appetite
Nau$ea
C1ange in 3".el
-
8/20/2019 History and Pe Sheet Excel
7/12
Rectal 3lee,ing
Ca"n$tipati"n
Diarr1ea
4ell". ee$ "r $-in
URINAR4
Fre>uenc
Urgenc
3urnng5pain
3l"", in urine
Inc"ntinence
C1ange in urinar $trengt1
VASCULAR
Cal! pain .it1 .al-ing
Leg Cra#ping
NORMAL
WIE(%T
RR
TEMPERATURE
I< $1ape an, $##etr
Pupillar Reacti"n T" Lig1t
I< re!lecti"n$ in c"rnea$
C"2er9Unc"2er Te$t
E7tra"cular #"2e#ent$ C"n8ugate #"2e#ent$) ,e2iati"
C"n2ergenceI< Optic Di$c $1arpne$$ "r clarit "! ,i$c "utli
c"l"r "! ,i$c
$i=e "! central p1$i"l"gic cap
pre$ence "! 2en"u$ pul$ati"n$
c"#parati2e $##etr "! ee$
I< Retina arterie$) 2ein$) AV cr"$$ing$) !"
le$i"n$
I< De!"r#itie$) lu#p$ an, $-in le$i"n$
TU( TEST
I< Ear canal) ear,ru#) 1an,le "! #alleu$) $1"rt an, l"ng pr"ce$$ "! #alleu$
-
8/20/2019 History and Pe Sheet Excel
8/12
R%INNES TEST
WE3ER TEST
A$$#etr) ,e!"r#it
Na$al #uc"$a< $.elling) 0lee,ing an, e7u,ate
,e2iati"n) in!la##ati"n) p"r!"rati"n
c"l"r) #"i$ture) lu#p$) ulcer$) crac-ing "r $caline$$
c"l"r) ulcer$) .1ite patc1e$ an, n",ule$
c"l"r "! gu#$
teet1< an #i$$ing) ,i$c"l"re,) #i$1appen "r a0n"r#all p"$iti"ne,
c"l"ra@ ; arc1itec1ture "! 1ar, palate
$##etr "! t"ngue
I< c"l"r an, te7ture "! ,"r$u# an, un,er$i,e$ "! t"ngue
I< $"!t palate) anteri"r an, p"$teri"r pillar$) u2ula) t"n$il$ an, p1arn7
c"l"r an, $##etr
e7u,ate) $.elling ulcerati"n ; t"n$ilar enlarge#ent
-
8/20/2019 History and Pe Sheet Excel
9/12
-
8/20/2019 History and Pe Sheet Excel
10/12
CANCER DM LIVER D6 OT%ERS NOTES
PLACE OUTCOME COMPLICATIONS5NOTES
MUSCULOS+ELETAL
Mu$cle Pain
:"int Pain
Sti!!ne$$
3ac- Pain
Re,ne$$ "! :"int$
S.elling "! :"int$
Trau#a
NEUROLO(IC
Di==ine$$
Fainting
Sei=ure$
Wea-ne$$
Nu#0ne$$
Tingling
Tre#"r
%EMATOLO(IC
Ea$e "! 0rui$ing
Ea$e "! 0lee,ing
ENDOCRINE
%eat "r c"l, int"lerance
S.eating
Fre>uent urinati"n
T1ir$t
C1ange in appetite
PS4C%IATRIC
Ner2"u$ne$$
Stre$$
-
8/20/2019 History and Pe Sheet Excel
11/12
Depre$$i"n
Me#"r L"$$
n$) n$tag#u$) li, lag
ne
ae an, #acula
-
8/20/2019 History and Pe Sheet Excel
12/12
top related