MEDICINE - Keck School of Medicine of USC

TEAM ID: (Include team name, supervising resident and attending at the time of admission):
HISTORY OF PRESENT ILLNESS (location, quality, severity, duration, timing, contest, modifying factors and associated signs and symptoms):
FAMILY HISTORY (all major illnesses):
SOCIAL HISTORY (alcohol, tobacco: how many per day, for how many years, illicit drug use / Living situation, homeless, recent travel, occupation, sexual
behavior, level of education):
ALLERGIES (Drug/food/environmental; specify reaction):
MEDICATIONS: (prescription, over-the-counter, dietary supplements, herbals):
REVIEW OF SYSTEMS: Document both Positives and Negatives among the following:
Constitutional symptoms (Fever (F), Chills (C), Weight change):
Eye problems (Loss of vision, Diplopia, Eye pain):
Last eye exam:
Ear, Nose, Mouth,Throat problems (Ear pain, Deafness, Epistaxis):
Respiratory problems (Cough, Sputum, Hemoptysis):
Cardiovascular problems (Chest pain, Dyspnea, Orthopnea, Edema, Cyanosis):
Gastrointestinal problems (Anorexia, Nausea, Vomiting, Constipation, Diarrhea, Abnormal Stool, Jaundice, Abdominal pain, Melena, Hematochezia,
Genitourinary problems (Frequency or polyuria, Urgency, Dysuria, Nocturia, Hematuria, Stone or gravel, Urethral discharge, Changes in testicles,
Genital sores):
OB-Gyn problems (Leukorrhea, Non-menstrual bleeding, Excessive menstrual flow, Irregular menstrual flow, Pelvic pain):
Last mammogram:
Menarche (yrs, cycle, duration, flow):
Oral contraceptives (name, dose, length of administration - month, years):
Musculoskeletal problems (Back pain, Bone infections, Skeletal deformities, Joint pain or swelling, Varicose veins, Leg ulcers):
Skin/Breast problems (Rashes, sores, ulcers, Skin thickening, indurations, nodules, masses):
Neurological problems (Headache, Numbness, Paralysis/weakness, Loss of sphincter control/urinary incontinence, Disturbance of gait or speech):
Psychiatric problems (Anxiety, Depression, Disturbing feelings of thoughts, Alteration in sleep/appetite):
Endocrine problems (Excessive thirst, Polyuria, Heat or cold intolerance):
Hematologic/Lymphatic problems (Anemia, Easy bruising or bleeding, Blood clots, Swollen glands, lymphedema, Blood transfusion, Blood transfusion
Allergy/Immunologic problems (Asthma, Allergic rhinitis / hay fever, Hives / urticaria / anaphylaxis):
Communicable disease (include h/o TB or + PPD):
Vaccination /immune status (Tetanus, Influenza, Hepatitis A, Hepatitis B, Pneumoccocal, H. Influenza, Chickenpox):
PHYSICAL EXAMINATION: Normal reference examination elements are included within brackets [ ]
HT (indicate cm or inch):
WT (indicate kg or lbs):
PULSE (beat/min):
RESP (breath/min):
PAIN ( _/10):
General Appearance: [Well developed (WD), Well nourished (WN),·No acute distress (NAD)]:
Medicine H P 12-4-10
Head: [No deformities, Normal cephalic, atraumatic (NCAT)]:
Lymph Nodes / Lymphatics: [No neck, axillary, inguinal, or other lymphadenopathy (LAD)]:
Eyes: [Vision grossly intact / No conjunctivitis /·No ptosis /·Extra ocular muscles intact (EOMI)/·Pupils equal round, reactive to light and accommodation
(PERRLA)/·Fundoscopic examination normal]:
Ears: [Hearing grossly intact /·No deformities /·External Auditory Canals (EAC) clear, Tympanic Membranes (TM) intact]:
Nose: [No marked airway obstruction /·Mucosa normal / Septum intact / No discharge present]:
Oral Cavity: [Moist mucus membranes (MMM), Mucosa normal, no sores or leukoplakia /·Hygiene good, teeth in good condition /·No lymphoid
Neck: [Supple full range of motion (ROM)/·No palpable masses /·Thyroid: no masses, enlargement ,or tenderness /·No venous distention /·Trachea
Back: [No deformities or tenderness of the spine /·No costovertebral angle (CVA) tenderness]:
Chest/Breast: [Symmetrical nontender (NT)/·No palpable masses or ulceration /·No nipple retraction or discharge]:
Respiratory: [Lungs clear to auscultation, and percussion bilaterally (CTAP B/L) /·Chest wall symmetrical, no deformities, no increased work of
Cardiovascular: [Regular rate and rhythm (RRR)/·Heart sounds normal, no murmurs, rubs or gallops (M/R/G), No lifts, heaves or thrills, point of maximal
intensity (PMI) normal /·Carotid, Aorta, Femoral pulses normal without bruits /·Peripheral pulses present, equal and symmetrical]:
Abdomen/GI: [Flat, soft, not distended (ND), non tender (NT) / Bowel sound (BS) present and normally active /·No rebound, guarding or rigidity present
/·No hepatosplenomegaly (HSM)/·No palpable masses or ulceration /·No scars or hernias present]:
Rectal: [No hemorrhoids, masses or tenderness /·Sphincter tone normal, ·Stool negative for occult blood]:
If Deferred, MUST specify why:
Male Genitalia: No penile lesions or discharge /·Both testicles in scrotum /·No masses or swelling / Prostate symmetrical mobile not enlarged and of
normal consistency]:
If Deferred, MUST specify why:
Pelvic: [No lesions of vulva /No bladder tenderness or masses /·No vaginal discharge or lesions /·Urethral meatus normal, no discharge /·No Cervical
motion tenderness (CMT), no discharge or lesions / ·Fundus symmetrical, not enlarged, freely moveable /·No adnexal masses or tenderness ]:
If Deferred, MUST specify why:
Neurological: [No weakness, paralysis, or tremor /·Cranial nerves (CN) II-XII intact symmetrical /·Normal deep tendon reflexes (DTR)/·Sensation intact to
light touch, position, pin prick, and vibration /·No numbness or tingling /·No cerebellar signs /·Toes down-going /·Normal gait]:
Psychiatric: [Alert and oriented to time, place, and person (A&Ox3)/·Memory, judgment, and insight intact /·No agitation, depression, anxiety, psychosis]:
Musculoskeletal / Extremities: [No clubbing, cyanosis or edema (CCE)/·Normal muscle tone and bulk normal /·No muscle spasm, no atrophy present /·
Head, neck, spine, pelvis, extremity x4 No skeletal deformities or dislocations, ·Full range of motion (FROM), nontender to palpation (NTTP) / normal gait]:
Skin: [No induration, nodules, or skin tightening /·No rashes, lesions, ulcerations /·Describe rash (maculopapular, papular, macular, patch, plaques, etc)
or lesion location & symmetry]:
SIGNATURE (Include your name, title (e.g. R3), SID#:
Medicine H P 12-4-10