Patient Name: Date:

Age: Time:
Address: Hospital Reg#:
Gender: Occupation:
Ethnicity: Religion:

Presenting complaint:

History of Presenting Complaint:

Patient Name: Date:
Age: Time:
Address: Hospital Reg#:
Gender: Occupation:
Ethnicity: Religion:

Review of systems:
General: weight loss/gain, fatigue, fever, change in appetite, trauma
CNS: dizziness, fainting, seizures, weakness, tingling, tremor, headache, vision problems, hearing
problems
CVS: chest pain, palpitations, SOB on exertion, SOB on rest, pedal edema
RESP: wheezing, cough, dyspnea, coryzal symptoms
ABDO: nausea, constipation, vomiting, diarrhea, rectal bleeding, change in appetite, abd pain
Genitourinary: incontinence, dysuria, hematuria, oliguria, polyuria, urgency, frequency
Musculoskeletal: muscle pain, joint pain, swelling of joint, stiffness, back pain
Skin: rashes, lumps, itching, dryness, colour changes, hair/nail changes

Past Medical History

Past Surgical History

Patient Name: Date:
Age: Time:
Address: Hospital Reg#:
Gender: Occupation:
Ethnicity: Religion:

Drug History:

Allergies:

Family History

Social History:
Living conditions, Smoking, Alcohol use, Exercise, Sleep, Diet, Sexual history, Impact of Illness etc.
Patient Name: Date:
Age: Time:
Address: Hospital Reg#:
Gender: Occupation:
Ethnicity: Religion:

Summary

Physical Examination
Vitals:
T: P: BP: RR: RBS: SPO2:
General Inspection

Cardiovascular exam
Inspection: chest wall deformity, active precordium, scars
Hands: peripheral cyanosis, capillary refill , clubbing, Olser’s nodes, Janeway lesions, splinter
hemorrhages, collapsing pulse, radio-radial delay, radio-femoral delay,
Pulse:
Face: pallor of conjunctiva, corneal arcus, xanthelasma, central cyanosis
Neck: raised JVP, tracheal deviation
Palpation: thrills, parasternal heave, apex beat
Ausculation: S1, S2, Mumurs

Respiratory Examination
Inspection: chest wall deformity, scars, use of accessory muscles to breath, symmetrical rise and fall of
chest wall, cyanosed
Patient Name: Date:
Age: Time:
Address: Hospital Reg#:
Gender: Occupation:
Ethnicity: Religion:

Hands: tobacco staining, peripheral cyanosis, clubbing, asterixis

Face: pallor of conjunctiva, pursed lips breathing, central cyanosis
Neck: raised JVP, tracheal deviation, lymphadenopathy
Apex beat:
Chest wall expansion:
Tactile vocal fremitus:
Percussion:
Auscultation:

Gastrointestinal Examination:
Inspection: scars, abdominal distension, jaundiced, visible hernias, masses, gynecomastia, hair loss
Hands: palmar erythema, clubbing, koilonychia, leuconychia, duputren’s contracture, axterixis
Arms: bruising, scratch marks
Face: sclera icterus, conjunctival pallor, xanthelasma, angular stomatitis, oral thrush, glossitis, ulcers
Neck: lymphadenopathy
Palpation:
Percussion:
Auscultation:
Central Nervous System
Motor RUL LUL RLL LLL
Muscle bulk
Fasciculation
Tone
Power
Co-ordination

Reflexes Biceps Triceps Supinator Knee Ankle Plantar

Right
Left
Patient Name: Date:
Age: Time:
Address: Hospital Reg#:
Gender: Occupation:
Ethnicity: Religion:

Sensory Touch Pain Vibrations Proprioception

Right upper limb
Left upper limb
Right lower limb
Left lower limb

Problem List:

Differential Diagnoses:

Investigation & Results:

Patient Name: Date:
Age: Time:
Address: Hospital Reg#:
Gender: Occupation:
Ethnicity: Religion:

Plan:
1. A - admit to ward
2. D – diet eg. keep NPO/ diet as tolerated/ low salt etc.
3. A – ambulation. Eg. strict bed rest/ allow ambulation/
4. V – vitals eg. vitals Q4 hrly/ Q8 hrly etc
5. I – Investigations eg. if more investigations required/ chase results of previous ones
6. D – Drugs required

Prescription: Add all drugs to be discharged on along with relevant information