1. JOSE A.S. SANTIAGO M.D.

2. SIGNS AND SYMPTOMS Signs: Objective findings What you see/feel/hear/smell on the patient Obtained by physical examination

3. SIGNS AND SYMPTOMS Symptoms: Subjective findings What the patient feels Complaints of the patient Obtained by history-taking

4. GENERAL DATA Name: Age: Sex: Birthday: Place of birth: Nationality: Religion:

5. CHIEF COMPLAINT Main reason why patients go to the hospital Usually written in the patient’s own words Examples: 1.Pain in my right foot 2.Pain in my legs 3.Pain in the back

6. HISTORY OF PRESENT ILLNESS Present complaints of the patient Start questions with- WHAT WHEN HOW

7. PAST MEDICAL HISTORY Childhood diseases/Immunizations Previous accidents Previous hospitalization Previous operation Treatments/Medications received History of allergy

8. FAMILY HISTORY Status of parents/siblings/children/other relatives Look for diseases that are transmitted within the family

9. SOCIAL HISTORY Employment history Smoking/drinking history Living conditions

10. PAIN (SYMPTOM) LOCATION:Upper/Lower extremity Upper/Lower back CHARACTER:Description of the pain DURATION ONSET RADIATION FACTORS THAT ALTER THE PROBLEM RELATED SYMPTOMS

11. Asking for the location of pain Q:Where do you have pain? Q:Where does it hurt? Q:Where do you feel uncomfortable? Q:Where does it hurt most?

12. Asking for the onset of pain Q:When did the pain start? Q:When did it start? Q:When did the pain begin? Q:When did it begin?

13. Asking for the duration of pain Q:How long does the pain last? Q:Does the pain last for several seconds? Q:Does it last for minutes or hours?

14. Asking for the character of pain Q:What is the pain like? Q:What kind of pain is it? Q:How bad is the pain? Q:How severe is the pain? Q:Is it better or worse now?

15. Asking for the radiation of pain Q:Does the pain move to other parts of your body? Q:Does it affect other parts of your body? Q:Has the pain spread?

16. Asking for related symptoms Q:What causes the pain? Q:What are your other symptoms? Q:Aside from pain, what other symptoms do you feel? Q:Aside from pain, what else do you feel?

17. Asking for other factors that alter the problem Q:What do you do when you feel pain? Q:Is the pain relieved with any change in position? Q:What makes the pain disappear?

18. TENDERNESS (SIGN) When you touch a part of the patient’s body and he complains of pain,you say : Is it TENDER?

19. FEVER Temperature >37.8 C Oral-under the tongue Otic/Aural-from the ear Axillary-in the armpit Rectal/Anal-from the rectum

20. PHYSICAL EXAMINATION: INSPECTION PALPATION AUSCULTATION PERCUSSION