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Date

PT initials Allergies

Age Medications

Resolved:

Chief Complaint

HPI

Pos and Negs

Past Medical History Hospitalizations:

Social History

Illness / Injury:

Family History Heritable Disease Screen: Ca, DM, HTN, HD, Mental, Seizure, Stroke Dx Screen: DM HTN Liver D

Ca HD Lung D. Stroke TB

Mom's obstetrical hx:

Birth Hx: Health Maintenance: EtOH______________________ Tobacco______________________ppd Seatbelts_____________ Firearms_____________ Drugs____________ Exercise____________________________________________________ Sleep ______________________________________________________ Immunizations______________ Up to Date Exposures __________________________________(lead, occupational) Diet _______________________________________________________

Growth History: Development: sat____ walk____ run____ jump____ grasp_____ transfer_____ objects in box____ single words_____ phrases____ communicate____

Extra HPI Space

Extra Medications Space

Extra Past History Space

Extra Family History Space

Extra Social History Space

ROS Constitutional: General (+ / -), Energy (+ / -), Sleep (+ / -), Appetite (+ / -), Fever / Chill / Sweats (+ / -), Weight (+ / -)

Skin: Pruritus (+ / -), Sores (+ / -), Pigment (+ / -), Bruising (+ / -), Hair (+ / -), Nails (+ / -), Mole change (+ / -) New Moles (+ / -)

Head: Trauma (+ / -), Headaches (+ / -), Dizziness (+ / -), Syncope (+ / -)

Eyes: Blindness (+ / -), Blurriness (+ / -), Spots (+ / -), Flashes (+ / -), Inflammation (+ / -), Glasses (+ / -)

Ears: Deafness (+ / -), Otalgia (+ / -), Tinnitus (+ / -)

Nose: Rhinitis (+ / -), Epistaxis (+ / -), Sinusitis (+ / -)

Mouth / Throat: Dental prob (+ / -), Dentures (+ / -), Sores (+ / -), Hoarseness (+ / -), Dysphagia (+ / -)

Neck: Pain (+ / -)

Lymph Nodes: Swelling (+ / -)

Breasts: Masses (+ / -), Tenderness (+ / -), Discharge (+ / -)

Respiratory: Exercise Tol (+ / -), Orthopnea (+ / -), PNDyspnia (+ / -), Wheeze (+ / -), Cough / sputum (+ / -), Hemoptysis (+ / -), Pleurisy (+ / -)

CV: Palpitations (+ / -), Pain (+ / -), Dyspnea (+ / -), Orthopnea (+ / -), PNDyspnea (+ / -)

GI: Pain (+ / -) Indigestion (+ / -) Heartburn (+ / -) Nausea (+ /- ) Vomiting (+ / -) Diarrhea (+ / -), Constipation (+ / -), Bowel Change (+ / -) Melena (+ / -) bleeding (+ / -) Jaundice (+ / -)

UT: Dysuria (+ / -) Nocturia (+ / -), Hematuria (+ / -) Urgency (+ / -) Incontinence (+ / -)

F Genitalia: Vaginitis (+ / -) Sores (+ / -) VD (+ / -) Menarche (+ / -) _________ Menses (+ / -)_________ Dysmenorrhea (+ / -) ___________ metrorrhagia (+ / -) _____________, PMS (+ / -) menopause (+ / -) ___________ Hot flashes (+ / -) sexual dysfunction (+ / -) blood post sex (+ / -)

M Genitalia: Sores (+ / -) Discharge (+ / -) Scrotal Pain (+ / -) Hernia (+ / -) Sex Dysfunction (+ / -)

Joints / Extremities: Cramps (+ / -) Varicosities (+ / -) Phlebitis (+ / -) Edema (+ / -) Arthralgias (+ / -) Arthritis (+ / -) Low Back Pain (+ / -)

Endocrine: Heat / cold intolerant (+ / -) Polydipsia (+ / -) Polyuria (+ / -) Polyphagia (+ / -)

CNS: Diplopia (+ / -) Dysphasia (+ / -) Dysphagia (+ / -) Paralysis (+ / -) Paresthesia (+ / -), Clumsiness (+ / -), Balance (+ / -) Gait (+ / -) Involuntary Move (+ / -) Dizziness (+ / -) , Syncope (+ / -) Headaches (+ / -) Memory (+ / -) Depression (+ / -) Anxiety (+ / -), Tremor (+ / -), Seizures (+ / -)

Physical Exam Vital Signs: Temp ___ Route Pulse ___/min RR ___/min BP ___/___ sitting Ht ____ Wt ____ Eye: General look Sclera / Conjunctiva Pupil / Cornea (light response) Cardinal sign Fundiscope

Ears: External Inspection

Otoscope

Nose: Tip Head back, compress, shine in

Mouth: Inspection (depressor)

L. Nodes: Preauricular, post-auricular, occipital, post triangle, SCM, ant triangle, tonsillar, submandibular, submental, SUPRAclavicular L --> M opened fossa

Thyroid Exam

P Thorax: Inspect, palpate, percuss, auscultate

Axillae: WASH hands after A Lung fields: Inspect, Palpate, Percuss, Auscultate,

Neck: Jugular Veins / Carotid Arteries

Cardiac: inspect PMI; palpate PMI; Auscultate w/ diaphragm --> A to P to 3rd / 4th ICS LSB to tricuspid to mitral THEN mitral to AAL: sit up, lean forward for Erb's Point; Lay pt down, bell at 3rd to 4th to tricuspid to mitral then pt in LLDecub & inch back from mitral to LSB.

Abdomen: Inspect, Auscultate, Percuss (liver - mark / measure; spleen); Palpate (light / deep then liver / spleen).

Inguinal Area: external rotation, nodes, pulses, auscultate

NM Exam Laying: Inspect, Palpate (edema, pulses)

NM Exam Seated: look at shoulder area, arms pulses, pronator drift, distal motor (pull); observe / palpate legs for temp/color change, hip flexors, Reflexes (biceps, triceps, brachioradialis, patella, ankle).

Mental and General Appearance: Appearance, mood, emotional rxns, agitation, unusual mannerisms, speech quality/organization, anxiety/phobias, memory, attention, concentration, hyperactivity, AAO x3, participation in conversation/answering questions