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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:

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S!"#!$ %IS&'!$Case No.

I GENERAL DATA 

II CHIEF COMPLAINT:

III HISTORY OF PRESENT ILLNESS

IV. PAST MEDICAL HISTORY 

V. FAMILY HISTORY 

VI. PERSONAL AND SOCIAL HISTORY 

VII. REVIEW OF SYSTEMS

VIII. PHYSICAL EXAMINATION

GENERAL SURVEY: SKIN:

HEENT

Head:

Eyes:

Eas: 

N!se:

T"!a# $! M!%#"(:

Ne&': THORAX AND LUNGS:

CARDIOVASCULAR:

GASTROINTESTINAL:

PERIPHERAL VASCULAR SYSTEM:

MUSCULOSKELETAL:

NERVOUS SYSTEM:

CN I:

CN II( III:

CN III( IV( VI:

CN V:CN VII:

CN VIII:

CN XI:

CN XII:

IX. INITIAL IMPRESSION

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CASE DISCUSSION: