DOCUMENTATION OF HISTORY AND PHYSICAL EXAM

Patient Name (Initials only) :_____	Date examined ______

Preceptor Name:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS (chronology and progression, pertinent positive and negatives)

PAST MEDICAL HISTORY

Childhood and adult illness (HTN, TB, Ca, CAD, Bleeding Disorders, Sickle Cell)

Previous Hospitalizations/Surgery/Trauma/Fractures

Medications (Prescribed/OTC/Vitamins/Supplements/Herbal)

(Write generic names)

Medication Allergies/Adverse Reactions

Immunizations ___ Flu ____ Pneumonia ____Tdap _____Zoster

FAMILY HISTORY (HTN, TB, Cancer, CAD, Bleeding Disorders, Sickle Cell, diabetes, anemia, asthma, consanguinity)

SOCIAL HISTORY

Living Arrangement (s/m/w/d/partner)

Residence (house, apt., shelter, homeless; safety measures)

Sexual history (if appropriate)	Occupation

Environmental Exposures	Travel History

Tobacco, Alcohol and Other Drug Use

Diet and Exercise

Education (highest level attained)

REVIEW OF SYSTEMS-Please use lay language when talking to patients – you can document in medical terms. Describe all positive and pertinent negative findings.

Constitutional (fever, chills, night sweats, weight change, fatigue, malaise, nutrition, deformities, grooming)

Eyes (vision, pain, discharge, photophobia)

Ears/Nose/Throat (hearing, tinnitus, dizziness pain, discharge, smell, , hoarseness, nose bleeds smell, hearing, discharges, lesions, hoarseness)

Mouth / Dental (tooth decay, gum disease, last visit to dentist, speech problems, sinus drainage, taste, snoring)

Breast (lumps, nipple discharge, family history of breast cancer, self breast exam)

Cardiovascular (Palpitation, angina, heart attack, chest pain, shortness of breath, PND, orthopnea, claudication, syncope, hypertension, cyanosis, varicosities, edema)

Respiratory (asthma, dyspnea, cough/sputum, hemoptysis, TB skin test status)

Gastrointestinal (dysphagia, anorexia, nausea, vomiting, hematemesis, diarrhea, constipation, melena, rectal bleeding, change in bowel habits, hemorrhoids, jaundice, abdominal pain, food intolerance)

Genito-Urinary (dysuria, hematuria, frequency, polyuria, urgency, hesitancy, incontinence, renal stones, nocturia, infection, frequency dysuria, retention, incontinence)

Male Reproductive ( penile discharge, STD history, testicular pain or mass, infertility, impotence, libido)

Female Reproductive – menarche, last period, age of menopause, postmenopausal symptoms, postmenopausal bleeding, abnormal periods, , STD history, last Pap test, OB-Hx, discharge, odor, infertility, libido, method of contraception)

Musculoskeletal (joint pain (mono or poly articular), edema, heat, redness, stiffness, deformity, muscle pain, tenderness, fatigue (e.g. with arthritis), atrophy)

Neurological (headache, syncope, vertigo, seizures, loss of vision, diplopia, parasthesias paralysis, weakness in any limbs, tremor, ataxia, memory loss)

Skin (itching, rash, lump and bumps, hair and/or nail change, de/pigmentation)

Endocrine: (excessive thirst, sweating, dizziness, palpitations, weight change)

Hematologic/Lymphatic: (bruising, cyanosis, rashes, lesions, enlargement of lymph nodes, petechiae, purpura)

Psychiatric: (stress, insomnia, previous psychiatric illness, depression, anxiety, hallucinations, memory loss)

PHYSICAL EXAMINATION (Please describe your findings)

Vital Signs:

Ht.___________ Wt.___________	BMI__________

Temp_________ Pulse________BP___/____

RR________Pain________

General Appearance: (habitus, level of consciousness, distress)

Head (Hair, scalp and cranium)

Eyes

Lids and conjunctivae (discharge, icterus, ptosis, edema)

Pupils and irises (reaction to light and accommodation, size, symmetry, extraocular movements, visual fields, visual acuity)

Optic discs and posterior segments (size, Cup to disc ratio, appearance, vessel changes, exudates, hemorrhages)

Ears/Nose/Throat

External ears, nose (scars, lesions, masses, foreign body)

Otoscopic exam (external auditory canals, tympanic membranes/mobility)

Hearing (whispered voice, Rinne and Webber test)

Nose (Nasal Mucosa, septum, turbinates)

Mouth / Dental

Inspection of lips, teeth and gums

Oropharynx (oral mucosa, tonsils, tongue, palate, salivary glands, posterior pharynx)

Neck

Overall appearance (masses, symmetry, tracheal position, crepitus)

Thyroid (enlargement, tenderness, mass)

Lymph nodes

Respiratory

Inspection/respiratory effort and rhythm (shape, intercostal retractions, use of accessory muscles,)

Palpation of chest (chest movements, tactile fremitus, tenderness)

Percussion of the chest (dullness, hyperresonance)

Auscultation of lungs (breath sounds, adventitious sounds, rubs)

Cardiovascular

Neck Veins

Palpation of the heart (PMI location, size, thrills)

Auscultation: (normal sounds, abnormal sounds, murmurs)

Examination of:

Carotid arteries (pulses, bruits, amplitude)

Abdominal Aorta (size, bruits)

Femoral arteries (pulse, amplitude, bruits)

Pedal Pulses (pulse, amplitude)

Extremities (edema, varicosities)

Gastrointestinal

Inspection/auscultation of abdomen (masses, appearance of abdominal wall)

Palpation/percussion of liver, spleen, and general abdomen (enlargement, irregularities, ascites, masses)

Examination for presence/absence of hernia (inguinal, femoral, ventral)

Examination of anus, perineum, rectum (including patency, sphincter tone, hemorrhoids, rectal masses when indicated)

Obtain stool sample for occult blood (when indicated)

Lymphatic (Palpation of Nodes in 2 or more areas)

Neck	Axillae	Groin	Other

Skin and Subcutaneous Tissue

Inspection (rashes, lesions, ulcers)

Palpation (induration, subcutaneous nodules, tightening)

Back, Extremities, Musculoskeletal

Gait

Inspection/palpation of digits, nails (clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Examination of the Joints, Bones, and Muscles in one or more of the six areas below:

Head and Neck

Left Upper Extremity

Right Upper Extremity

Spine, ribs, and pelvis/hips

Right Lower Extremity

Left Lower Extremity

Include for each area:

Inspection/palpation / Range of Motion / Stability / Muscle Strength & Tone

Neurological

Level of consciousness, higher functions and speech

Test of cranial nerves with notation of deficits

Motor system including deep tendon reflexes, strength, tone, & cerebral function

Sensation (touch, pain, vibration, proprioception & Babinski)

Cerebellar signs

Gait

Abnormal movements (tremors, choreoathetoid, dystonia, tics)

Psychiatric:

Description of insight and judgment

Assessment of mental status (including orientation to time, place, person, recent and remote memory, mood and affect,depression, anxiety, agitation)

List 3 main problems identified in this patient

1. __________________________

2. __________________________

3. __________________________

List 3 differential diagnoses for Problem #1 (above)

Signature	Student Name (printed)

Comments from Preceptor:

DOCUMENTATION OF HISTORY AND PHYSICAL EXAM

Wayne State University

2008-10-20

Admin

Wayne State University School of Medicine