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LYCEUM NORTHWESTERN UNIVERSITY Francisco Q. Duque Foundation

College of Medicine

MONIQUE ANGELA T. GANGANDoctor of Medicine III

Date of Interview:Name of Preceptor:

PEDI!"IC #I$!%"&Case No.

I GENERAL DATA

II CHIEF COMPLAINT:

III HISTORY OF PRESENT ILLNESS

IV. PAST MEDICAL HISTORY 1. PRENATAL:

2. BIRTH:3. POST NATAL AND NATAL:4. FEEDING HISTORY 5. PAST ILLNESSES AND IMMUNIZATIONS:. GROWTH AND DEVELOPMENT:

V. FAMILY HISTORY 

VI. SOCIAL! PERSONAL AND ENVIRONMENTAL HISTORY 

VII. REVIEW OF SYSTEMS

VIII. PHYSICAL E"AMINATION

GENERAL SURVEY: 

V#$%& S#'():

'lood pressure: mm#g

Pulse "ate: (eat per minute

"espiration rate: c)cles per minute

 !emperature *+illar),: - C

A($*+,-,/$+#0 D%$%:

#ead circumference: cms

(dominal circumference: cms

eig/t: 0gs

#eig/t: cms

'MI: 0g1m

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SIN:

HEENT

H/%:

E/):

E%+): N,)/:

T*+,%$ ,+ M,$*,:

N/06: 

THORA" AND LUNGS:

CARDIOVASCULAR:

GASTROINTESTINAL:

PERIPHERAL VASCULAR SYSTEM:

MUSCULOSELETAL:

NERVOUS SYSTEM:CN I:

CN II! III:

CN III! IV! VI:

CN V:

CN VII:

CN VIII:

CN "I:

CN "II:

I". INITIAL IMPRESSION

". DIFFERENTIAL DIAGNOSIS

"I. MANAGEMENT

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CASE DISCUSSION: