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ID: Major Illnesses – DM HTN Lipids CAD Thyroid
Name Age Gender Hospital number Stroke/TIA Lung Liver Kidney CHF CA
MEDICAL HX: Hospitalizations and major medical problems:
Diagnosis Date Presentation Treatment Sequelae Hospitalizations
CC:

HPI: Characterization of symptoms: when did you first feel unwell?

Symptom + Onset/chronology Duration Quantity (1-10)
Location Provoked? Timing + Freq Severity

MEDS: Dose Freq Route Since when Side Effects

Quality Aggravating Alleviating Associated Sx/

Factors Factors RF

ALLERGIES:

Health maintenance: PAP mammogram FOBT/Scope PSA

course of sx progression since onset constant vs. intermittent

radiation personal hx function/quality of life
Lipids TC LDL HDL TG Fasting glucose DEXA

Immunizations:
Infectious illnesses: measles, mumps, rubella, DPT, chickenpox, scarlet fever
rheumatic fever, pneumonia, TB, hepatitis

Injuries/disability: Recent travel:

System-related ROS:
SOCIAL HX:
Occupation: Hometown:
Partner:
REVIEW HPI “Is there anything else you would like to tell me?” Children:

IMPRESSION: PLAN:
1. 1. Smoking EtOH Drug Use

Diet? Exercise? Caffeinated beverages?

SEXUAL HX: Sexually active? Y N Men, women, or both?

Having any concerns? Frequency , type, satisfaction with intercourse
age at 1st intercourse_____ number of partners______

G ___ P_____

FAMILY HX: age, current health, major illnesses, cause of death

Father Mother Grandparents Siblings

PMH:
General:

CAD? CHF? HTN? Lipid disorder? STROKE/TIA?

SURGICAL & OB :
Type Date Complications Result CANCER? COPD? Asthma? GI? Kidney? Arthritis?

DM? Thyroid? CNS/PNS (seizure, paralysis)? Psychiatric?

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ROS: PHYSICAL EXAM: **wash hands**
GENERAL –fevers, chills, sweats; weight +/- ; D in appetite; fatigue
VITAL SIGNS: T______ P____ RR____BP __________
SKIN – rashes, lesions , sweating, pruritis, easy bruising, difficult healing ht. ______ wt.__________ BMI _________ Pain______ Pulse ox _____%

swelling, petechiae, photosensitivity, changes in hair or nails GENERAL: __________________________________________________________

SKIN:______________________________________________cap refill__________
clubbing____________cyanosis_______________edema ____________________
HEAD / NECK – headache, dizziness, trauma, swollen LNs
HEAD: NC/AT________________________________________________________
face___________________________________CN V __________VII _________
EYES – vision changes; glasses, blurring; diplopia; pain
EYES: conjunctiva____________________________EOMI____________________
inflammation/discharge, dry eyes, scotoma, photophobia
VFI___________________________PERRLA _____________________________

EARS – hearing loss, pain, tinnitus, vertigo; drainage ophthalmoscopic _____________________________________________________

EARS: TMs__________________________hearing_________________________

NOSE – epistaxis, discharge, sneezing; obstruction, chronic sinusitis NOSE:_______________________________________________________________

THROAT: _____________________________ palatal elev_______ gag reflex_____

MOUTH/ THROAT– teeth, gums, oral ulcers, pain

dry mouth, trouble swallowing, hoarseness, sore throat NECK:__________________________LNs ________________________________
Carotid pulses ___________________________ bruits ______________________
CV – chest pain or pressure, palpitations, edema, syncope Thyroid____________________________________________________________
exercise tolerance, fatigue, circulatory probs; murmurs, claudication LUNGS: inspect_______________________________________________________
auscultate__________________________________________________________
LUNGS – dyspnea on exertion; cough, sputum, hemoptysis percuss ( w/ diaph excursion)___________________________________________
asthma or wheezing; cyanosis, orthopnea, PND CV: palpate PMI ______________________________________________________
auscultate @ 4 areas w/diaphragm: rate & rhythm, murmurs, rubs, gallops, clicks
BREASTS – pain, masses, discharge, change in appearance, self-exam
_____________________________________________________________________
check for aortic insufficiency (LSB w/ pt forward in exhalation)________________
GI – nausea / vomiting, dysphagia, odynophagia; dyspepsia
reflux or heartburn, loss of appetite, food intolerance
Pt. LYING DOWN:
CV: Auscultation @ BASE and LSB_______________________________________
abdominal pain; hematemesis; jaundice, change in bowel habits
LL DECUBITUS: apex _______________________________________________
diarrhea / constipation; melena , hematochezia
JVP_______________________________________________________________
ABDOMEN:__________________________________________________________
GU – obstructive symptoms, dysuria, frequency, urgency _______________________________________ bowel sounds_______ bruits______
hematuria, pyuria, previous UTI’s; discharge, nocturia, incontinence percuss______________________liver span ______________________________
palpate____________________________________________________________

MENSTRUAL – menarche; last period, length of cycle, duration of flow PULSES: dorsalis pedis ____________ posterior tibial _________edema_________

how regular, how heavy; pain w/ menstruation or intercourse femoral pulse ( + auscultate)____________________________________
LE MS exam: ________________________________________________________
vaginal bleeding or discharge, intermenstrual bleeding; age of menopause
Pt. SITTING: CVA tenderness____________________________________________

ENDOCRINE – thyroid, adrenal, hormonal; temperature intolerance; UE MS exam: wrists _______________________elbows______________________

osteoporosis; edema, polyuria, polydipsia, polyphagia shoulders ____________________ neck ________________________

NEURO: Mental status____________________________CNs__________________
Sensation: touch_________ pain_________ position_________ vibration_______
MS – arthralgias, arthritis, ROM, stiffness, myalgias
Reflexes: biceps_________ brachioradialis ___________triceps_______________
swelling, erythema, tenderness; gout, neck or low back pain
patellar_________achilles___________________babinski______________
Cerebellar: finger tapping________________ heel to shin____________________
NEURO – syncope, vertigo, LOC, seizures
numbness / tingling, weakness, equilibrium, coordination/gait Pt. STANDING
Spine: _______________________________________________________________

PSYCH – anxiety; mania; memory loss, depression: UE drift_________________________ Romberg _____________________________

interest, guilt, energy, sleep, concentration, appetite, psychomotor, suicide Gait and station______________ swing and stance______ heel / toe walking_______