CC:  Pack years: # packs/day * # years

Location smoking
 Illegal drug use
 What? Quantity? Frequency? Route?
Severity  Sexual Hx
 Are you currently sexually active?
 Are you in an intimate relationship?
Times Multiple partners? # in last year?
 Men women or both?
 Oral, anal, vaginal? Give receive or
Characteristics both?
 Protection? Contraceptives, STD
protection
Agitation/Allocation
 Periods? Regular? When was the last?
 Pregnant?
 Do you have any problems? Pain?
Environment
 Discharge? Rash?
 Hx of STD?
Other Symptoms  Abusive relationship?
 Safe
o Stress/Safety
o Abused/Afraid
PMH o Friends/family
 Childhood illness o Emergency plan
 Trauma Full H&P
HPI
 Hospitalizations
PMH
 Surgeries
FH
 Chronic illness
SH
 Gynecologic/reproductive: periods, pregnancy,
ROS
birth control
PE, vitals, general appearance
 Health maintenance: immunizations, screenings Assessment
 Medications, supplements Plan
 Allergies
FHx
Vitals:
 Diabetes
 Hypertension
Weight
 Cancer Temp:
 Heart disease; age of occurrence Respiratory Rate:
 Genetic Blood Pressure:
 Psychiatric Pulse:
 Contagious O2 Saturation:
 Toxic
SHx
 Occupation Extra Info
 Highest level of education  Depression screen
 Household  Sleep
 Significant other/ marital status  Insomnia
 stressors  Guilt
 Lifestyle  Energy
 Diet  Concentration
 Exercise  Appetite
 Hobbies  Psychomotor
 Caffeine use  Suicidal
 Alcohol
 Tobacco
 What kind? How much?
ROS d. Odynophagia
1. General e. Dysphagia
a. Alert/ Responsive f. Pain
b. Weight loss/gain g. stiffness
c. Malaise 11. Cardio
d. Fever a. Palpitations
e. Chills b. Chest pain
f. Weakness c. SOB
g. diaphoresis d. Tachycardia
2. Skin e. Paroxysmal nocturnal dyspnea
a. Rashes f. Claudication
b. Itching g. edema
c. Dry skin 12. Pulmonary
d. Sweating more/less a. Coughs
e. Color b. Hemoptysis
f. Hair/nails c. Wheezing
3. Muscular d. dyspnea
a. Muscle aches 13. Gastro
b. Weakness a. Emesis
c. Numbness b. Hematemesis
d. Tingling c. BM changes
4. Bone d. Loose watery stools, diarrhea
a. Joint pain e. Abdominal pain
b. Mobility f. Black tarry stools (melena)
5. Nervous g. Reflux
a. Dizziness h. Belching/burping/weird taste
b. Fainting 14. Urinary
c. Numbness a. Incontinence
d. Tingling b. Urgency
e. Seizures c. Frequency
6. Eyes d. Hematuria
a. Vision changes e. nocturia
b. Double vision 15. Genital
c. photophobia a. Sexual dysfunction, pain
d. Vision blurriness 16. OB
e. Eye pain a. Periods
f. Dry eyes i. When
g. redness ii. Pain
7. Ears iii. How long
a. Difficulty/change in hearing b. Children?
b. Tinnitus i. How many
c. Otalgia ii. Route of delivery
d. discharge iii. Problems
8. Nose c. Breasts
a. Nasal discharge i. Lumps
b. Sense of smell ii. Pain
c. Epistaxis iii. Discharge
d. Congestion iv. Redness
e. Sinus pain v. Nursing?
9. Mouth/throat vi. Self exam?
a. Dry mouth 17. Psych
b. Sores/pain a. Depression
c. Difficulty chewing/swallowing
d. Tooth pain
10. Throat/thyroid/neck
a. Change in voice sound/hoarseness
b. Goiter
c. Lumps
Physical Exam RECTAL: Good sphincter tone with no anal,
GENERAL: Well developed, well nourished, alert perineal or rectal lesions. Prostate is not tender,
and cooperative, and appears to be in no acute enlarged, boggy, or nodular.
distress. GENITALIA: Genital exam revealed normally
SKIN, HAIR, NAILS: Skin normal color, texture and developed male genitalia. No scrotal mass or
turgor with no lesions or eruptions. No lesions on tenderness, no hernias or inquinal
scalp. Hair and nail normal texture. lymphadenopathy. No perineal or perianal
HEAD –No palpable masses or lymph nodes. No abnormalities are seen. No genital lesions or
lesions or deformities. Normocephalic. urethral discharge.
EARS – Clear tympanic membranes with visible
cone of light. Normally developed external female genitalia with
EYES – Pupils equal, round, reactive to light and no external lesions or eruptions. Vagina and cervix
accommodation PERRLA, extraocular movements have no lesions, inflammation, discharge or
intact EOMI tenderness. Cervix is nontender. Uterus is within
NOSE – Moist mucous membranes, No normal limits with no adnexal fullness.
hypertrophy, erythema, and rhinorrhea in both
nostrils.
NECK – Neck supple, non-tender without
lymphadenopathy, masses, or thyromegaly.
THROAT – Oral cavity and phyarnx normal. No
inflammation, swelling, exudate, or lesions. Teeth
and gingiva in good general condition
LUNGS: Clear to auscultation and percussion
without rales, rhonchi, wheezing or diminished
breath sounds. Normal chest expansion. Normal
tactile fremitus and egophany.
HEART/CARDIOVASCULAR: RRR. Normal S1 and S2.
No S3, S4 or murmurs.There is no peripheral
edema, cyanosis or pallor. Extremities are warm
and well perfused. Capillary refill is less than 2
seconds. No carotid bruits.
ABDOMEN: Positive bowel sounds. Soft, non
distended, nontender. No hepatomegaly or
splenomagly. No guarding or rebound. No masses.
MUSCULOSKELETAL: Adequately aligned spine.
ROM intact spine and extremities. No joint
erythema or tenderness. Normal muscular
development. Normal gait.
NEUROLOGIC: : CN II-XII intact. Strength and
sensation symmetric and intact throughout.
Reflexes 2+ throughout. Cerebellar testing normal.
PSYCHIATRIC: The mental examination revealed
the patient was oriented to person, place, and
time. The patient was able to demonstrate good
judgement and reason, without hallucinations,
abnormal affect or abnormal behaviors during the
examination. Patient is not suicidal.