- Dr Stella E. Okereke-Nwokeji
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
