Eina Jane Marie © 2010. All rights reserved. 1 of 2

Date and Time: ID: Age: ___ Gender: ___ Ethnicity: Insurance:

AD/Living Will Copy Health Proxy: _______________ (relationship)

CC: “ HPI: PMH: PSH: SH:

ETOH (kind ______, amount _____ x day/week/month) Smoking ( ___PPD x ____ yrs) quit? When? ________

Recreational drugs (kind _____, amt _____, duration_______) Married / Divorced / Single / Children # Retired / Career ______________

Meds/OTC/Herbals: Allergies/Reactions: NKDA FMH: mother/father/siblings/grandparents/children M F

Review of Systems: General: denies fatigue, loss/increase appetite, weight change, weakness, fever, chills, night sweats Head: denies lumps, asymmetry, syncope, headache, dizziness, vertigo, recent trauma Eyes: denies pain, redness, itching, burning, discharge, swelling, excessive tearing, blurring of vision, diplopia, spots, photophobia, changes in vision or visual fields, glasses/corrective lenses/contact lens, date of last eye exam and name of provide

Ears: denies pain, discharge, infections, tinnitus, changes in hearing, injury, hearing aid, audiometry; date and provider name Nose: denies epistaxis, obstruction, airflow, discharge, frequent colds, olfactory changes, postnasal drip, sinus pain or infection. Mouth/Throat: denies bleeding gums, sores in mouth, toothache, changes in taste, dentures, sore throat, difficulty chewing or swallowing, hoarseness, voice changes, date of last dental exam and provider. ADL: Dental Hygiene. Neck/Nodes: denies pain, stiffness, masses, swelling, swollen glands Breast/Axilla: denies lumps, discharge, pain, tenderness, dimpling, contour changes, nipple changes

SBE: When, how often, last mammography, date and provider Respiratory: denies cough, sputum production, hemoptysis, chest pain, shortness of breath, wheezing, asthma, bronchitis, pneumonia, emphysema, date of last CXR, date of PPD and results. Cardiovascular: denies chest pain or tightness, palpitations, dyspnea, murmur, edema, paroxysmal nocturnal dyspnea, known heart murmur, date of last EKG and results, date of cardiology consult and provider. GI: denies Anorexia, nausea, vomiting, dysphagia, indigestion, belching, heartburn, hematemesis, abdominal pain, ulcers, jaundice, food intolerance, diarrhea, constipation, change in bowel habits, bloody or tarry stools, pain or rectal itching, rectal bleeding. Last rectal exam, Guiac and results GU: denies frequency, urgency, burning, dysuria, hematuria, nocturia, incontinence, change in color or odor, dribbling, retention, oliguria. ADL: Urinary pattern, urology consult, date of exam and provider

Male Genital: Weak urine stream, discharge from penis, lesions, testicular pain or swelling, lumps on testicles, sexual dysfunction, STD’s. ADL: TSE, use of condoms, sexuality

Female Genital: Menstrual history, (age of onset, frequency of menses, duration of menses), LMP, menorrhagia, metrorrhagia, post-menopausal bleeding, amenorrhea, dysmenorrhea, vaginal discharge, lesions on vulva, vulva pruritus, pregnancies, (Gravida-Para-Abortions-Live births), dyspareunia, STD’s Age of menarche: _____ Number of pregnancies: G Flow/Frequency of menses: ______ Number of Term >20wks: T Duration of menses: _______ Number of Preterm <20 wks: P Exposure to DES: Number of abortions/miscarriages: A Complications of pregnancies: Number of Living: L

ADL: Last GYN exam, date and result of last pap smear, birth control Vascular: denies edema, phlebitis, calf pain, intermittent claudication, varicose veins, emboli Musculoskeletal: denies pains in joints, swelling, heat, redness, stiffness, muscle weakness, muscle aching or pain, back pain or injury, limitation in movement, ROM

Eina Jane Marie © 2010. All rights reserved. 2 of 2

Neuro: denies fainting, dizziness, seizures, numbness, tingling, parasthesias, weakness, speech disorders, tremors, headaches, head injuries, imbalance, loss of balance or coordination, mood or temperament changes, memory changes, loss of consciousness Endocrine: denies temperature intolerance or sensitivity to heat or cold, polyuria, polydipsia, polyphagia, glycosuria, weight changes, voice changes, change in glove or shoe size, fatigue Hematology: denies bleeding tendencies, bruising, lymph node enlargement, blood type, history of transfusions Psychology: denies suicidal ideation, depression, history of mental illness, anxiety, depression

Physical Exam: Vitals: BP: HR: RR: SaO2: T: HT: WT: BMI: General: AAOx3, mood ______, adult, gender ______, in no acute distress, nutritional status, personal hygiene, posture,

anxiety, appears stated age Skin: texture, color, temperature, turgor, any lesions

Note hair distribution, amount, hair texture Note color of nail beds and shape of nails

Head: Note size, shape, symmetry, unusual lesions Eye: Position and alignment, eyebrow, eyelidslacrimal glands, cornea, sclera (jaundice), conjunctiva (color, injection), cornea, pupils

Test visual fields, pupillary reaction ! PERRLA (pupils equal, round, reactive to light and accommodation), EOMI (extra ocular movements intact), nystagmus

Fundoscopic exam: cataracts, red reflex, optic disc, vessels: papilledema, hemorrhages, retinopathy

Snellen chart Ears: Inspect auricles, canals, TM

Auditory acuity (whispering, clapping) Weber (forehead, equidistant, which ear is the sound louder?

Lateralization to left or right?) unilateral conductive loudest in affective ear

Rinne (normal AC > BC +Rinne, conductive AC < BC –Rinne, sensorineural AC > BC +Rinne ) Nose/Sinuses: Inspect normal nose, septum, nasal mucosa. Pain/pressure frontal/maxillary sinuses Mouth/Throat: Jaw motion, lips, salivary glands, cheeks, tongue, teeth, gums, oral mucosa, pharynx, soft/hard palate, tonsils Neck/Nodes: neck, supple, no masses, trachea midline, no carotid bruits

Note size, consistency, mobility, tenderness: preauricular, postauricular, occipital, tonsillar, submandibular, submental, superficial anterior cervical, supraclavicular, deep cervical

Thyroid gland: visible, symmetrical. Note size, symmetry, position of lobes, presence of nodules. Usually unpalpable. No goiter/nodules

Breast: Size, symmetry, shape (protrusions, retractions), discharge, consistency, tenderness, nodules (location, size, shape, consistency, mobility, tenderness), axillary lymph nodes Respiratory: easy, unlabored, clear bilat; ausculate posterior, tactile fremitus, percuss dullness/hyperresonance, Auscultate decreased sounds, added sounds: crackles, wheezes, rhonchi, bronchophony, egophony, pectoriloquy Cardiovascular: RRR, normal S1 S2, no murmurs/rubs/gallops, grade ___/6 murmur (timing, shape, location, pitch: snap, rub, click), radiates to carotid GI: +BS, soft, non-tender, auscultate sounds, murmurs, rubs, percuss tympany/dullness, organomegaly, ascites, palp guarding, tenderness rebound, hernias Vascular: no ____ R/L pitting edema Pulses:

DP PT POP FEM RADIAL Right Left

Genital/Rectum: N/A deferred Musculoskeletal: muscles, joints, symmetry, swelling, DTR, ROM, tenderness, pain/pressure Neuro: vibration, touch, pain, temp, strength, rapid-alternative movements, EKG: Date: Interpretation: Labs: Date:

WBC Hgb Plt

Hct

Date/Diagnostics/Results

ASA: Mallampati: CHADS2:

Impression: Assessment Plan w/ Rationale 1. 2.

3.

4. 5.

Na Cl Bun Glu

K HCO3 Cr GFR

PT

INR

PTT

Ca Mg

Phos