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Chief Complaint (CC): Use patients own words (eg. My leg has been
hurting)
I started having left leg pain since last Wednesday
Pain
This is a 24 year old patient coming in to the hospital 02/07/2017 with complaining left
leg pain starting Wednesday 02/01/2017. Patient stated that the lesion started like a
pimple on his left shin then began to get bigger and redder over the week time period.
He also stated that on 02/06 he started feeling nauseous and dizzy and had cold
sweat. He checked his temperature and it was 105.1. At the emergency room, he was
determined to have cellulitis of left low leg and was taken to surgery to drain the
abscess. The fluid from the abscess was sent for screening and the result was positive
for HIV.
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History and Physical Form Medical Skills Course
Past Medical History: past (and ongoing) medical conditions and surgical
procedures. Include date of diagnoses or duration of illness.
Childhood Illnesses: None
Medical Illnesses:
None
Family History: include all conditions for first degree relatives, hereditary
conditions in other family members. Include approximate age of diagnosis of
that condition. Include Pertinent negatives related to HPI(such as negative
Family history for heart disease in CP case)
Father has diabetes mellitus
Risk Behaviors: tobacco, alcohol, drugs, sexual Hx, diet, violence, high risk
activities
Smoke 3-4 cigarette a day.
Drink once a month socially, 3-4 drinks.
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History and Physical Form Medical Skills Course
Medication list: include dose, interval, and reason for taking the medication.
Include OTC and herbal remedies. Use generic names.
Ceftriaxone 1gm IV /q8h cellulitis
Docusate 100mg PO BID prevent constipation
Vancomycin 1gm IV q12h cellulits
Drug Allergies or Adverse Drug Events: name the drug and describe the
reaction
NKDA, NKFA/
Preventive Care:
Vaccinations: flu Pneumovax
N/A
Review of Systems: instruct the patient to answer yes or no. Use everyday
terms. If present, please enter a (+) in the box. If negative, please enter a (-) In
the box. Add additional information and/or explain positive findings in the space
provided.
GENERAL- change in overall health - weight change (+) fever other or
explanation:
SKIN: - rash - lumps - itching - dryness - Other or explanation: None
NECK: - swollen glands - lumps - pain or stiffness - other or explanation: None
HEAD: - headache - history of head injury - dizziness or lightheadedness - other or
explanation: None
EYES: - pain - redness - double vision - blurred vision/loss of vision - other or
explanation: None
EARS: - hearing loss - earache - tinnitus - vertigo - other or explanation: None
NOSE: - discharge - stuffiness - frequent colds - nosebleeds - other or
explanation: None
MOUTH: - toothache - bleeding gums - lesions - other or explanation: None
THROAT: - sore throat - hoarseness - difficulty swallowing - other or
explanation: None
NECK: - swollen glands - lumps - pain or stiffness - other or explanation: None
RESPIRATORY: - cough - shortness of breath -wheezing - other or explanation:
None
CARDIOVASCULAR SYSTEM: - chest discomfort - swelling - palpitations - heart
trouble
other or explanation: None
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History and Physical Form Medical Skills Course
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History and Physical Form Medical Skills Course
HEENT:
Eyes (include inspection, visual fields, extra-ocular muscles, pupillary
reaction):
PERRLA, conjunctiva pale, sclera not icteric, EOMI, Visual fields intact to confrontation
Facial sensation:
Intact to light touch
Neck / Thyroid (include shoulder shrug, lymph node palpation, and palpation
of thyroid):
Heart & Vascular (assess JVP, palpate carotids, palpate apical impulse,
auscultation):
No JVD noted with head at 30
Carotid pulses palpable and equal bilaterally, normal upstroke
Heart: RRR with no murmurs or gallops appreciated; apical impulse palpable at 5th
intercostal space in the mid-claviclar line
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History and Physical Form Medical Skills Course
Neurological:
Mental status (Note level of consciousness, orientation and speech during
the interview):
Muscle stretch
reflexes
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History and Physical Form Medical Skills Course
WBC 9.8
HB/HCt 15/42
Cr 1.2
Bun 12
ALK 141
Na 134
K 3.5
Cl 99
Anion Gap 13
Summary Statement: In one sentence, summarize the key elements from the
patients history, physical exam and diagnostic studies (if applicable).
This is a 24 year old patient with HIV and currently getting treatment for left
lower leg cellulitis. Patient had drainage surgery for abscess and is now on
antibiotic therapy.
Assessment:
List the patients Primary problem first under #1.
Include up to 3 possible diagnoses related to the presenting problem under
A, B, and C.
List the relevant points from the history, physical examination and pertinent
diagnostic tests (if applicable) under each of the possible diagnoses. In
addition, list other active problems that also need monitoring and
management under # 2 and # 3.
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History and Physical Form Medical Skills Course
C) Diagnosis: ________HIV_________________________________________.
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History and Physical Form Medical Skills Course
Diagnostic Plan (describe how you will begin to investigate the presenting
problem listed above under #1, including initial diagnostic tests and
imaging.
1. Continue with current antibiotic treatment.
2. Follow up with CT scan of left leg for potential osteomyelitis
3. Consult Heme to address HIV diagnosis.
4. HIV and safe sex practice education
5. Refer to HIV support programs
6. Smoking cessation education
REV 11/20/2013 GW, REV 11/04/2014 MDF, REV 6/9/2015 GW, MDF, SG, LG, IE, REV 10/12/2016 TTH.