H&p Cheat Sheet.docx

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CC: Location  

Severity

Times

Characteristics

Agitation/Allocation

Environment

Other Symptoms

PMH         

Childhood illness Trauma Hospitalizations Surgeries Chronic illness Gynecologic/reproductive: periods, pregnancy, birth control Health maintenance: immunizations, screenings Medications, supplements Allergies

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Diabetes Hypertension Cancer Heart disease; age of occurrence Genetic Psychiatric Contagious Toxic

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Occupation Highest level of education Household  Significant other/ marital status  stressors Lifestyle  Diet  Exercise  Hobbies Caffeine use Alcohol Tobacco  What kind? How much?

FHx

Pack years: # packs/day * # years smoking Illegal drug use  What? Quantity? Frequency? Route? Sexual Hx  Are you currently sexually active?  Are you in an intimate relationship? Multiple partners? # in last year?  Men women or both?  Oral, anal, vaginal? Give receive or both?  Protection? Contraceptives, STD protection  Periods? Regular? When was the last?  Pregnant?  Do you have any problems? Pain?  Discharge? Rash?  Hx of STD?  Abusive relationship?  Safe o Stress/Safety o Abused/Afraid o Friends/family o Emergency plan

Full H&P HPI PMH FH SH ROS PE, vitals, general appearance Assessment Plan

Vitals: Weight Temp: Respiratory Rate: Blood Pressure: Pulse: O2 Saturation:

SHx

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Extra Info 

Depression screen  Sleep  Insomnia  Guilt  Energy  Concentration  Appetite  Psychomotor  Suicidal

ROS 1.

General a. Alert/ Responsive b. Weight loss/gain c. Malaise d. Fever e. Chills f. Weakness g. diaphoresis 2. Skin a. Rashes b. Itching c. Dry skin d. Sweating more/less e. Color f. Hair/nails 3. Muscular a. Muscle aches b. Weakness c. Numbness d. Tingling 4. Bone a. Joint pain b. Mobility 5. Nervous a. Dizziness b. Fainting c. Numbness d. Tingling e. Seizures 6. Eyes a. Vision changes b. Double vision c. photophobia d. Vision blurriness e. Eye pain f. Dry eyes g. redness 7. Ears a. Difficulty/change in hearing b. Tinnitus c. Otalgia d. discharge 8. Nose a. Nasal discharge b. Sense of smell c. Epistaxis d. Congestion e. Sinus pain 9. Mouth/throat a. Dry mouth b. Sores/pain c. Difficulty chewing/swallowing d. Tooth pain 10. Throat/thyroid/neck a. Change in voice sound/hoarseness b. Goiter c. Lumps

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d. Odynophagia e. Dysphagia f. Pain g. stiffness Cardio a. Palpitations b. Chest pain c. SOB d. Tachycardia e. Paroxysmal nocturnal dyspnea f. Claudication g. edema Pulmonary a. Coughs b. Hemoptysis c. Wheezing d. dyspnea Gastro a. Emesis b. Hematemesis c. BM changes d. Loose watery stools, diarrhea e. Abdominal pain f. Black tarry stools (melena) g. Reflux h. Belching/burping/weird taste Urinary a. Incontinence b. Urgency c. Frequency d. Hematuria e. nocturia Genital a. Sexual dysfunction, pain OB a. Periods i. When ii. Pain iii. How long b. Children? i. How many ii. Route of delivery iii. Problems c. Breasts i. Lumps ii. Pain iii. Discharge iv. Redness v. Nursing? vi. Self exam? Psych a. Depression

Physical Exam GENERAL: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. SKIN, HAIR, NAILS: Skin normal color, texture and turgor with no lesions or eruptions. No lesions on scalp. Hair and nail normal texture. HEAD –No palpable masses or lymph nodes. No lesions or deformities. Normocephalic. EARS – Clear tympanic membranes with visible cone of light. EYES – Pupils equal, round, reactive to light and accommodation PERRLA, extraocular movements intact EOMI NOSE – Moist mucous membranes, No hypertrophy, erythema, and rhinorrhea in both nostrils. NECK – Neck supple, non-tender without lymphadenopathy, masses, or thyromegaly. THROAT – Oral cavity and phyarnx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. Normal chest expansion. Normal tactile fremitus and egophany. HEART/CARDIOVASCULAR: RRR. Normal S1 and S2. No S3, S4 or murmurs.There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. ABDOMEN: Positive bowel sounds. Soft, non distended, nontender. No hepatomegaly or splenomagly. No guarding or rebound. No masses. MUSCULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait. NEUROLOGIC: : CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal.

RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular. GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge. Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness.