significant medical problems.Name of informant(patient, relative).
Chief Compliant: Reason given by patient for seeking medical care
and the duration of the symptom.List all of the patients medical problems.
History of Present Illness (HPI): Describe the course of the patient's
illness,including when it began, character of the symptoms,location
where the symptoms began; aggravating or alleviating factors;
pertinent positives and negatives.
Describe past illnesses or surgeries,and past diagnostic testing.
Past Medical History (PMH): Past diseases, surgeries,hospitalizations;
medical problems;history of diabetes,hypertension, peptic ulcer disease,
asthma, myocardial infarction, cancer.In children include birth history,
prenatal history,immunizations,and type of feedings.
Medications:
Allergies: Penicillin, codeine?Family History: Medical problems in family, including the patient's disorder.
Asthma, coronary artery disease,heart failure, cancer, tuberculosis.
Social History: Alcohol, smoking, drug usage.
Marital status, employment situation.Level of education.
Review of Systems (ROS):
General: Weight gain or loss, loss of appetite, fever,chills, fatigue, night sweats.Skin: Rashes, skin discolorations.
Head: Headaches, dizziness, masses, seizures.
Eyes: Visual changes, eye pain.
Ears: Tinnitus, vertigo, hearing loss.
Nose: Nose bleeds, discharge, sinus diseases.
Mouth and Throat: Dental disease, hoarseness,throat pain.
Respiratory: Cough, shortness of breath, sputum(color).
Cardiovascular: Chest pain, orthopnea, paroxysmalnocturnal dyspnea;
dyspnea on exertion,claudication,edema, valvular disease.
Gastrointestinal: Dysphagia, abdominal pain,nausea, vomiting,
hematemesis, diarrhea,constipation,melena (black tarry stools),
hematochezia (bright red blood per rectum).
Genitourinary: Dysuria, frequency, hesitancy,hematuria, discharge.
Gynecological: Gravida/para, abortions, last menstrual period
(frequency, duration),age of menarche,menopause; dysmenorrhea,
contraception, vaginal bleeding,breast masses.
Endocrine: Polyuria, polydipsia, skin or hair changes,heat intolerance.
Musculoskeletal: Joint pain or swelling, arthritis,myalgias.
Skin and Lymphatics: Easy bruising,lymphadenopathy.
Neuropsychiatric: Weakness, seizures, memory changes, depression.
Physical Examination
General appearance: Note whether the patient appearsill, well, or malnourished.Vital Signs: Temperature, heart rate, respirations, blood pressure.
Skin: Rashes, scars, moles, capillary refill (in seconds).
Lymph Nodes: Cervical, supraclavicular, axillary, inguinal nodes; size, tenderness.
Head: Bruising, masses. Check fontanels in pediatric patients.
Eyes: Pupils equal round and react to light and accommodation(PERRLA);
extra ocular movements intact(EOMI), and visual fields.Funduscopy
(papilledema,arteriovenous nicking, hemorrhages, exudates); scleral icterus, ptosis.
Ears: Acuity, tympanic membranes (dull, shiny, intact,injected, bulging).
Mouth and Throat: Mucus membrane color and moisture;oral lesions,
dentition,pharynx, tonsils.
Neck: Jugulovenous distention (JVD) at a 45 degree incline, thyromegaly,
lymphadenopathy,masses, bruits,abdominojugular reflux.
Chest: Equal expansion, tactile fremitus, percussion,auscultation, rhonchi,
crackles,rubs,breath sounds,egophony, whispered pectoriloquy.
Heart: Point of maximal impulse (PMI), thrills (palpable turbulence);
regular rate and rhythm (RRR),first and second heart sounds (S1, S2);
gallops (S3, S4),murmurs (grade 1-6), pulses (graded 0-2+).
Breast: Dimpling, tenderness, masses, nipple discharge;axillary masses.
Abdomen: Contour (flat, scaphoid, obese, distended);scars,
bowel sounds,bruits, tenderness,masses, liver span by percussion;
hepatomegaly,splenomegaly;guarding, rebound, percussion note
(tympanic),costovertebral angle tenderness(CVAT), suprapubic tenderness.
Genitourinary: Inguinal masses, hernias, scrotum,testicles, varicoceles.
Pelvic Examination: Vaginal mucosa, cervical discharge,uterine size,
masses,adnexal masses, ovaries.
Extremities: Joint swelling, range of motion, edema(grade 1-4+);
cyanosis,clubbing, edema (CCE);pulses(radial, ulnar, femoral, popliteal,
posterior tibial, dorsalis pedis; simultaneous palpation of radial and
femoral pulses).
Rectal Examination: Sphincter tone, masses, fissures;test for occult blood,
prostate (nodules,tenderness,size).
Neurological: Mental status and affect; gait, strength(graded 0-5);
touch sensation,pressure, pain,position and vibration; deep tendon reflexes
(biceps, triceps,patellar,ankle; graded 0-4+);Romberg test
(ability to stand erect with arms outstretched and eyes closed).
Cranial Nerve Examination:
I: SmellII: Vision and visual fields
III, IV, VI: Pupil responses to light, extraocular eye movements, ptosis
V: Facial sensation, ability to open jaw against resistance,corneal reflex.
VII: Close eyes tightly, smile, show teeth
VIII: Hears watch tic; Weber test (lateralization of sound when tuning
fork is placed on top of head);Rinne test (air conduction last longer
than bone conduction when tuning fork is placed on mastoid process)
IX, X: Palette moves in midline when patient says “ah,” speech
XI: Shoulder shrug and turns head against resistance
XII: Stick out tongue in midline
Labs: Electrolytes (sodium, potassium, bicarbonate,chloride, BUN,
creatinine), CBC (hemoglobin,hematocrit,WBC count, platelets,differential);
X-rays,ECG, urine analysis (UA),liver function tests (LFTs).Assessment
(Impression):Assign a number to each problem and discuss separately.
Discuss differential diagnosis and give reasons that support the working
diagnosis;give reasons for excluding other diagnoses.
Plan: Describe therapeutic plan for each numbered problem, including
testing,laboratory studies,medications,and antibiotics.
