History and Physical (H&P)

HISTORY AND PHYSICAL EXAM (H&P)

HISTORY

CHIEF COMPLAINT (CC):

HISTORY OF PRESENT ILLNESS (HPI);

Symptoms - Onset, Duration, Frequency, Location

Pain- associated symptoms; precipitating/Aggravating/alleviating; Quality of pain (dull, sharp, burning, throbbing etc); Radiation or Referred; Severity (mild, moderate, severe);Setting (onset, duration, frequency, location); Timing and Chronology 

PAST MEDICAL HISTORY;

Childhood Illnesses: Mumps, Measles, Rubella, Chicken Pox

Adult Illness:

Injuries/Accidents:

Hospitalizations:

Immunizations: Influenza, Pneumovax etc.

Medical Conditions: D/M, HTN, CHF, COPD etc.

Preventive Care/Screening: Pap. Mammogram, Colonoscopy etc.

PAST SURGICAL HISTORY:

Appendectomy

Lumpectomy

FAMILY HISTORY (parents and siblings):

HTN, D/M, CVA, Cancer, MI, Asthma, Depression etc.

SOCIAL HISTORY

Living arrangements

Marital status

Employment/Occupation

Diet

Physical activity

Sexual health (more than one sexual partner, sex with men, women, both or neither?)

HABITS

Tobacco

Alcohol

Illicit Drugs (Cocaine, Marijuana, Heroin, Amphetamines, Ecstasy)

MEDICATIONS:

Prescribed (all prescription meds)

OTC (Vitamins, supplements, and minerals)

Herbs

ALLERGIES:

Medications

Environmental (food animals, plants, latex, iodine, etc.)

REVIEW OF SYSTEMS (ROS)

(Use No, None, not present, or denies when entering patient’s responses. Where there are positive responses, describe what the patient tells you. Pt reports hematuria (mild, moderate or severe?)

GENERAL:

Weight: Normal

Fever: none

Chills: none

Night Sweats: none

Lassitude/Tiredness: none

ENDOCRINE:

Heat/Cold Intolerance: none

Polyuria: none

Polydipsia: none

Nocturia: none 

Hair changes

Heat or cold intolerance

Change on glove or shoe size

Tremors

HEENT:

Headaches: none

Nasal Discharge/Stuffiness: none

Hearing Loss: none

Loss of Vision: none

Drainage/Edema from ears: none

Blurred Vision: none

Double Vision: none

PULMONARY:

Cough: not present

Sputum Production on cough: none

Hemoptysis: none

Shorthness of breath: none

Pleuritic Chest Pains: none

CARDIAC:

Chest Pain: no

Palpitations: none

Syncope: none

Dizziness: none

Dyspnea on Exertion: none

Paroxysmal nocturnal dyspnea: none

Orthopnea: none

Peripheral Edema: none

BREASTS:

Skin changes: no

Masses: None

Nipple Discharge (color/consistency)

Pain

GASTROINTESTINAL:

Appetite: normal

Dysphagia: none

Abdominal Pain: none

Nausea/Vomiting: none

Bowel Movements: normal bowel movements

GENITO-URINARY:

Dysuria: none

Urgency:

Hematuria:

Nocturia: none

Masses/Tenderness’s: not present

Straining or incomplete voiding: no

Incontinence: none

Flank/Abdominal Pain: none

Sexual Function: none

MALE: Penile discharge, Warts, Testicular pain/masses, Hernia, STDS, Difficulty with erection or libido

FEMALE: Vaginal discharge; Pelvic pain/masses; STDs; Contraception; Abnornal pap smears; Last menses (regular, frequency, duration, flow); Menopause (hot flashes, hormones); Number of pregnacy; Number of living children; Number of abortion/Miscarriages

NEUROLOGIC

Loss of Motor Skills: none

Sensory Loss: none

EXTREMITIES:

Leg edema

Sensation

Clots

Pain with walking

LYMPHHATICS:

Enlarged and tender nodes

PSYCHIATRIC:

Anxiety:

Depression:

Panic Disorder:

Memory loss/changes

Nervousness:

Irritability:

Fears:

Violent behavior:

Sexual disturbances:

VITAL SIGNS:

BP 158/80: (10/4/1990)

Pulse 58: (10/4/1990)

Respiration: 14 (10/4/1990)

Temperature: 97.9 F [36.6 C] (10/4/1990)

Pain score: 7 (10/4/1990)

PHYSICAL EXAM (PE)

GENERAL: NOT IN ACUTE DISTRESS. PATIENT APPEARS TO BE STABLE

HEAD: ATRAUMTIC, NORMOCEPHALIC.

NECK: TRACHEA IN MIDLINE. MASSES, BRUITS, JVD, THYROID

EYES: PERRLA, EOM

EAR:  CANALS: PATENT

NOSE: NARES PATENT

PHARYNX: NO TONSILAR EXUDATE OR ERYTHEMA, NO MASSES

NECK: NO LYMPHADENOPATHY, NO THYROMEGALY

HEART: RATE RHYTHM, REGULAR, NO MM, NO RUBS, NO GALLOP

BREAST: NIPPLE DISCHARGE, MASSES, CONTOUR, COLOR CHANGES

LUNG: CLEAR TO AUSCULTATION.

ABDOMEN: NOT DISTENDED, SOFT, NO MASSES, NO HEPATOSPLENOMEGALY, BRUITS, REBOUND TENDERNESS, NORMAL BS

GENITO-URINARY:  NML MALE, NO HERNIA

RECTAL: TONE, MASSES, HEMORRHOIDS, BLOOD

MUSCULOSKELETAL: STENGTH, MASS, MUSCLE, TONE, ATROPHY, FASCICULATIONS, TREMORS, BABINSKI SIGN, HEEL WALKING, TOE WALKING, CHORES

PROSTATE CONTOUR: NML

INTEGUMENT: INTACT, DRY, HAIR/NAILS/SKIN COLR, SWELLING, INFLAMMATION, RASH, MOLES, LESIONS, NO BREAKDOWN, and PRESSURE SORES:

NEURO: ALERT & ORIENTED X 3, CRANIAL NERVES GROSSLY INTACT; SENSORY; NO PINPRICK BILAT, NO LIGHT TOUCH BILAT; MOTOR; VOLUNTARY CONTRACTION

FEMALE EXTERNAL (GU): NORMAL LESIONS, DISCHARGE-VAGINA, TENDER CERVIX, TENDER UTERUS OR ADNEXA, MASSESS, UTERUS SIZE/SHAPE

MALE EXTERNAL (GU): NORMAL CIRCUMCISION, DISCHARGE-URETHRA, LESIONS, TESTES, SCOTAL MASSES, HERNIA, HYDROCELE

LYMPHATICS: NODES- LOCATIONS, SIZE, MOBILE, FIXED

PSYCHIATRIC:

   MINI MENTAL STATUS EXAM –

PLACE: CITY, COUNTY, STATE

TIME: DAY, DATE, MONTH, YEAR

   RECALL: 3 TIMES

SERIAL: 7’S

NAMING: 2 ITEMS

WRITE A SENTENCE

FOLLOW DIRECTIONS: TAKE A PAPER, FOLD IN HALF, PUT ON DESK

COPY DRAWING OF 2 PENTAGONS

         AFFECT/DRESS/EMOTIONAL STATUS/POSTURE

         HALLUCINATIONS – VISUAL AUDITORY

         DELUSIONS

         ILLUSIONS

MEDICATIONS:

1. Lisinopril 10mg once dail

2. Hydrochlothiazide (HCTZ) 12.5mg once daily

3. Metformin 500mg BID

4. Lipitor 10mg QHS

5. Xarelto 20mg once daily

ASSESSMENT/PLAN:

HTN (hypertension)

-Lisinopril 10mg once day

-DASH diet

-HCTZ 12.5mg once daily

-Measure bp twice daily and record for next appt.

D/M (Diabetes Mellitus)

-Diabetic diet

-SSI (Sliding Scale Insulin)

-ACHS (Accu-check AC (before breakfast) and HS (night)

-Metformin 500mg BID

-Continue to monitor

HLD (hyperlipidemia)

-Continue Lipitor 10mg QHS

-Low fat diet

-Monitor lipid level q3 months

-Start 30 mins at least 3 x daily of moderate exercise

-Monitor for side effect – muscle ache 

DVT (LE) (Deep Venous Thrombosis – Lower Extremities)

- Continue Xarelto 20mg once daily

- Monitor closely for bruises

- Monitor renal function