Patient’s Profile

Identification Data:
Client’s Name:
Age:
Sex:
Date of Birth:
Mother:
Father:
Hospital Registration Number:
Ward
Bed No:
Address:
Education:
Occupation:
Marital Status:
Religion:
Date of Admission:
Date of Discharge:
Diagnosis:
Surgery (if any):
Date of Surgery:
Doctor In-charge:

I.

History of Illness:

Chief complaints:

Present medical history:

Present surgical history:

Past medical history:

Past surgical history: N/A

Family History:

S. Name of Age/ Occupation Relation to Health Education

No. family Sex family Status
members member
Physical Examination:
General Appearance:
Body build: Has more stored fats, slight muscles

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Height:

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Weight:

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Vital Signs:
Pulse:
Respiration:
BP: N/A
Color of skin:
Head:
Shape and size of the skull: Symmetrical and proportionate to the body size.
Scalp: Intact, without lesions or tenderness. (-) infestation.
Face: Symmetrical at rest, with intact facial movements.

Eyes: Symmetrical in size, shape, and position.

Vision: unaided vision

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Eyebrow and eyelid: (-) swelling, redness, or lesions

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Eyeball: Normal in size and movement

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Conjunctiva: Pinkish in color and moist.

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Sclera: White and free of yellowing

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Cornea and iris: Transparent cornea; iris with a round, regular shape
and appropriate color.

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Pupils: (+) PERRLA

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Lens: Transparent and free of opacities

Ears:

External ear: Intact, (-) lesions or discharge

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Tympanic membrane: Intact, pearly gray, and translucent.

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Hearing problem: Clear hearing with no signs of hearing loss. (whisper

test)

Nose:

External nares: Symmetrical and patent

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Nostrils: Patent and without discharge

Mouth and pharynx:

Mouth: Moist, pinkish in color, and without lesions.

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Teeth: White with slight cavity. Rotten teeth of 2nd premolar.

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Tongue: Pinkish in color, moist, and without lesions.

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Throat and pharynx: Pinkish in color and moist, without exudate or

swelling.

Neck:

Thyroid gland: Not palpable or enlarged, midline

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Lymph Nodes: Not palpable or enlarged

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Range of motion: Full and painless, can be moved without difficulties

Chest:
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Breath sounds: no distinct abnormal sounds

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Lungs: all lung fields were free of abnormal sounds upon auscultation

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Heart: the beat were in normal rhythm (HR:)

Abdomen:

Inspection: no visible masses or lesions; the navel is in the midline

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Auscultation: (+) borborygmus in all quadrants

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Palpation: (-) tenderness or masses in all quadrants.

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Percussion: Tympanic over the stomach, dull over the liver and spleen.

Extremities:

Upper: medium brown skin color, warm with good capillary refill

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Lower: medium brown skin color, warm with (-) edema and good
capillary refill, (+) mosquito bite scars
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Back: Straight spine, no deformities or tenderness.

Systematic examination:

Central Nervous System: Alert & OrientedX4; Normal gait and

coordination

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Sensory System: intact sensation to touch, temperature, and vibration.

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Respiratory System: Unlabored, symmetrical chest wall movements

upon breathing.

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Cardiovascular System: Heart rate was within normal ranges; no

murmurs were heard upon auscultation

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Gastrointestinal System: (+) borborygmus on 4 quadrants; no

tenderness upon palpation

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Musculoskeletal System: Full range of motion on Upper and Lower

extremities

Integumentary System: Skin is intact, with minimal scarring from

mosquito bites; has good skin turgor