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History Physical Format

This document provides a template for documenting a patient's history and physical exam. The subjective section includes the chief complaint, history of present illness, past medical/surgical history, allergies, medications, social history, and family history. The review of systems covers all body systems. The objective section outlines how to perform and document a full physical exam, including vital signs, examination of each body system, and cranial nerve assessment. Specific tests and scales are provided to evaluate various physical findings.

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filchibuff
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181 views

History Physical Format

This document provides a template for documenting a patient's history and physical exam. The subjective section includes the chief complaint, history of present illness, past medical/surgical history, allergies, medications, social history, and family history. The review of systems covers all body systems. The objective section outlines how to perform and document a full physical exam, including vital signs, examination of each body system, and cranial nerve assessment. Specific tests and scales are provided to evaluate various physical findings.

Uploaded by

filchibuff
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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History & Physical Format

SUBJECTIVE (History)
Identification
name, address, tel.#, DOB, informant, referring provider
CC (chief complaint)
list of symptoms & duration. reason for seeking care
HPI (history of present illness) - PQRST
Provocative/palliative - precipitating/relieving
Quality/quantity - character
Region - location/radiation
Severity - constant/intermittent
Timing - onset/frequency/duration
PMH (past medical /surgical history)
general health, weight loss, hepatitis, rheumatic fever, mono, flu, arthritis, Ca,
gout, asthma/COPD, pneumonia, thyroid dx, blood dyscrasias, ASCVD, HTN, UTIs, DM,
seizures, operations, injuries, PUD/GERD, hospitalizations, psych hx
Allergies
Meds (Rx & OTC)
SH (social history)
birthplace, residence, education, occupation, marital status, ETOH, smoking, drugs, etc., sexual
activity - MEN, WOMEN or BOTH
CAGE Review
Ever Feel Need to CUT DOWN
Ever Felt ANNOYED by criticism of drinking
Ever Had GUILTY Feelings
Ever Taken Morning EYE OPENER
FH (family history)
age & cause of death of relatives'
family diseases (CAD, CA, DM, psych)
SUBJECTIVE (Review of Systems)
skin, hair, nails - lesions, rashes, pruritis, changes in moles; change in distribution;
lymph nodes - enlargement, pain
bones , joints muscles - fractures, pain, stiffness, weakness, atrophy
blood - anemia, bruising
head - H/A, trauma, vertigo, syncope, seizures, memory
eyes- visual loss, diplopia, trauma, inflammation glasses
ears - deafness, tinnitis, discharge, pain
nose - discharge, obstruction, epistaxis
mouth - sores, gingival bleeding, teeth, abn. taste, jaw pain
throat - ST, hoarseness, voice changes, URI
neck - swelling/stiffness, adenopathy, goiter,
breasts - lumps, pain, nipple discharge, last mammogram
endocrine - polyphagia/dipsia/uria, dec. energy/fatigue
respiratory - dyspnea, orthopnea, wheezing, cough, sputum, hemoptysis, pain, pleurisy, night sweats, TB,
#pillows, pneumonia, asthma
CV (cardiovascular) - CP, palpitations, claudication peripheral edema, ascites, cold feet, phlebitis,
cyanosis
GI - appetite/wgt change, dysphagia, N/V, hematemesis, BRBPR, melena, abd, pain/colic, icterus,
diarrhea, constipation, change in bowels, tenesmus, hemorrhoids ,rectal pain, hernia
GU - polyuria, oliguria, dysuria/strangury, hematuria, pyuria, incontinence, nocturia, pain passage of
stones, UTI, pyelo & STD hx

MS - arthralgia, arthritis, myalgia, joint stiffness/swelling/ heat/pain, podagra/gout


nervous - smell, chewing, visual, facial weakness, hearing, balance, speech & swallowing, taste,
motor - weakness, paralysis, atrophy, seizures, incoordination
sensory - pain, paresthesias, anesthesia
autonomic - incontinence, sweating, erythema, cyanosis, pallor, temp sensitivity
mental status - relations w family, lability of mood, hallucinations, delusions, depression, somnolence,
insomnia
OBJECTIVE (Physical Exam - sample recordings)
vital signs & general appearance: age, sex, well developed/nourished, appears stated age, NAD
head - normocephalic, no masses /lesions, cicatrices, malar flushing
eyes - visual fields intact (cut)by confrontation, PERRLA , conjunctiva clear, sclera white, anicteric, (1-2
beat nystagmus on lateral gaze.) EOMI, no ptosis; fundi: red reflex present (B). discs flat w sharp margins,
vessels present w/o crossing defects, retinal hemorrhages
ears - TM's non-injected(erythematous, bulging), good light reflex, no protrusion or retraction; Weber
midline, Rinne ac>bc, Whisper test 3:3
nose - nares patent, no deformity, septal deviation or perforation
throat - pharynx non-injected, palate rises symmetrically, gag present,
mouth - buccal mucosa, moist and intact, tonsils present, dentition intact, caries, tongue midline w/o
fasciculations
neck, axilla & breasts - no LAD (lymphadenopathy), masses, or thyromegaly/focal lump, carotid pulses
2+ & = (B), no bruits, supple full ROM trachea midline, breasts symmetric, no retraction, lesions, masses
or tenderness
back, thorax & lungs - chest expansion symmetric, CTA (clear to auscultation), eupnea, no adventitious
sounds (rales, crackles, wheezes)
CV (cardiovascular) - RRR no m/r/g (systolic ejection murmur, rubs, gallops)
abdomen - soft non-tender w/o masses, tympany to percussion in all 4 quads, BS present
(hyper/hypoactive, absent); no HSM (hepatosplenomegaly), no bruits
extremities - extremity size symmetric w/o swelling/atrophy, temp warm (B). All pulses present, 2+ &=
(B), no LAD, skin - pink-tan color, good turgor w/o lesions, redness, cyanosis, edema or cicatrices;
nails - no clubbing or deformities w good cap refill
musculoskeletal - gait normal, able to tandem walk, no Rhomberg's sign; joints and muscles symmetric, no
swelling, masses, deformity or tenderness to palpation; no heat or swelling of joints; full ROM; muscle
strength 5/5- able to Amitin flexion against resistance & w/o tenderness
muscle grading evaluate D (deltoid), T (triceps), B (biceps), WF (wrist flexion), WE (wrist extension),
Quad (quadriceps), PF (plantar flexion) DF (dorsiflexion) scoring 0-5 out of 5 according to following scale:
5
4
3
2
1
0

Normal
Good
Fair
Poor
Trace
Zero

Complete ROM against gravity with full resistance


Complete ROM against gravity with some resist
Complete ROM against gravity
Complete ROM with gravity eliminated
Evidence of slight contractility. No joint motion
No evidence of contractility

genitalia/rectum - no lesions, inflammation or discharge from penis, rectum: no fissure, hemorrhoids,


fistula or lesions in perianal area; sphincter tone good; prostate not enlarged, no masses, nodules or
tenderness. Stool brown, guaiac neg.
pelvic - no vaginal/cervical lesions, uterus size & position; no adnexal tenderness
nervous - (LOC, DTR's, MMS) - CN II-XII grossly intact, alert oriented, cooperative
sensory - pinprick, light touch & vibration intact; proprioception tested (unable to differentiate sharp/dull
mid-calf
motor - no atrophy, weakness, tremors or clonus; RAM (rapid, alt. movement) finger-to-nose/heel-to-shin
intact; Rhomberg negative
DTR's - all 2+ & = (B); Babinski absent toes upgoing, downgoing or equivocal (inconclusive); plantar
response in extensor on (L); Naming & repetition intact; memory 3:3; (B) Pronator drift - (R)>(L); gaze
preference; neglect; extinguishing sensory (light touch to ea. ext then to both simultaneously): extinguishes
(L or R) side to direct sen. stim.

reflex grading evaluate biceps (C5, C6); triceps (C6, C7, C8); brachioradialis (C5, C6); patellar (L2, L3,
L4); Achilles(S1, S2); plantar/Babinski (L4, L5, S1, S2) based on following scale:
4+
3+
2+
1+
0

very brisk/hyperactive - clonus


more brisk than average
average/normal
low normal/diminished
no response or equivocal

Cranial Nerve Evaluation (using specific tests)


CN I (Olfactory) - smell mint leaves/tobacco
CN II (Optic) - visual acuity & funduscopic
CN III (Oculomotor) - pupillary reaction
CN IV (Trochlear) - pupillary reaction
CN V (Trigeminal) - clench teeth, open jaw, lip/chin test for light touch
CN VI (Abducens) - EOM
CN VII (Facial) - raise eyebrow/frown/show teeth/smile/puff cheek
CN VIII (Acoustic) - whisper test; Weber/Rinne tests
CN IX (Glossopharyngeal) - hoarseness, tongue movement
CN X (Vagus) - saying "ah," & note palate and uvula move upward
CN XI (Spinal Accessory) - shrug shoulders
CN XII (Hypoglossal) - inspect tongue for atrophy/fasciculations

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