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    History and Physical Sheet

    Uploaded by

    jonnyahn
    This document contains a patient's medical history and physical exam findings. It includes sections on the patient's chief complaint, history of present illness, past medical history, review of systems, social history, medications, vital signs, physical exam findings, problem list, and plan of care. The document collects comprehensive information on the patient to inform their diagnosis and clinical management.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    History and Physical Sheet

    Uploaded by

    jonnyahn
    291 views4 pages
    This document contains a patient's medical history and physical exam findings. It includes sections on the patient's chief complaint, history of present illness, past medical history, review of systems, social history, medications, vital signs, physical exam findings, problem list, and plan of care. The document collects comprehensive information on the patient to inform their diagnosis and clinical management.

    Original Description:

    History and Physical Sheet for Medical students with review of systems.

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    © © All Rights Reserved

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    This document contains a patient's medical history and physical exam findings. It includes sections on the patient's chief complaint, history of present illness, past medical history, review of systems, social history, medications, vital signs, physical exam findings, problem list, and plan of care. The document collects comprehensive information on the patient to inform their diagnosis and clinical management.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    291 views4 pages

    History and Physical Sheet

    Uploaded by

    jonnyahn
    This document contains a patient's medical history and physical exam findings. It includes sections on the patient's chief complaint, history of present illness, past medical history, review of systems, social history, medications, vital signs, physical exam findings, problem list, and plan of care. The document collects comprehensive information on the patient to inform their diagnosis and clinical management.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    At a glance
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    The document appears to be a template for collecting a patient's medical history and performing a physical exam. It includes sections for symptoms, medications, physical exam findings, problem list, and baselines.

    Details are collected about the chief complaint, past medical history, surgical history, social history, review of systems, current medications, and family history.

    The physical exam emphasizes inspecting, palpating, auscultating and percussing different body systems such as the head, eyes, neck, heart, lungs, abdomen, muscles, lymph nodes, skin and nerves. It also checks for things like pedal pulses, thyroid, distress and strength.

    Name: MRN: Room #: Day Admit: LOS:

    CC:

    HPI:
    Note: Timeline when exactly, usual state of healthy, first unusual sign, progression, what
    happened in ER?














    PMHx: Previous hospitalizations:
    Diabetes: Last A1C Last Eye Exam Neuropathy Medication Microalbumin


    HLD: Last LDL Last TG Statin? _______ Dose: _______


    CAD: MI? x _____; When? How many?
    - CABG? ______ Stents Plavix? Last E. fraction ______ Last Echo:
    - Medications


    HTN: Last BP or range/Medication


    CHF: Functional status on NML day, how is it worse? Baseline? Dry weight?
    - SOB? Orthopnea pillows? Chest pain? JVD? Leg swelling


    COPD: Smoking? ______ pack a DAY or YEARS. Inhaler? Last PFT.







    PSHx:



    FHx:




    SHx:
    - Live with? _________________ Person to contact:
    1. Tobacco

    2. EtOH

    3. Marijuana ! Cocaine ! Meth ! Heroin ! Other

    4. Received treatment for any drug problem?

    ROS: (Ask about actual diagnoses)
    Gen: Weight Loss Weight Gain Fever Chills Sleep Prblms Fatigue Malaise

    HEENT: Headache Trauma Vertigo Passing out Seizures Memory

    GI: !Appetite Nausea Vomiting Hematemesis Blood per rectum melena Diarrhea
    Constipation Rectal pain Hernia

    CV: Chest pain Palpitations Ascites Cyanosis Phlebitis

    RESP: Dyspnea Orthopnea Wheezing Cough Sputum Hemoptysis # pillows Asthma

    GU: Polyuria/Oliguria Pain with urination Blood BPH Incontinence Stones STD UTI

    MSK: Muscle pain Weakness Joint swelling Joint pain Shoulder pain Back pain Gout

    NEURO: Smell Visual Facial weakness Numbness/Tingle Balance Speech Swallowing

    SKIN: Lesions Rash Itching Change in moles Change in Distribution

    ENDO: Polyphagia Polydipsia Decreased energy/Fatigue

    PSYCH: SIGECAPS MOOD: Depression Anxiety

    HEME: Anemia Easy Bruising

    Medications
    Antibiotics: Start: Stop: Day:

    Beta-blocker:

    Diuretic:

    Diabetes:

    ACEI/ARB:

    Anticoagulation:

    Psychiatric:
    Drugs: Schedule: Drugs: Schedule:
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV IM SQ
    SL DAILY BID
    TID QID PRN q4h
    q8h q12h q24h
    PO IV SQ SL
    DAILY BID TID QID
    PRN
    q4h q8h q12h q24h
    Additional Notes: (compliance, etc)

    Time/Location:
    Temp
    BP
    sitting or supine?

    HR:
    RR:
    SaO2
    room/O2








    Imaging/Other Labs:





    Physical Exam: Inspect, Palpate, Ausculatate, Percuss
    Emphasize describe fully
    Gen: Alert x O: Person Place and Time (Date year)? Distress/Pain?
    Head/Mouth: Ulcers? Dry?
    Eyes: Injection? Jaundice? EOMI? PERRL?
    Nose/Ears: Dry, erythema
    Neck/Throat: Thyroid?
    CV: CHECK PEDAL PULSES. Tilt?
    Pulm: CTAB
    Abdominal: Percussion?
    Musculoskeletal:
    Lymph:
    Skin:
    Neuro:
    Reflexes:
    Strength: 3/5 is gravity only
    + / - Romberg



















    Problem List:
    Problem and DDx: Action/Plan/Work-up
    #




    #




    #




    #




    #:






    #:


    #







    Baselines:













    Primary Care Physician:




    _____________________________________________________






    To do list:

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