General Data

o R.S.T
o 58 years old
o Male
o Occupation
o Marital Status
o Roman Catholic
o Born in San Juan
o Currently resides in Cainta, Rizal
This is the case of Mr. PT, 26 year old
Roman Catholic and a student from Makati
City

Personal and Social

o
o
o
o
o
o
o

Marital and sexual history

ROS
o
o
o
o
o
o
o
o
o
o

Skin- Changes in skin, nails, hair,

lesions
HEENT- visual, hearing
Respiratory
Cardiac
Gastrointestinal
GU
Lymphatic
Musculoskeletal
Neurologic
Hematologic

Diet
Habits
Smoking history
Alcohol
Substance use/abuse
Nutrition
Exercise

Past Medical History

o
o
o
o
o
o

Chief complain
HPI
Place/Provokes: causative, relieving,
exacerbating factors
Quality: sharp, dull, stabbing,
burning, crushing
Radiates: Primary location, Area
where it radiates, localization
Severity (0
10)/Intensity/Progression
Time: Onset, Duration, Persistence,
number of occurences
2. Medications (include dosage)
3. Results of previous laboratory workup
4. Results of previous ancillary
procedures
5. State of health just before onset of
problem
6. What led the patient to seek
consult?

Endocrine

Allergies
Illnesses
Operations
Transfusions
Injuries
Medications

Family History
o
o
o
o
o
o

Hypertension
Diabetes mellitus
Heart diseases
Asthma
Tuberculosis
Cancer

PE
BP-160/90mmHg; PR: 69bpm; RR: 20cpm;
Temp. 36.2C, Ht. Wt., BMI
General Survey: GCS 12 (E4V2M6),
drowsy, not in cardiorespiratory distress,
incomprehensible speech, regards
examiner, doesnt follow commands, with
coarse tremors especially on passive
movement
Distress: Speaks in phrases, tripod,
orthopnea, squatting
Level of consciousness
Conscious, sedated, drowsy
Orientation: time, place, and person
Memory: immediate, recent, remote
Attention Calculation
Notes for any evidence of respiratory
distress
o Altered sensorium
o Central cyanosis
o Speaks in phrases
o Tripod position

o
o
o

Prominence of SCM
Retractions
Abdominal paradox

Mental State, Ambulatory, Not in CP

distress, Well-nourished, well-hydrated,
well-looking

Cranial Nerves
o
o

o
o

Skin/Cutaneous: no jaundice, warm, dry

skin,
EENT:(+) hematoma L periorbital area,
anicteric sclerae, pink palpebral
conjunctiva, pupils 2-3 mm ERTL
Ears: No deformities, no ear tenderness,
no tragal tenderness, non-hyperemic
external auditory canal
Nose: Nasal septum midline, no
deformities, no swelling, no discharge
Mouth: dry buccal mucosa, tonsils not
enlarged, no gum bleeding No parotid
gland enlargement
Neck: thyroid gland not enlarged, no
mass, no cervical lymphadenopathies
Lungs: Symmetrical chest expansion, no
retractions, resonant on percussion on left
lower lung filed, clear breath sounds
Heart: Neck veins not distended, JVP
3cm at 30 degrees, carotid artery pulse
with rapid upstroke and gradual
downstroke, (-) carotid bruit,
adynamicprecordium, apex beat at the
5thleft intercostal space mid clavicular
line, (-) murmurs, (-) heaves, lifts, +2 in all
pulses
Abdomen: flabby, (+) appendectomy
scar, normoactivebowel sounds,
tympaniticon all quadrants, (-) tenderness
on all quadrants, no hepatosplenomegaly
Rectal Exam: no gross external lesions,
good sphincter tone, empty rectal vault,
(+)anal wink
Genitourinary: (-) CVA tenderness
Extremities: (+) coarse tremors, (-)
clubbing, (-) cyanosis, pulses full and
equal

Mental Status
o
o
o

Level of consciousness
Orientation
Memory
Language

o
o
o

CN I no anosmia
CN II isocoric pupils 2-3mm
equally reactive to light and
accommodation
CN III, IV, VI extraocular
movements full and equal
CN V V1-V3 intact, no sensory
deficit
CN VII can smile, frown, close
eyes, raise eyebrows, facial
symmetry
CN VIII gross hearing intact
CN IX, X uvula midline on
phonation
CN XI can shrug shoulders equally
against resistance, can turn head
side to side against resistance
CN XII tongue midline upon
protrusion

Motor
o
o
o
o
o
o
o
o
o
o
o

Pronator Drift
Manual Muscle Testing
Motor: 5/5 on both flexion and
extension of lower extremities,
5/5 on both flexion and extension
of upper extremities
0 = no movement
1 = flicker or trace of contraction
but no
associated movement
2 = gravity eliminated
3 = movement against gravity but
not against
resistance
4 = movement against moderate
resistance
5 = full power

Coordination/ Cerebellar
o
o
o
o
o
o

Dysmetria (FTNT), Dysdiadokinesia

(APST)
Ataxia
Nystagmus
Intentional Tremors
Slurred speech
Hypotonia

Reflex (DTR)
o
o
o

++- normal
+++- hyperreflexia
++++- clonus

Upper and lower extremities right

and left

Sensory
o
o

No sensory deficits
50% deficit

Menigeal Signs
o
o
o

Nuchal rigidity
Kernigs
Brudzinski

Gait
Face Ask the person to smile
Arms Ask the person to raise both arms
Smile Ask the person to repeat a simple
phrase. Is their speech slurred or strange?
TIME: If you observe any of these signs,
call 9-1-1 immediately
-------------------------------------------------------------------SALIENT FEATURES