History & Physical Exam pocketeard Name, adress, age, DOB, sex, race, religion, ‘occupation, attending/dictating physician, “date of admission CC - Chief Complair This ... year old/race/sex complaining of ... History of Present Illness Onset, symptoms, location, quality, quantity, timing, setting, agaravating or relieving factors, associated probl ‘Childhood diseases, adult discases (medical, surgical, obstetric, gynecologic and psychiatric illnesses), fceidents and injuries, Immunization (¢iphtheria, pertussis, polio, ‘tetanus, measles, mumps, influenza, ‘hepatitis B, hem. influenzae, pneumococc’) blood transfusion, ‘cardiac risk factors (male > 45, smoking, Fi obesity, diabetes, lipids, [neat eee ere reich pee ee a a er ga ee at ob a Slements Smoking mount, duration, typ) aleohal caffeine, substance abuse Eucation, occupation, marital tus, children, ese cet Parents, siblings, spouse, children: ‘ages, medical conditions, chronic and malignant diseases, hereditary diseases, causes of death and age at death _Reproductive/S Last menstrual period (duration, flow, regulafity, frequency), postmenopaussl hhemorthage, menarche, pregnancies, births, abortion, stilbirths, children, contraception, sexual life, libido, STD, discharge Insp apparent state of health, apparent age, signs of acute/chronic disease, nutritional status (normal, slim, cachectic, fat, posture, gait, dress, hygiene, cooperation; height, ight; Odor: alcohol, acetone, purulent, otten, fecal, urinous, medicinal Pulse rate (tachycardia); ratory rate (tachypnea); Tenpertre fe) Blood pressure (right, left; standing, lying); Mood: ight, appetite, seeping habit, fever, fatigue, weakness, general health Skin: color, rashes, sores, hhemorthages, hai los, cha HEENT: headache, migraine, vision changes, ‘ataracts, diplopia, tala, otormea, hearing changes rhinorhes, epstans, snus, sor throat, hoarseness Breasts: discharge, pain, enlargement, lesions, galactorriea tory: pleuritic pain, tachypnea, bronchitis, COPD, 18 Cardiovascular: angina, pepitations, CHE chronie cough, sputum, (nocturnal) dyspnea, cyanosis, edema, ascites, audleation, phlebitis, hypertension le ausea, vomiting, regurgitation: 4 atulene, dominal pain, constipation, area, 7 stols, hemorrhoid, hematochexl, elena, jaundice, pruritus Genitourinary: frequency, polyuria, dura, nocturia, flank pain; hematuria, discharge, dribbling, incontinence, retention, cole sido, potency, iy Hematologic: pallor, bleeding, bruising, ‘node swelling, recurrent infections Endoerine: polyphagia/-uria, goiter lethargy, hot/cold intolerance, nervousness, ‘obesity, change in sex characteristics, ‘amenorrhea, gynecomastia, flushing ric: nervousness, tension, affect, depression, anxiety, attention, volition, hallucinations, suicide ideation status (as indicated) Orientation: person, place, time; Memory: remote/recent memory, new learning ability: ‘Retention: spelling backward, “serial 75 Consciousness: alert, somnolent, comatose; Speech, language: quantity, rate, ioudness, laity lueney: hoarseness, aphasia; Posture, facial expression: ajtation, involuntary movements, tis, tremors; I: happiness, depression, anger, Thought, perception: processes, content, insight, Judgement (© 202-2005 - tm cence Pating LC wnmmedtacomIngp color (aio, redness jundice, Cyan) Fp tempest, motte, ‘igor (exscentian edema} creat topic Fae Rist len, lope i rst writs lope Nails: clubbing, paronychia ee ‘lymph Nodes Cervical allay, “HEENT Head (sal sal, Face): Isp shape size, sai i eurosecretion, mening eck sires; ere pam (creumserie, das) fy Tet a ey nel ei Itap symmetry eye poston bist, ‘xaphthalmey, bows Is ptosis ecropon, ‘chalazion, xanthelasma), conjunctivae (color, Injeeton) seer (aundie), coves sey, ups PERALA = pup qual round Feactve 10 ight ond secon; Palp tyebals eosistnoy isc gona {cretion aerial he: fest exesular movements (OM), ophthaimoscopy ted rel ote die veel pape emocrages relnopaty) Ears nap, Palp shaplsmmetry of uric, ‘oop ito ls on ; tor aay ipein, lpg), ifhearnged Webe/Mane test rochlea, inguinal sp ert artery pulse, “Aus flow murmur, Meas jugular venous P Heart Pap pulsstions, apical impute, radial alse (heart rate, rythm); ere cardiac Sunes relative absolute); Ause eer sounds, extra sounds (R55, siting), ‘alps ($4 murmurs liming teh; Peripheral vascular: Isp sin colo edema varicose veins Palpperiheral pulses (adi, Femoral, posterior til, dorsal peas) Insp skin, umbilicus, shape, volume, symmetry; distension, hernia, scars; Ause: ‘bowel sounds (motility), vascular murmurs, ‘ition rubs; Pere abdomen (tympantes, duliness), organ sizes, uid wave (sete Palp sboominal quadrants for guarding, ‘ender coud pain apenas ‘masses, hernias ver (hepatemegaly), spleen Gplenomegaly gallbladder (Murphys sign}, kidneys, bladder, pulses Female genitalia Insp aba, clitoris, urethral orfce (discharge, intoitus; skin ‘eruptions. inflammation, tumors, otrusions;Palp lymph nodes (inguinal), anal matin cr ey adnexa; Speeulum exam of vagina, cervix; Palp rectovaginal examination Nase: Insp extemal nose, Insp pecan) septum nasal mucosa, Pap ontlimasiry Sinus (pan on pressure) Test ofaction ‘Mouth: Insp, Pap jaw motion lips, salvary lands, cheeks, tongue teeth, mucosa pharyn. Sota goiter, nodules Insp ape of chest (fori), respiratory ‘movementsehythm (achypnes), expansion, fetvactions (C3) accessory muscles (termomastidl Palp compresion pin, tactile femitus, Iymph nodes fxr, supra) Infecc Peresound aati ules, yperesorance, diaphragmatic excursion; ‘Ase tenth sounds vest, Insp siz, symmetry, shape (protrusions, retraction skin (lees, ‘edema, nipple shape, discharge; Palp consistency, tenderness, nodules (ocation, ty Insp anus fissures, hemorrhoids, tumors); ‘Trachea: Ins, Palp mobility tenderness; _Palp sphincter walls (onus stenoses bloc, ‘Thyroid: Insp Pap consistency, siz, lumps; mueus poyos masses; Male: Palp prostate bronchovesiclar symmetry deceased (HS, temo: muscles (europe atrophi, Sounds adged sounds (recies whecrs, IYPETORHG strength (paras, arly) thonehi, bronchophony, egophony, tame (rigor spastic); Fu pa Male genitalia: Insp, Palp penis Gexual maturiy) prepuce (phimoss) las urethra Ineats (discharge), scrotum feria, hdrocee), testes lumps, tenderness), dyes sperma cord (aoc) (Sze, surfee, consistency, tenderness) rete: np Pal msi ones #2, symmetry, sweling, {unetonl impairment deformiey stn {venous pattern, eynoss tema: Spinal "lum: Insp, Palp ROM, curvatures tenderness: pan'onprestue/pere ‘Cranial nerves: function tess 1-12 Motor system: extrapyramidal symptoms tinger-to-nose, rp alterating meremers Fontes, pronaior di exes: biceps, ices, radsperostal patellar, Achilles tendon; "i ‘remaster, anal refiexe Sensory Examination: touch, pain, ‘temperature, vibration _ Size, shape, consistency, delineation, size, mobility tenderness), lary Wm ‘sou eoto-ea2e