A/P CC: Name

HPI: MRN
RM #
Admit Date

Meds (abx, pain, sedation, prophylaxis)
ROS Fam Hx
Constit: f/c, wt loss, nt sweats, fatigue
Eyes: eye pain, vision
ENT: in hearing, congestion, rhinorrhea, sore
throat, swallowing diff
CV: chest pain, SOB, palpitations, PND, orthopnea,
edema, calf pain
Resp: SOB, cough Social Hx
GI: n/v, diarr/constip, abd pain, blood in stool, Alcohol (last drink?)
hematemesis Tobacco
GU: burning, hematuria, urgency, frequency, Illicit Substances
nocturia, incont Living
Neuro: H/A, syncope, numb, tingling, weak Employment
MSK: musc/jt pain, weak, jt stiffness Married/Single/Divorced
Derm: rashes, itching Home Meds
Endo: heat or cold intolerance, polyuria,
polydipsia, polyphagia
Heme: bleeding, bruising, blood clots

PMHx/PSurgHx

Allergies
Vitals / I&O Phys Exam labs (CBC, BMP, other, imaging)

/ Subj Other labs (LFTs, Micro) To do

CBC

VS:
Tmax Phys Exam:
HR Eyes: PERRL, EOMI, pallor, icterus
BP ENT: moist mem, oral ulcers, hearing BMP
Neck: LAD, thyromegaly
RR CV: JVD, carotid bruit, RRR, m/r/g, periph pulses
Resp: CTAB, wheezing/rhonchi, resp effort Imaging (CXR, Echo, CT, MRI)
O2
Abd: ND/NT, +BS, guarding, rebound, organomeg
I/O Neuro: CN2-12 intact, numb, tingling, reflexes
MSK: muscle tone and ROM
Skin: rashes, ulcers Ca P Mg

/ Subj Other labs (LFTs, Micro) To do

CBC

VS:
Tmax Phys Exam:
HR Eyes: PERRL, EOMI, pallor, icterus
BP ENT: moist mem, oral ulcers, hearing BMP
Neck: LAD, thyromegaly
RR CV: JVD, carotid bruit, RRR, m/r/g, periph pulses
Resp: CTAB, wheezing/rhonchi, resp effort Imaging (CXR, Echo, CT, MRI)
O2
Abd: ND/NT, +BS, guarding, rebound, organomeg
I/O Neuro: CN2-12 intact, numb, tingling, reflexes
MSK: muscle tone and ROM
Skin: rashes, ulcers Ca P Mg

/ Subj Other labs (LFTs, Micro) To do

CBC

VS:
Tmax Phys Exam:
HR Eyes: PERRL, EOMI, pallor, icterus
BP ENT: moist mem, oral ulcers, hearing BMP
Neck: LAD, thyromegaly
RR CV: JVD, carotid bruit, RRR, m/r/g, periph pulses
Resp: CTAB, wheezing/rhonchi, resp effort Imaging (CXR, Echo, CT, MRI)
O2
Abd: ND/NT, +BS, guarding, rebound, organomeg
I/O Neuro: CN2-12 intact, numb, tingling, reflexes
MSK: muscle tone and ROM
Skin: rashes, ulcers Ca P Mg

/ Subj Other labs (LFTs, Micro) To do

CBC

VS:
Tmax Phys Exam:
HR Eyes: PERRL, EOMI, pallor, icterus
BP ENT: moist mem, oral ulcers, hearing BMP
Neck: LAD, thyromegaly
RR CV: JVD, carotid bruit, RRR, m/r/g, periph pulses
Resp: CTAB, wheezing/rhonchi, resp effort Imaging (CXR, Echo, CT, MRI)
O2
Abd: ND/NT, +BS, guarding, rebound, organomeg
I/O Neuro: CN2-12 intact, numb, tingling, reflexes
MSK: muscle tone and ROM
Skin: rashes, ulcers Ca P Mg