Hebron University

Internal Medicine Case Presentation Form

PATIENT PROFILE
Name: Age: Gender:
City of living: Marital status: Children:

HISTORY SOURCE
□ Self □ Other _______________________

CHIEF COMPLAINT (s)

HISTORY OF PRESENT ILLNESS

(Detailed description of the development of the patient's current complaint/illness.
Use a mental list of possible diagnoses (a differential diagnosis) to guide your
questions.)
 CURRENT MEDICATIONS

Medications Dose and frequency Last taken

Including (prescription, vitamins, herbals...)

ALLERGIES/ADVERSE DRUG REACTIONS (agent, specify reaction)

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

SOCIAL HISTORY

Tobacco: □ NONE □ ACTIVE □ QUIT □ PK/YRS:

Alcohol: □ NONE □ FREQUENCY □ LAST DRINK

Illicit drugs: □ NONE □ TYPE(S):
Marital status
Living situation
Occupation
Exposures
Travel
Other

FAMILY HISTORY (expand further if hereditary disease is suspected)

Parents:

Siblings:

Children:
REVIEW OF SYSTEMS
1. General
Fever Chills Adenopathy
Anorexia Diaphoresis Lightheadedness
Weight gain Weight loss
2. Endocrine/Metabolic
Thyroid disorder Temp intolerance Goiter
Radiation exposure Diabetes Lipid disorder
3. Hematologic
Anemia Leukemia
Transfusions Bruising Bleeding
4. Skin
Pruritus Rash Mole changes
Skin cancer Tattoos Hair or nail changes
5. Eyes
Corrective lenses Cataracts Glaucoma
Photophobia Visual change Laser surgery
6. ENT
Infections Hearing loss Vertigo
Tinnitus Epistaxis Hoarseness
7. Oral
Condition of teeth Dentures Lesions
Pain Infections
8. Cardiovascular
Chest pain Chest pressure Palpitations
Syncope Orthopnea PND
Palpitations Edema
9. Pulmonary
Dyspnea Cough Hemoptysis
Sputum Wheezing Tuberculosis
10. Breasts
Mass Tenderness Discharge
Asymmetry Gynecomastia Implants
Mammography
11. Gastrointestinal
Dysphagia Odynophagia Heartburn
Abdominal pain Nausea/vomiting Hematemesis
Hematochezia Melena Diarrhea
Constipation Jaundice Hemorrhoids
12. Musculoskeletal
Pain Arthritis Deformity
Stiffness Swelling Injury
13. Neurologic
Paresthesia Paralysis/paresis Headache
Head trauma Syncope Seizures
Tremor Weakness
Gait abnormality Dysarthria
14. Psychiatric
Anxiety Depression Psychosis
Memory loss Psych treatment
15. Genitourinary
Hematuria Dysuria Urgency
Frequency Nocturia Incontinence
Change in stream Infection Nephrolithiasis

Describe abnormal:
PHYSICAL EXAM
Vital Signs: BP T HR RR
General Appearance:
Head:
Eyes:
ENT:
Neck:
Heart:
Lungs:
Abdomen:
Extremities:
Vascular:
Skin:
Musculoskeletal:
Neuro Exam:
Urogenital:

DIAGNOSTICS
EKG interpretation:

XR findings:

UA:

Other laboratory/radiological tests:

ASSESSMENT/DIFFERENTIAL DIAGNOSIS

PLAN