MEDICINE
HISTORY & PHYSICAL.
TEAM ID: (Include team name, supervising resident and attending at the time of admission):
PMD:
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS (location, quality, severity, duration, timing, contest, modifying factors and associated signs and symptoms):
PAST MEDICAL HISTORY:
SURGICAL HISTORY:
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):
ADVANCE DIRECTIVE:
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,
Hemorrhoids):
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:
LMP:
Gravida/Para/Abort/Stillbirth:
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
reaction):
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 [ ]
VITAL SIGNS:
HT (indicate cm or inch):
WT (indicate kg or lbs):
BP:
PULSE (beat/min):
RESP (breath/min):
TEMP:
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
hyperplasia]:
Neck: [Supple full range of motion (ROM)/·No palpable masses /·Thyroid: no masses, enlargement ,or tenderness /·No venous distention /·Trachea
midline]:
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
breathing]:
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]:
LABORATORY AND RADIOGRAPHIC DATA:
OTHER DIAGNOSTIC STUDIES:
ASSESSMENT / PLAN:
SIGNATURE (Include your name, title (e.g. R3), SID#:
Medicine H P 12-4-10