www.medfools.com thanks koop ID: Major Illnesses …

1 thanks koopID:Name Age Gender Hospital numberCC:HPI: Characterization of symptoms: when did you first feel unwell?Symptom +LocationOnset/chronology Provoked?DurationTiming + FreqQuantity (1-10)SeverityQualityAggravatingFactorsA lleviatingFactorsAssociated Sx/RFcourse of sx progression since onset constant vs. intermittentradiation personal hx function/quality of lifeSystem-related ROS:REVIEW HPI Is there anything else you would like to tell me? PMH:General:SURGICAL & OB :Type Date Complications ResultMajor Illnesses DM HTN Lipids CAD ThyroidStroke/TIA Lung Liver Kidney CHF CAMEDS: Dose Freq Route Since when Side EffectsALLERGIES:Health maintenance: PAP mammogram FOBT/Scope PSAL ipids TCLDLHDLTG Fasting glucose DEXAI mmunizations:Infectious Illnesses : measles, mumps, rubella, DPT, chickenpox, scarlet fever rheumatic fever, pneumonia, TB, hepatitisInjuries/disability:Recent travel:SOCIAL HX:Occupation:Hometown:Partner:Children: Smoking EtOH Drug UseDiet?

2 Exercise? Caffeinated beverages?SEXUAL HX: Sexually active? Y N Men, women, or both?Having any concerns? Frequency , type, satisfaction with intercourseage at 1st intercourse_____ number of partners_____G ___ P_____FAMILY HX: age, current health, Major Illnesses , cause of deathFather Mother Grandparents SiblingsCAD? CHF? HTN? Lipid disorder? STROKE/TIA?CANCER? COPD? Asthma? GI? Kidney? Arthritis?DM? Thyroid? CNS/PNS (seizure, paralysis)? Psychiatric? :1. MEDICAL HX: Hospitalizations and Major medical problems: Diagnosis Date Presentation Treatment Sequelae thanks koopROS:GENERAL fevers, chills, sweats; weight +/- ; D in appetite; fatigueSKIN rashes, lesions , sweating, pruritis, easy bruising, difficult healingswelling, petechiae, photosensitivity, changes in hair or nailsHEAD / NECK headache, dizziness, trauma, swollen LNsEYES vision changes; glasses, blurring; diplopia; paininflammation/discharge, dry eyes, scotoma, photophobiaEARS hearing loss, pain, tinnitus, vertigo; drainageNOSE epistaxis, discharge, sneezing.

3 Obstruction, chronic sinusitisMOUTH/ THROAT teeth, gums, oral ulcers, paindry mouth, trouble swallowing, hoarseness, sore throatCV chest pain or pressure, palpitations, edema, syncopeexercise tolerance, fatigue, circulatory probs; murmurs, claudicationLUNGS dyspnea on exertion; cough, sputum, hemoptysisasthma or wheezing; cyanosis, orthopnea, PNDBREASTS pain, masses, discharge, change in appearance, self-examGI nausea / vomiting, dysphagia, odynophagia; dyspepsiareflux or heartburn, loss of appetite, food intoleranceabdominal pain; hematemesis; jaundice, change in bowel habitsdiarrhea / constipation; melena , hematocheziaGU obstructive symptoms, dysuria, frequency, urgencyhematuria, pyuria, previous UTI s; discharge, nocturia, incontinenceMENSTRUAL menarche; last period, length of cycle, duration of flowhow regular, how heavy; pain w/ menstruation or intercoursevaginal bleeding or discharge, intermenstrual bleeding; age of menopauseENDOCRINE thyroid, adrenal, hormonal; temperature intolerance;osteoporosis; edema, polyuria, polydipsia, polyphagiaMS arthralgias, arthritis, ROM, stiffness, myalgiasswelling, erythema, tenderness.

4 Gout, neck or low back painNEURO syncope, vertigo, LOC, seizuresnumbness / tingling, weakness, equilibrium, coordination/gaitPSYCH anxiety; mania; memory loss, depression:interest, guilt, energy, sleep, concentration, appetite, psychomotor, suicidePHYSICAL EXAM: **wash hands**VITAL SIGNS: T_____ P____ RR____BP _____ ht. _____ BMI _____ Pain_____ Pulse ox _____%GENERAL: _____SKIN:_____cap refill_____ clubbing_____cyanosis_____edema _____HEAD: NC/AT_____ face_____CN V _____VII _____EYES: conjunctiva_____EOMI_____ VFI_____PERRLA _____ ophthalmoscopic _____EARS: TMs_____hearing_____NOSE:_____THROAT: _____ palatal elev_____ gag reflex_____NECK:_____LNs _____ Carotid pulses _____ bruits _____ Thyroid_____LUNGS: inspect_____ auscultate_____ percuss ( w/ diaph excursion)_____CV: palpate PMI _____ auscultate @ 4 areas w/diaphragm: rate & rhythm, murmurs, rubs, gallops, clicks_____ check for aortic insufficiency (LSB w/ pt forward in exhalation)_____Pt.

5 LYING DOWN:CV: Auscultation @ BASE and LSB_____ LL DECUBITUS: apex _____ JVP_____ABDOMEN:_____ bowel sounds_____ bruits_____ percuss_____liver span _____ palpate_____PULSES: dorsalis pedis _____ posterior tibial _____edema_____ femoral pulse ( + auscultate)_____LE MS exam: _____Pt. SITTING: CVA tenderness_____UE MS exam: wrists _____elbows_____ shoulders _____ neck _____NEURO: Mental status_____CNs_____ Sensation: touch_____ pain_____ position_____ vibration_____ Reflexes: biceps_____ brachioradialis _____triceps_____ patellar_____achilles_____babinski_____ Cerebellar: finger tapping_____ heel to shin_____Pt. STANDINGS pine: _____UE drift_____ Romberg _____Gait and station_____ swing and stance_____ heel / toe walking_____