H P Medicine

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ID: Name

Age

Gender

Hospital number

Major Illnesses – DM Stroke/TIA Lung

HTN Liver

Lipids Kidney

CAD CHF

MEDICAL HX: Hospitalizations and major medical problems: Diagnosis Date Presentation Treatment Sequelae

Thyroid CA 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:

Quality

Aggravating Factors

Alleviating Factors

Dose

Freq

Route

Since when

Side Effects

Associated Sx/ RF

ALLERGIES:

course of sx radiation

progression since onset personal hx

Health maintenance:

PAP

Lipids

LDL

mammogram

FOBT/Scope

PSA

constant vs. intermittent function/quality of life TC

HDL

TG

Fasting glucose

DEXA

Immunizations: Infectious illnesses: measles, mumps, rubella, DPT, chickenpox, scarlet fever rheumatic fever, pneumonia, TB, hepatitis Injuries/disability: System-related ROS:

Recent travel:

SOCIAL HX: Occupation:

Hometown:

Partner: REVIEW HPI “Is there anything else you would like to tell me?” IMPRESSION: 1.

Children:

PLAN: 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? SURGICAL & OB : Type Date

Complications

Result

CANCER? DM?

CHF?

HTN?

COPD? Thyroid?

Lipid disorder?

Asthma?

GI?

STROKE/TIA? Kidney?

CNS/PNS (seizure, paralysis)?

Arthritis? Psychiatric?

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ROS: GENERAL –fevers, chills, sweats; weight +/- ; D in appetite;

PHYSICAL EXAM: **wash hands** fatigue

VITAL SIGNS: T______

ht. ______ wt.__________ BMI _________ Pain______ Pulse ox _____%

SKIN – rashes, lesions , sweating, pruritis, easy bruising, difficult healing swelling,

petechiae,

photosensitivity,

changes in hair or nails

P____ RR____BP __________

GENERAL: __________________________________________________________ SKIN:______________________________________________cap refill__________

HEAD / NECK – headache, EYES –

dizziness,

vision changes; glasses,

inflammation/discharge,

trauma,

blurring;

dry eyes,

EARS – hearing loss,

pain,

swollen LNs

diplopia;

scotoma,

tinnitus,

pain

photophobia

vertigo;

drainage

clubbing____________cyanosis_______________edema ____________________ HEAD: NC/AT________________________________________________________ face___________________________________CN V __________VII _________ EYES: conjunctiva____________________________EOMI____________________ VFI___________________________PERRLA _____________________________ ophthalmoscopic _____________________________________________________ EARS:

NOSE – epistaxis,

discharge,

sneezing;

obstruction,

chronic sinusitis

TMs__________________________hearing_________________________

NOSE:_______________________________________________________________ THROAT: _____________________________ palatal elev_______ gag reflex_____

MOUTH/ THROAT– dry mouth,

teeth,

gums,

trouble swallowing,

oral ulcers,

hoarseness,

pain sore throat

NECK:__________________________LNs ________________________________ Carotid pulses ___________________________ bruits ______________________

CV – chest pain or pressure,

palpitations,

exercise tolerance, fatigue, circulatory probs;

edema, murmurs,

syncope

Thyroid____________________________________________________________

claudication

LUNGS: inspect_______________________________________________________ auscultate__________________________________________________________

LUNGS – dyspnea on exertion; asthma or wheezing;

cough,

cyanosis,

nausea / vomiting,

reflux or heartburn,

diarrhea

/

dysphagia,

hematemesis;

PND

change in appearance, odynophagia;

loss of appetite,

abdominal pain;

hemoptysis

orthopnea,

BREASTS – pain, masses, discharge, GI –

sputum,

dyspepsia

food intolerance

jaundice,

constipation;

self-exam

change in bowel habits

melena ,

hematochezia

percuss ( w/ diaph excursion)___________________________________________ CV: palpate PMI ______________________________________________________ auscultate @ 4 areas w/diaphragm: rate & rhythm, murmurs, rubs, gallops, clicks _____________________________________________________________________ check for aortic insufficiency (LSB w/ pt forward in exhalation)________________ Pt. LYING DOWN: CV: Auscultation @ BASE and LSB_______________________________________ LL DECUBITUS: apex _______________________________________________ JVP_______________________________________________________________ ABDOMEN:__________________________________________________________

GU – obstructive symptoms,

dysuria,

frequency,

hematuria, pyuria, previous UTI’s; discharge,

nocturia,

urgency incontinence

_______________________________________ bowel sounds_______ bruits______ percuss______________________liver span ______________________________ palpate____________________________________________________________

MENSTRUAL – menarche; last period, length of cycle, duration of flow how regular,

how heavy;

pain w/ menstruation or intercourse

PULSES: dorsalis pedis ____________ posterior tibial _________edema_________ femoral pulse ( + auscultate)____________________________________ LE MS exam: ________________________________________________________

vaginal bleeding or discharge,

intermenstrual bleeding; age of menopause Pt. SITTING: CVA tenderness____________________________________________

ENDOCRINE – thyroid, adrenal, hormonal; osteoporosis;

edema,

polyuria,

temperature intolerance; polydipsia,

polyphagia

UE MS exam: wrists _______________________elbows______________________ shoulders ____________________ neck ________________________ NEURO: Mental status____________________________CNs__________________

MS – swelling,

arthralgias, erythema,

arthritis, tenderness;

ROM,

stiffness,

gout,

myalgias

neck or low back pain

Sensation: touch_________ pain_________ position_________ vibration_______ Reflexes: biceps_________ brachioradialis ___________triceps_______________ patellar_________achilles___________________babinski______________ Cerebellar: finger tapping________________ heel to shin____________________

NEURO – syncope, numbness / tingling,

vertigo, weakness,

LOC, equilibrium,

seizures coordination/gait

Pt. STANDING Spine: _______________________________________________________________

depression:

UE drift_________________________ Romberg _____________________________

interest, guilt, energy, sleep, concentration, appetite, psychomotor, suicide

Gait and station______________ swing and stance______ heel / toe walking_______

PSYCH – anxiety;

mania;

memory loss,