Patient History & Physical Examination

swoodr/woody06

PATIENT NAME : _________________________________________

ROOM # : __________ DATE : __________________
DOB: _______________
AGE : _________________
GENDER: _________
RACE : ___________________________

CC :

Source : (person, reliability)

HPI :

Pertinent Negs

location (radiate, referred)

quality (pain type)
quantity (scale)(how affect life)
timing (start, freq., length, prog.)(better/worse)
setting (when, where, health beforehand)
affecting factors (alleviate, exascerbate)
assoc manifestations (fever, chills, nausea, vomit, wt change)
personal concerns (what does patient think it is)

PMH :

MEDICATIONS : (presc.,OTC,vitamins,herbal)

recent/chronic illness ____________________________________

hosp./serious illness _______________________________
surgeries ______________________________________________
accidents/injuries/trauma ____________________________
DM ______ HTN ______ CAD ______ HypChol _______
Asthma ______ Arthritis/Gout ______ Other tests _________
Infect. Dis. (TB, STDs, etc.)__________________________

DRUG ALLERGIES : ______________________

rxn ______________________________________

General Health Maintenance :

Immuniz.: MMR ____ DTP ____ varicella ____ polio _____
Hib ____ hepB ____ influenza ____ pneumovax ____
Screen: chol _____ HBP _____ TB _____ DM _____ HIV _____
cancer screening : breast _____ colorectal _____ prostate _____

FAMILY Hx : (age, health, c.o.d.)

Family w/ Sim. Prob. ____________________________________
DM ______ HTN ______ CAD ______ HypChol _______
Cancer ________________________________________

OB/GYN : Preg. _____ Term _____ abortions ______

LMP _______ nrml? _________ contracep. __________
pap _________ mammogram ________ pelvic __________
SOCIAL Hx :
occupation __________________________________________
married _______ homelife _____________________________
support system ________________________________
spirit./rel. ___________________ community _____________
rel/cult. customs ______________________________________
dietary (WtActVarExc) ____________________________
________________________________ app. _____
sleep ___________________ stress ______________________
R&R ________________ travel __________________
smoking ____________________________________________
EtOH ________________________ last use _________
drugs ________________________ last use _________
sexual probs/activity _____________________________
support ________________________ fun __________________

ROS : (see other page)

Summarize.

PHYSICAL EXAM
VITALS : supine BP ___________ Pulse __________

RR __________ Temp _________ Wt _________ Ht _________

sitting BP ___________ Pulse __________

General : ____________________________________
pallor _____ icterus _____ WNWD ______
Skin : _______________________________________
rashes _______ erythema _______ edema ______
Head : __________________________ NCAT ______
Eyes : _______________________________________
cornea ______ iris ______ jaundice ______
PERRLA ______ EOMI ______ fundus ______
Ears : _______________________________________
Rinne ______ Weber ______
Nose : _______________________________________
Mouth/Throat : _______________________________
gag reflex ______ tongue ______ tonsil ______
teeth _______________ TMJ ______
Neck : ______________________________________
LN ______ thyroid ______ bruit _______
ROM _______ JVD _______
Chest : ______________________________________
Breasts : _____________________________________
CVS : ______________________________________
rhythm (R, I, II) _______ S3 ______ S4 ______
murmurs __________________
PMI _______________
pulses ______________________________

PROBLEM LIST :

ASSESSMENT :

PLAN:

Labs :

Lungs : ______________________________________________________
wheezes _______ rales ______ egophony _________
Abdomen : ___________________________________________________
tender ______ masses ______ scars ______ NTND _______
bowel sounds _______ CVAT _______ aorta _______
rebound _____ psoas sign _____ obturator sign ______ Murphy ______
hepatomegaly _______ splenomegaly _______
Rectal : ________________________________________ prostate ________
Genitourinary : _________________________________________________
Musculoskeletal : ________________________________________________
atrophy ______ malalignment ______ tenderness ______ warmth ______
ROM __________ function ________ back ________________________
Neurologic : ____________________________________________________
mental status : affect _____________ mood ____________
sensorium ___________ intellect ______________
thought _____________ somatic _____________
A&O x3 _________ gait __________ Rombergs _________
CN II-XII ___________________________________________
Strength (upper & lower extremities) ________________________
Tone (upper & lower extremities) _________________________
Reflexes: DTR __________________ primitive ______________
Sensory : touch ___________ pain/T ___________ vibration __________
cerebellar test ________________________________________________

1. General
______Poor state of health
______Fever
______Chills
______Usual weight
______Change in weight
______Weakness
______Fatigue
______Sweats
______Hot or cold intolerance
______History of anemia
______Bleeding tendencies
______Blood transfusions
______Exposure to radiation
______Violent relationships

7. Neck
______Lumps
______Goiter
______Pain on movement
______Tenderness
______History of "swollen glands"
______Thyroid trouble

2. Head
______"Dizziness"
______Headaches
______Pain
______Fainting
______History of head injury
______Stroke

8. Chest
______Cough
______Pain
______Shortness of breath
______Sputum production (quantity
and appearance)
______Tuberculosis
______Asthma
______Pleurisy
______Bronchitis
______Coughing up blood
______Wheezing
______Last X-ray
______Last test for tuberculosis
______History of BCG vacc.

3. Eyes
______Use of eyeglasses
______Current vision
______Change in vision
______Double vision
______Excessive tearing
______Pain
______Recent eye examination
______Pain looking at light
______Redness
______Discharge
______Infections
______History of glaucoma
______Cataracts
______Injuries

9. Cardiac
______Pain
______High blood pressure
______Palpitations
______Shortness of breath
with exertion
______Shortness of breath
when lying flat
______Sudden shortness of
breath while sleeping
______History of heart attack
______Rheumatic fever
______Heart murmur
______Last ECG
______Other tests for heart f(x)

4. Ears
______Hearing impairment
______Use of hearing aid
______Discharge
______"Dizziness"
______Pain
______Ringing in ears
______Infections

10. Vascular
______Pain in leg, calf, thigh
or hips while walking
______Swelling of legs
______Varicose veins
______Thrombophlebitis
______Coolness of extremity
______Loss of hair on legs
______Discoloration of extremity
______Ulcers

5. Nose
______Nosebleeds
______Infections
______Discharge
______Frequency of colds
______Nasal obstruction
______History of injury
______Sinus infections
______Hay fever
6. Mouth and Throat
______Condition of teeth
______Last dental appointment
______Condition of gums
______Bleeding gums
______Frequent sore throat
______Burning of tongue
______Hoarseness
______Voice changes
______Postnasal drip

11. Breasts
______Lumps
______Discharge
______Pain
______Tenderness
______Self-examination
12. Gastrointestinal
______Appetite
______Excessive hunger
______Excessive thirst
______Nausea
______Swallowing
______Constipation
______Diarrhea
______Heartburn
______Vomiting
______Abdominal pain
______Change in stool color

______in stool caliber

______in stool consistency
______in freq. of bowel mvmt
______Vomiting up blood
______Rectal bleeding
______Black, tarry stools
______Laxative or antacid use
______Excessive belching
______Food intolerance
______Change in abdominal size
______Hemorrhoids
______Infections
______Jaundice
______Rectal pain
______Previous abdominal X-rays
______Hepatitis
______Liver disease
______Gall bladder
13. Urinary
______Frequency
______Urgency
______Prob. starting the stream
______Incontinence
______Excessive urination
______Pain on urination
______Burning
______Blood in urine
______Infections
______Stones
______Bed wetting
______Flank pain
______Awakening at night to
urinate
______History of retention
______Urine color
______Urine odor
14. Male genetalia
______Lesions on penis
______Discharge
______Impotence
______Pain
______Scrotal masses
______Hernias
______Ability to enjoy sex
______Fertility problems
______Prostate problems
______Hx of venereal dz and tx
15. Female Genitalia
______Lesions on ext. genitalia
______Itching
______Discharge
______Last Pap smear and result
______Pain on intercourse
______Birth control methods
______Ability to enjoy sex
______Fertility problems
______Hernias
______Hx. of venereal dz. and tx.
______Hx of DES exposure
______Age at menarche
______Interval between periods
______Duration of periods
______Amount of flow
______Date of last period
______Bleeding between periods
______Number of pregnancies
______Abortions

______Term deliveries
______Compls of pregnancies
______Descriptions of labor
______Number of living children
______Menstrual pain
______Age at menopause
______Menopausal symptoms
______Postmenopausal bleed
16. Skin
______Rashes
______Itching
______Hives
______Easy bruisability
______History of eczema
______Dryness
______Changes in skin color
______ in hair texture
______ in nail texture
______Hx of skin disorders
______Lumps
______Use of hair dyes
17. Musculoskeletal
______Weakness
______Paralysis
______Muscle stiffness
______Limitation of movement
______Joint pain
______Joint stiffness
______Arthritis
______Gout
______Back problems
______Muscle cramps
______Deformities
18. Neurologic
______Fainting
______"Dizziness"
______"Blackouts"
______Paralysis
______Strokes
______"Numbness"
______Tingling
______Burning
______Tremors
______Loss of Memory
______Psychiatric Disorders
______Mood Disorders
______Nervousness
______Speech Disorders
______Unsteadiness of Gait
______General behavior changes
______Loss of consciousness
______Hallucinations
______Disorientation

HEENT
Head
Hair:
Face:
Symmetry:
Skull / Scalp:

Eyes
Position and Alignment:
Extraocular Structures:
brows:
lacrimal apparatus:
lids:
lashes:
Conjunctiva and Sclera:
Corneas and Lenses:
Iris:
Visual acuity and Visual Fields:
Pupils (II,III):
size (equal):
direct and consensual reaction:
accommodation:
Extraocular muscles (III,IV,VI):
eye movement:
nystamus:
Fundus:
retina:
optic disc:
vessels:
macula:

Ears
Pinnae:
Mastoid Percussion:
Canal:
Tympanic Membrane:
Hearing (VIII):
Weber:
Rinne:
L:

R:

Nose
Mucosa:
Septum:
Turbinates:
Sinuses (palpation, transillumination):

Mouth / Throat
Lips:
Mucosa:
Teeth:
Gums:
Tongue (deviation, appearance, XII):
Palates / Uvula:
Tonsils:
Pharynx (X):

Neck
Inspection:
trachea (midline, deviation):
masses:
Palpation:
Glands:
parotid:
submandibular:
thyroid:
bruit present:

Lymph nodes
1. pre-auricular:

6. submental:

2. posterior auricular:

7. superficial cervical:

3. occipital:

8. posterior cervical chain:

4. tonsillar:

9. deep cervical chain:

5. submaxillary:

10. supraclavicular (Virchows):

Lungs
Inspection:
breathing pattern (rate, rhythm, depth, effort):
abnormal movements (retraction, asymmetry, accessory
muscle use, paradoxical inspiration):
shape (barrel, pectus carinatum or excavatum):
Palpation:
tenderness:
fremitus (toy boat):

Percussion:
consolidation (dullness):
level of diaphragm:
diaphragmatic excursion:
Auscultation:
breath sounds (pitch, intensity, duration):
rales, wheezes, rubs:
egophany (e a):
whispered pectoriliquoy (sixty-six):
Repeat for Anterior Chest:

Cardiovascular

Inspection and Palpation:

chest (scars):
JVP and venous pulse:
peripheral pulses (R/L lag, regularity, strength, contour):
1. carotid:
5. politeal:
2. brachial:
6. posterior tibialis:
3. radial:
7. dorsalis pedis:
4. femoral:
PMI (location, diameter, amplitude, duration):

Auscultation (supine, sitting, left lateral decubitus):

rate:
rhythm:
S1:
S3:
S2:
S4:
extra sounds (timing, shape, location, radiation, intensity):
carotid (bruit present):

Abdomen
Inspection:
skin (scars, striae, dilated veins):
umbilicus:
contour:
symmetry:
enlarged organs or masses:
peristalsis or pulsations:

Percussion:
areas of tenderness:
gas distribution:
air-fluid level, shifting dullness, fluid wave:
liver span (nl: 6-12 cm):
splenomegaly:
Palpation (sore points last):
rigidity:
masses:
peritonitis:
abdominal aorta:
rebound tenderness:
liver span:

Auscultation:
bowel sounds:
bruits:
friction rubs:

spleen:
Rovsings sign:
psoas sign:
obturator sign:
Murphys sign:

Musculoskeletal
Inspection and Palpation:
range of motion:
inflammation (erythema, swelling, warmth, tenderness):
crepitus:
deformity (bone or soft tissue):
surrounding tissues (atrophy or skin changes):
strength:
symmetry of movement:

Function:
gait:
spine curvature:
Drawer sign:
Phalens test:
Tinel's sign:

Neurological
Cranial nerves:
I: smell soap
V: sens: face; motor: mastication muscles
VII: facial expressions
IX/X: gag
XI: head turn, shoulder shrug
Motor:
strength (0-5, nerve function):
shoulders:
arms:
wrists:
grip:

fingers:
hips:
knees:
ankles (clonus):

Cerebellar:
rapid alternating movements (dysdiadochokinesis):
point-to-point test (dysmetria):
Rhomberg test:
gait (tandem walk, heel-toe, hop in place, rise from sit):
Sensory:
light touch (cotton whisp):
pain (sharp vs. dull):
position (of toes and fingers):
stereognosis:

vibration (128 Hz fork):

temperature (if pain abnl.):
two-point discrimination:
graphesthesia:

Reflexes (0-4+):
biceps (C5-6):
quadriceps (L3-4):
triceps (C7-8):
Achilles (S1-2):
brachioradialis (C5-6):
Primitive reflexes:
Babinski:
snout sign:
grasp sign:
glabellar sign:
suck sign:
Mini-Mental Status Exam ( = 30):
orientation (time and location = 10):
registration (identify 3 objects = 3):
attention and calculation (serial 7s = 5):
recall (3 objects = 3):
language (name, repeat, follow, read, write, draw = 9