PHYSICAL DIAGNOSIS

DECURY WARD WORK GUIDE

Date and time of Interview: ______________________________ Supporting Data (OLD CARTS)

A. Onset (Kailan po nagsimula?)
I. HISTORY TAKING
B. Location (Saan po nagsimula? Lumilipat po ba? Pakituro
A. GENERAL DATA
kung saan)
Name of the patient: _____________________________________
C. Duration (Gaano katagal yung karamdaman? Umaabot
Sex: ______ Age: _____ Date of birth: ______________________
po ba nang minuto o nang ilang oras?)
Nationality: ______________ Civil Status: ____________________
D. Character (Paano niyo po ilarawan yung nararamadan
Religion: ________________ Occupation: ____________________
niyo?) Below is a list of info in guiding your patient:
Handedness: ____________________________________________
a. Pain (Pain scale of 1-10; 1 is least painful, 10 is the most painful)
Present Address: _________________________________________ § Dull and aching, deep-seated (Kumikirot)
_________________________________________________________ § Cramping (Pinupulikat)
No. of previous admission: _______________________________ § Throbbing (Pumipintig/tumitibok-tibok)
Date of current admission: ________________________________ § Stabbing/sharp (Parang sinasaksak)
§ Gnawing (Ngumingitngit)
Informant: _______________________
Mother Reliability: _____________
§ Heavy (Mabigat na parang may dumadagan)
§ Generalized, pumping pain; pain peaks and radiates, then
B. CHIEF COMPLAINT declines and numbs out (colicky) (Humihilab)
_________________________________________________________ § Squeezing (Pinipiga/pinipisil)
_________________________________________________________
ya Alfonso Pause Envile Memorial District Hospital T
laugh dimula CrM2 =o no Scan sa § Writhing/twisting (Namimilipit)
§ Constricting (Naninikip)
C. HISTORY OF PRESENT ILLNESS
§ Burning (Humahapdi)
Narrative: Use this table to fill in the patient’s story pertaining to the
§ Pulsating (Pumipitik-pitik)
development of signs and symptoms that prompted him/her to visit
b. Numbness
the hospital
§ Numb (Namamanhid)
laghat-morning
=

§ Like being pricked w/ a needle/ tingling (tinutusok ng karayom)

am

naholoy In
Kaling -

kuling
magsikka hagbocah jay Kalaylarling
= di natalance
any premo
§ Radiating (Kumakalat)
transferina c. Wound
,

box fox my Kalsada

bemangga sa
blood
27
-

moth
ist =
§ Size (Gaano po kalaki?)
Many
<
hindi natu premo 2nd-
=

§ Color/change of color (May pagbabago po ba sa kulay simula

0 7
wewe
e 30 am
noong unang araw?)
-

3 the - 3 rd
Fam
:

↓
and nat
-

nakakay
II
I

-
=⑱ [1 4 Haw

abir hipag
en in -
U
-

§ Discharge (May kakaiba po bang lumalabas tulad ng nana?)

ured
§ Swelling (May pamamaga po ba?)
·

ins
w

a
mypagild an a
§ Erythema (Pamumula?)
§ Smell (May kakaiba po bang amoy?)
to milupon ??
panno
-> d. Lumps/Masses
=
§ Size from onset to present (Gaano po yan kalaki noong una
reswer IDER = 30 mins :
niyong napansin at gaano po katagal bago po lumaki nang
gonzaya

-
=
no intervention ganyan?)
§ Site (Saang banda niyo po unang napansin?)
-
-

Alfanzo Ponde Envile Memorial ⑰ e

zoNugas
District Hospital

§ Shape
§ Skin surface (pagbabago sa itsura?)
⑰ makalabad

In 27 gumo holog
~
§ Color (May pagbabago po ba sa kulay?)
nu
unang
fumamm
paside quiet

⑧
=

iPm
=anaw maypa-admit
nahulog a semento § Consistency (Kapag kinakapa nyo po, matigas po ba o
umuwi 1pm
mya
malambot?)
=

clo-digto] nice a
-
nuruty any
bakay=sdos cro2
=
30 mins .

From hospi § Mobility (Nagagalaw nyo po ba?)

=Rest =Pink volierer I
hah: § Tenderness (Masakit po ba?)
e. Fever
I
S une =cant walk : maswhit a
my thigh = confused
0
PM =dyhapsot unhage § Temperature (nasukat po ba gamit thermometer?)
=vanit
,

-binnliks Alfonso Pause Envile Memorial District Hospital pu any

mobili
hospi dan
§ Timing (refer to Section G. Timing)
f. Difficulty of Breathing
14 days -X-ray
May
27 =
&
say
=
agaw pay
-

swer
masclit § Appearance during DOB (itsura pag nahihirapan huminga?)
reliever
att § First time or recurring? (Ngayon lang po ba o pabalik balik?)
-
- Drin Lasi

§ Triggering factors for DOB (nagdulot ng hirap sa paghinga?)

-
70hyb=
Salinan
g. Cough
Gaspar chach
-

pai
(June 4)
=advice Dr any

§ Wet or dry cough? (May plema po ba o wala?)

.

-(I scan

10 alis 12 Come
transfusio § Color of phlegm if wet (Ano po kulay ng plema?)
non
am =

§ Consistency of phlegm (malapot po ba o malabnaw?)

↳emergencyonly
room
§ Hemoptysis (May kasama po bang dugo? Gaano po karami?)
the affected
§ Wakes up due to cough (Nagigising po ba dahil sa pag ubo?)
area
Check

mababa Ortho ward

any

:
dugo
m
§ Triggering factors (Ano po nagdulot ng pag ubo niyo?)
h. Colds
- § Is the patient able to sleep due to colds? (Nakakatulog po ba
kahit may sipon?)
§ Triggering factors (Ano po nagdulot ng sipon niyo?)
i. Vomiting
§ Projectile (Malakas po ba ang pagsuka?)
June 1-nanghiamin as dego few
wala
kays mag
Come
§ Amount (Gaano karami?)
§ Color (Ano po kulay?)
June 2 -

Request is dego
j. Diarrhea
Junc4
-

Sinabay § Consistency (Basa po ba o tuyo ang tae?)

§ No. of episodes in a day (Gaano po kadalas ang pagbawas sa
isang araw?)
§ Volume (Gaano po karami ang pagtatae?)

PDx DECURY WARDWORK GUIDE – Contents of this guide are limited only to the customs and practices done in SPUP School of Medicine. Guide in other schools may differ. 1 of 7
 PDx Decury Ward work Guide
k. Loss of Consciousness Allergy
§ Insights before LOC (May maalala po ba bago mawalan ng (Medication, Food, other
malay?)
• If yes, ask for any prior activities before the onset of LOC
• Ask also if there are inciting factors before onset of LOC
substances)
X
(dizziness, pain, etc.) Immunizations

covide
§ Is the patient alone when LOC occurred? (Mag-isa lang po ba (If incomplete, try to elicit
kayo nung nawalan kayo ng malay? O may kasama po?) the vaccines being
• If with a companion, make sure that the companion is also administered)
present during the interview. If present, ask the companion
§ Duration of LOC and the alleviating factors done during LOC Pregnancy
(ask the companion who was present during the LOC of (If pregnant, indicate GP
patient) TPAL, date of delivery, AOG,
l. Seizures manner of delivery,
§ When did the first seizure occur? (Kailan po yung unang complications,
kombulsyon?) sex/condition of the baby)
§ How often? (Gaano kadalas?) Menstruation

Fre
§ Ask for the pattern of seizure (Paano po yung kombulsyon? (Indicate menarche,
Saan nag umpisa? Sa kaliwang kamay? Paa? Sa kanang menopause, last menstrual
kamay? Paa? O sabay-sabay na nagkombulsyon?) period)
E. Aggravating/Alleviating Factors (Ano po ginagawa niyo Psychiatric illness
na biglang lumalala o gumiginhawa nararamdaman niyo? (Indicate date of diagnosis,
May gamot po ba para mawala yung pakiramdam?) interventions done)
F. Radiation (Kumakalat ba sa ibang parte ng katawan?
Pakituro kung saan) Birth and Developmental
G. Timing History (indicate any
§ Biglaan po ba? (sudden) complications, type of
§ Patuloy-tuloy po ba? (continuous) delivery, and essential
§ Nawawala po ba tapos bumabalik? (Intermittent) milestones in development
§ May pattern po ba? (rhythmic/cyclic) relevant to your case)
§ Nawawala po ba ng ilang linggo tapos babalik? (relapsing)
H. Associated Signs and Symptoms (May kasama po bang E. FAMILY HISTORY
sintomas yang nararamdaman ninyo?) Father
Note: For the associated signs and symptoms, it is better to ask also • Age: __________

-
the entire OLD CARTS on that particular sign or symptom

Childhood illnesses
D. PAST MEDICAL HISTORY
• Comorbidities:
X
_______________________________________________________
_______________________________________________________
(Ask for the ff: Measles, • Cause of death (if deceased): __________________________
Polio, Chickenpox, Mumps,
Rubella, Typhoid Fever, Mother
Diphtheria, Pertussis, • Age: __________

X
Tetanus, Rheumatic Fever, • Comorbidities:
Varicella, Dengue Fever.
_______________________________________________________
Indicate the month/year of
occurrence if present. _______________________________________________________
• Cause of death (if deceased): __________________________
Ask also if there are other
childhood diseases present Siblings (ask for age, comorbidities, and cause of death if
aside from the ones deceased):
mentioned) _________________________________________________________

X
Adult Illnesses _________________________________________________________

⑲
(Indicate the date or at
least the month or year of
_________________________________________________________
-

diagnosis) _________________________________________________________
_________________________________________________________
Surgical History _________________________________________________________

⑲
(indicate the date, reason, _________________________________________________________
and procedure)
Children (ask for age, comorbidities, and cause of death if
deceased):

X
Accidents
_________________________________________________________

*
(indicate the date and
interventions done) _________________________________________________________
_________________________________________________________
_________________________________________________________
Hospitalizations _________________________________________________________
(date of previous admission,
_________________________________________________________
diagnosis, and
management done) List of Common Comorbidities
Hypertension Arthritis
Medications Heart disease TB
(indicate dosage and Stroke Allergies
regimen if possible. Ask for Diabetes Mellitus Asthma
Senior citizen booklet or Cancer
prescription if possible)

PHYSICAL DIAGNOSIS 2 of 7
 +

639640429349
PDx Decury Ward work Guide
F. PERSONAL AND SOCIAL HISTORY ☐Lumps (nakakapang bukol sa suso)
elementary
Educational attainment: __________________________________ ☐Discharge (gatas, dugo o nanang
lumalabas sa suso)
M
Marriage Status: _________________________________________
Cardiovascular ☐Chest pain/discomfort (pananakit ng
Patient’s place in the Family: ______________________________
Lacub
dibdib)
,

I hoy I concrete
House Structure: _________________________________________
Lam
☐Palpitation (ramdam ang pagtibok ng
Source of Water: _________________________________________
buban
b puso)
all
Diet: ____________________________________________________ ☐Syncope (hinihimatay)
mahilaba mais Silen gapas
Activities of Daily Living: __________________________________ ☐Paroxysmal nocturnal dyspnea (nagigising
,

aytus , ,

Alcohol consumption: sa gabi dahil nahihirapan huminga)

☐Orthopnea (Gaano karami ang
• Type of alcohol beverage consumed: ___________________
⑰ pinapatanong na unan sa pagtulog?)
• Estimated volume consumed in 1 bottle: _________________ Respiratory ☐Pleuritic Chest Pain (pananakit ng dibdib
X No. of years smoking: _______
No. of cigarettes a day: ______ X
habang humihinga)
Spouse/member of household who smokes: _______________ X ☐Cough
X
• No. of cigs a day: ________
x No. of years smoking: ________ ☐Sputum production (may plema po ba?)
Sleep pattern: ____________
5hrs Garbage disposal:-fine _____________ ☐Hemoptysis (kasamang dugo sa ubo)
I inside
Toilets and sewage: _________________ Pets: ________________ ☐Shortness of breath (Kinakapos sa
paghinga)
Substance Abuse: ________________________________________
X ☐Dyspnea (Nahihirapang huminga)
History of domestic abuse: ________________________________ ☐Wheezing (huni habang humihinga)

G. REVIEW OF SYSTEMS Gastrointestinal ☐Abdominal Pain (masakit ang tiyan)

Check the box if the patient is experiencing the symptom during the ☐Nausea (nagduduwal)
interview. If present, elicit OLD CARTS of that symptom ☐Vomiting (pagsusuka)
General/Constitutional ☐Fever/Chills (Lagnat o panginginig) ☐Regurgitation (Pagbalik ng nakain sa
symptoms ☐Easy Fatiguability (Mabilis mapagod) lalamunan)
☐Loss of appetite/poor feeding (Walang ☐Dysphagia (Hirap lumunok)
gana kumain) ☐Diarrhea (Pagtatae)
☐Weight loss/weight gain (pagbaba o ☐Constipation (Hirap sa pagdumi)
pagdagdag ng timbang) ☐Hematemesis (Pagsusuka ng dugo)
☐Body weakness (panghihina ng katawan) ☐Melena/hematochezia (Dugo sa dumi,
Integumentary ☐Skin/nail/hair changes like blistering or kulay itim o pula)
thickening (pagbabago sa balat, kuko, Genitourinary ☐Dysuria (masakit o hirap umihi)
buhok) ☐Anuria (walang naiihi)
☐Cyanosis (pangingitim ng balat) ☐Oliguria (Onting pag ihi)
☐Pallor (pamumutla) ☐Polyuria (Nakakarami ng pag ihi)
☐Jaundice (paninilaw) ☐Hematuria (Dugo sa ihi)
☐Erythema (pamumula) ☐Urgency (pagmamadali sa pag ihi)
☐Wound/lesions (sugat) ☐Genital Pruritus (pangangati ng ari)
☐Rashes (pamamantal) ☐Urethral Discharge (Lumalabas na nana, o
☐Itching (pangangati) likido sa ari)
☐Dryness (panunuyo) Extremities ☐Edema (Pagmamanas)
Head ☐Headache (pagsakit ng ulo) ☐Swelling of Joints (Pamamaga ng kasu-
☐Dizziness (pagkahilo) kasuan)
☐Vertigo (Pag-ikot ng paningin) ☐Stiffness (Paninigas sa paggalaw)
Eyes ☐Pain (pananakit ng mata) ☐Numbness (Pagmamanhid)
☐Blurring of Vision (Panlalabo ng paningin) ☐Intermittent Claudication (Pananakit ng
☐Use of Eye glasses, Grade on both eyes binti matapos mag ehersisyo)
(Paggamit ng salamin at anong grado) ☐Limitation of Movement (Limitasyon sa
☐Double Vision (pagkaduling o paggalaw)
pandodoble ng paningin) Nervous ☐Loss of consciousness (pagkawalan ng
☐Lacrimation (pagluluha ng mata) malay)
☐Photophobia (madaling masilaw) ☐Focal Weakness (panghihina sa kahit
Ears ☐Earache (pananakit ng tenga) anong parte ng katawan)
☐Deafness (mahina o walang pandinig) ☐Paresthesia (pagtusok-tusok na
☐Tinnitus (ringing na tunog) karamdaman)
HEENT ☐Speech Disorder (Problema sa
☐Ear discharge (paglabas ng nana o tubig)
Nose & sinuses ☐Changes in smell (pagbabago sa pang pananalita)
amoy) ☐Loss of Memory (Makakalimutin)
☐Nosebleed (pagdurugo sa ilong) ☐Confusion (Pagkalito)
☐Nasal obstruction (pagbabara sa ilong) ☐Sleep Disturbances (Problema sa
☐Nasal discharge (sipon) pagtulog)
☐Pain over paranasal sinuses ☐Irritability (Madali po bang mairita?)
Mouth and ☐Toothache (pananakit ng ngipin) Hematologic ☐Bleeding tendencies (Madaling
Throat ☐Gum bleeding (pagdurugo ng gilagid) pagdurugo)
☐Disturbance in taste (pagbago sa ☐Easy bruising (Madaling magkapasa)
panlasa) Endocrine ☐Intolerance to Heat and Cold (Madaling
☐Dry lips (pagbibitak ng labi) ginawin o mainitan)
☐Sore throat (masakit na lalamunan) ☐Polydipsia (Madalas mauhaw)
☐Hoarseness (pagpaos ng boses) ☐Polyphagia (Madalas gutom)
Neck ☐Pain (masakit ang leeg)
☐Stiffness (di maigalaw ang leeg)
☐Mass (bukol sa leeg)
Breast ☐Pain (pananakit sa suso)

PHYSICAL DIAGNOSIS 3 of 7
PDx Decury Ward work Guide
Size ☐Normal ☐Macroglossia ☐Microglossia Contour: ☐Delayed ☐Bounding
Color ____________________________________________________ Rhythm: ☐Regular ☐Irregular
Symmetry _______________________________________________ Equality of pulsation: ☐Equal ☐Unequal
☐Lesions ________________________________________________ Consistency of the walls: ☐Soft ☐Rigid
☐Thrills ☐Bruits
F. NECK
Inspection Inspection and Palpation
Symmetry ☐Symmetric ☐Asymmetric ☐Adynamic precordium ☐Dynamic precordium
Size ☐Normal ☐Unusually long ☐Short ☐Webbed ☐Hyperdynamic precordium ☐Precordial bulging
☐Deformity, mass and swelling ___________________________ ☐Visible pulsations
_________________________________________________________ Apex beat/apical impulse
☐Limitation in movement • Location: _____________________________________________
• Diameter: _____________
Palpation • Amplitude: ☐Normal gentle tap ☐Strong ☐Weak
☐Swollen glands ________________________________________ ☐Heaves/lifts ☐Thrills
☐Lumps/nodules ________________________________________
☐Tenderness ____________________________________________ Auscultation
☐Mass Rhythm: ☐Regular ☐Irregular
• Size: ___________________________ ☐Distinct S1 and S2 ☐Splitting S2
• Mobility: _______________________ Abnormal Heart Sounds: ☐S3 ☐S4
• Palpable? ☐yes ☐no
Murmurs:
G. LUNGS AND THORAX • Location (area of maximum intensity): __________________
Inspection • Radiation (area of minimum intensity): __________________
☐Symmetrical chest expansion ☐Subcostal Retractions • Timing: ☐Systolic ☐Diastolic
☐Suprasternal Retractions • Intensity:
☐Lesions ________________________________________________ o ☐Grade 1 – Very faint, heard only after listener has
☐Scar ___________________________________________________ tuned in; May not be heard in all position
☐Masses/bulges _________________________________________ o ☐Grade 2 – Faint, but hear immediately after placing
Deformities present: ☐scoliosis ☐kyphosis ☐kyphoscoliosis the stethoscope on the chest
☐gibbus ☐pectus carinatum ☐pectus excavatum o ☐Grade 3 – Moderately loud
o ☐Grade 4 – Loud with palpable thrill
Abnormalities in rate and rhythm of respiration: o ☐Grade 5 – Very loud, with thrill; May be heard when
☐Cheyne-Stokes breathing the stethoscope is partly off the chest
☐Biot’s breathing o ☐Grade 6 – Very loud, with thrill; May be heard with
☐Kussmaul breathing stethoscope entirely off the chest
☐Paradoxical respiration • Quality: ☐blowing ☐rumbling
• Pitch: ☐high pitched ☐low pitched
Palpation • Shape: ☐crescendo ☐decrescendo
Tactile fremitus: ☐equal ☐absent ☐decreased ☐increased ☐crescendo-decrescendo
☐Trachea midline
☐Chest wall tenderness or masses ________________________ I. GASTROINTESTINAL
_________________________________________________________ Inspection
☐Flat abdomen ☐Globular abdomen ☐Scaphoid
Percussion abdomen
☐Resonant ☐Hyperresonant ☐Dull ☐Lesions ________________________________________________
☐Scar ___________________________________________________
Auscultation ☐Masses/bulges _________________________________________
☐Vesicular ☐Bronchial ☐Bronchovesicular ☐Tracheal ☐Visible pulsations ☐Peristaltic waves
☐Decreased ☐Absent ☐Wheezes/rhonchi ☐Crackles/rales Auscultation
☐Stridor ☐Pleural friction rub Bowel sounds: ☐Normoactive
- (5-34/min.) In Iwin
☐Hypoactive (<5/min.) ☐Hyperactive (>34/min.)
☐Bronchophony (“ee” becomes larger) ☐Bruit ___________________________________________________
☐Egophony (“ee” heard as “ay”) ☐Friction rub ____________________________________________
☐Whispered pectoriloquy (Whispered words louder, clearer)
Percussion
H. CARDIOVASCULAR SYSTEM ☐Resonant ______________________________________________
Carotid Arteries and Jugular Veins ☐Tympanitic ____________________________________________
Jugular Veins ☐Dull ___________________________________________________
Jugular venous pressure: __________________________________ ☐Shifting dullness ________________________________________
☐Venous distention Liver span: ___________________ ☐Midsternal (4-8cm normal)
Carotid arteries (L & R) ☐Right midclavicular line (6-12cm normal)
Amplitude: ☐Strong ☐Weak

PHYSICAL DIAGNOSIS 5 of 7
 PDx Decury Ward work Guide
_________________________________________________________ Test for dysdiadochokinesia
_________________________________________________________ ☐Rapid alternating movements

Deep tendon reflexes ☐Romberg test

Brachioradialis L _______ R _______
Biceps L _______ R _______ REFERENCES
Triceps L _______ R _______ • Compiled by Tom Kairo T. Pacquing, RMT
Patella L _______ R _______ • UST Medicine decury guide
Achilles tendon L _______ R _______ • Pedia Decury guide
Deep Tendon Reflex Grading
• Rehab Medicine notes
4+ Hyperactive with clonus • Bates Guide to Physical Examination and History Taking
3+ Increased or hyperactive Pocket book
2+ Normal • Incendium decury guide
1+ Diminished
0 Absent
82cm
Primitive reflexes Ass to mm - R :

☐Snout ☐Grasp ☐Palmomental ☐Rooting ↳: 81am

Pathologic reflexes
☐Babinski ☐Chaddock/Oppenheim/Gordon ☐Hoffman
:

5 an
Umbi to R
:

mm
☐Clonus :

81 am
2
Signs of meningeal irritation Leg
30 c-swollen &
knee
☐Brudzinski ☐Kernig ☐Nuchal rigidity
& Yan from pattula
:

Girth
Cranial Nerve Exam :

28 u

I Any non-noxious odor or olfactory sensitivity? ☐Yes ☐No & Pan for Pattel
II Equally reactive to light and accommodation? ☐Yes ☐No
III, IV, VI Extraocular muscle intact? Fixes and follows? ☐Yes ☐No
V Is there facial sensation, corneal reflex, Jaw jerk ☐Yes ☐No
reflex?
VII Is there facial symmetry? Is there facial ☐Yes ☐No
movement?
VIII Reactive to sound? Or able to hear sounds and ☐Yes ☐No
respond?
IX, X Able to swallow, intact gag reflex, midline ☐Yes ☐No
uvula?
XI Turn head in both directions? Can shrug ☐Yes ☐No
shoulders? Flex neck when supine?
XII No tongue deviation or atrophy? ☐Yes ☐No

Assessment of Cerebral Function

This can be emphasized also in the MSE

Level of consciousness
☐Normal ☐Lethargic ☐Obtunded ☐Delirium ☐Stupor
☐Comatose
General Behavior and appearance
☐Appropriately groomed
☐Cooperative ☐Hostile ☐Indifferent
☐Hyperactive ☐Violent ☐Quiet ☐Immobile
Intellectual Performance
• Immediate memory (ask patient to repeat 7 digits forward and
5 digits backward) ☐Intact ☐Impaired
• Recent memory (ask patient his/her last meal)
☐Intact ☐Impaired
• Remote memory (ask the patient’s date of birth)
☐Intact ☐Impaired

Language
• Fluency ☐Intact ☐Impaired
• Repetition (ask patient to repeat a simple phrase or sentence or
a series of numbers) ☐Intact ☐Impaired

Assessment of Cerebellar Function

Test for dysmetria (Check if positive)
☐Finger-to-nose test ☐Heel-to-shin test

PHYSICAL DIAGNOSIS 7 of 7