Clinical Science 3

Internal Medicine Student History and Physical
van der Woodsen, Serena
DOB: 09/01/1958
MRN: 1234567891
Chief Complaint: Shortness of breath
History of Chief Complaint: 52-year-old AAF with h/o COPD, CHF, HTN, and DM II
presented to the ER with shortness of breath of 2 days duration. Onset was gradual, initially
noticing it when she walked up steps but is now present at rest. Worse with exertion and lying flat.
Improves with rest and albuterol, but does not completely alleviate it. Denies fevers/chills, chest
pain, palpitations, waking up at night short of breath, abdominal pain, nausea or vomiting.
Past Medical History:
Allergies: NKDA
Social History:.
Administrative assistant
30 pack-year history; currently 1 ppd
Denies alcohol and illicit drug use
No sick contacts and denies any recent travel
Past Surgical History:
Hysterectomy- 2001
Cholecystectomy- 2005
Family History:
Hypertension and MIs in father and mother
Hyperlipidemia in brother
Breast cancer in sister
Review of Systems:
General: Admits to 5 lbs. of weight gain in a month. Denies increased fatigue, sleeplessness or
HEENT: Denies headaches, trauma, blurry or double vision, visual loss or changes in senses of
smell, taste, or hearing.
Respiratory: See history of chief complaint. Admits to baseline dyspnea on exertion.
Cardiovascular: Denies chest pain, palpitations, irregular or rapid heartbeats.
Gastrointestinal: Denies changes in bowel habits, diarrhea, constipation, blood in stool, or black,
tarry stools.
Genitourinary: Denies changes in urinary habits, urinary frequency, urgency, dysuria, pyuria,
hematuria, or change in sex drive.
Musculoskeletal: Denies back pain, weak muscles or increased pain with movement.
Neurologic: Denies numbness, tingling, or tremors.
Hematological: Denies bleeding, easy bruising, or wounds that won’t heal.
Integumentary: Denies any rashes, petechiae, ecchymoses, or abnormal lesions.
Psychiatric: Denies depression, anxiety, suicidal or homicidal thoughts.
T: 99.2 P: 87 R: 22 BP: 160/75 PO: 96% on 2L NC Pain: 0/10
Physical Exam:
General Appearance: Appears stated age;
tachypneic but no acute distress. Alert and
communicating appropriately.
Head: Normocephalic, atraumatic.
Eyes: Conjunctiva and sclera non-injected,
non-icteric without pallor or petechiae.
Extraocular muscles intact (EOMI), pupils
equal, round and reactive to light and
accommodation (PERRLA).
Nose: Mucosa pink, moist without
deformities, bleeding or discharge.
Throat/Mouth: Lips pink, tongue pink
without atrophy, fissures or deviation from
midline on extension. Buccal mucosa, palate,
and uvula pink and moist without lesion or
masses. Edentulous.
Neck: Supple without nuchal rigidity.
Jugular venous pressure approximately 8 cm
H20. Carotid pulses are equal bilaterally
without bruits. Thyroid not enlarged, moves
with swallowing. Trachea midline, moves
freely with passive motion.
Lymph nodes: No enlargement or
tenderness of cervical, axillary, or inguinal
lymph nodes.
Lungs: Fine crackles in bases bilaterally, right
worse than left. End-expiratory wheezes in
upper lobes, but breath sounds present in all
lung fields.
Heart: Regular rate and rhythm (RRR) with
S1 equal to S2. II/VI systolic ejection
murmur present at right sternal border in 2nd
intercostals space that radiates into carotids.
No splitting, S3, S4. PMI laterally displaced.
Abdomen: Abdomen soft, nontender,
nondistended. Resonant to percussion, bowel
sounds present in all four quadrants.
Genitourinary: Perianal area intact without
lesion, rashes, inflammation, scars. Anal
Labs in ER:
surface intact without lesion, fissure, fistula,
hemorrhoids. Good sphincter tone. Rectal
walls smooth without nodules, masses,
tenderness. Stool dark brown without visible
blood. Guaiac negative.
Extremities: Warm, pink, non-tender with
peripheral pulses: radial, posterior tibial, and
dorsalis pedis +2/4 equal bilaterally. No
edema, varicosities, lesions, deformities.
Capillary refill 2-3 seconds bilaterally. Muscle
mass symmetrical bilaterally with full active,
passive range of motion (ROM).
Neurological: Oriented to person, place and
time. Immediate, recent and remote memory
intact; language appropriate and speech
intelligible. Handgrip strength, internal and
external rotation, symmetrical, strong.
Reflexes are +2/4 and equal bilaterally for
patellar, Achilles, biceps, triceps. Babinski
reflex is down-going bilaterally.
Structural Exam: Shoulders, iliac crest
height are level. No apparent abnormality of
kyphotic or lordotic curves. No scoliosis.
Paravertebral musculature is symmetrical and
non-tender with palpation.
Skin: Pink, warm, dry with good texture and
turgor. No rashes or lesions.
Chest x-ray (CXR): Stable cardiomegaly and pulmonary vascular congestion when compared to
previous film from 1/10/2011. No focal infiltrates or acute process identified.
Assessment and Plan: Your admission orders!
 Write admission orders in the format presented in class (ADCA VAN DIMLS)
 Orders can be written on progress note paper or typed
 Focus on being complete, thorough, and following the proper format; don’t worry if you
aren’t sure what the exact diagnosis or work up should be
 Don’t forget to put the date and time (military preferred) in the upper left corner, and sign
and print your name at the bottom of your orders
 Turn in to G 227 by 5 pm 24 hours after your Documentation session
 Contact the fellows ( or stop by G333) with any questions!