H&P (History and Physical Examination) 'imaginary patient'
HPI: (history of present illness)
xy y o B male pat. admitted on .. with CC (chief complaint); seeking for medical attention b/o; Pat. was in usual state of health until .. begins; location, quality (deep, sharp, stinging) , severity, timing (onset sudden, duration, frequency), aggravating or relieving factors;
PMx: (past/prior medical history)
general: high blood pressure (HTN), cholesterol, diabetes, thrombosis, operations, allergies;
specific: stroke, seizure, thyroid, heart attacks, pneumonia, asthma, stomach-bleeding, PUD (peptic ulcer disease), jaundice, kidney-problems, gynecology, arthrithis
(ever been serious ill; remote history of; status post s/p; prior hospitalizations);
current medications: pat is on numerous medications, including;
SHx: (social history)
general: retired, occupation, marital status: single, divorced, married, widowed, lives alone/with, in nursing home, regency, in assistant living;
smoke: packages per day for how many years, quit when;
alcohol: regular basis or occasional
FMx: (family medical history)
father/mother a&w (alive and well), age and health status, died b/o (because of), major diseases in family (diabetes, heart, cancer, HTN, ..)
ROS: (review of systems)
negativ for, positive for, unremarkebal, questionable, denies Hx of, no Hx of recent;
general: recent changes in wheight (gain/loss/intentional or not), nightsweats, fever, chills, appetite and bladder/bowl problems (frequency, colour, pain related), nausea and vomiting;
head: dizziness, lightheadness, black/pass outs, vision changes, headaches, vertigo;
Skin: rashes, lesions, warm, moist, cold, diaphoretic;
endocrine: intolerance against heat or cold, tremor, diarrhea, hair losses; polydypsia
heart: chest pain/thightness (on exertion), palpitations, SOB (shortness of breath), PND (how many pillows), ankle swelling, nocturia;
lung: coughing (productive, phlegm), colour (yellowish, witish, red);
GI: belly pain related to meals, heartburn, localized tenderness, bowel-habits-changes;constipation,
GU: burning sensations on passing water, small voids, difficulty, dysuria, urgency, back (CVAT: costovertebralangle), flank or suprpubic pain;
Gyn: discharge, vaginal itching;
Extrem: leg pain related to walking, swelling, radiating back pain, joint pain, numbness and tingling, weakness, morning stiffness, varicose veins;
Neuro: blurred speech/visions, vocal quality changes, limb weakness
PE: (physical exam)
eyes+ears with othoscope
sclerea/conjunctivae
light reaction (PERRLA)
EOMI
visual fields
sens V.
motor VII
look mouth (plaque, moist)
stick out tongue
swallow
move head (supple, FROM)
(CN I-XII unremarkabel) lymph nodes
thyroid
JVD (+during palp liver)
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heart (+move left)
lungs frontal
carotides
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lungs (CAT, P&A normal)
spine
CVAT
bowl sounds (BS)
palp masses, lumps
liver, spleen
pulse in groin
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pulses pop(pes
strength legs/hips/arms
sens, proprio, vibrat
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reflexes (DTR)
babinski
higher coordination
(O): (objectives)
Gen: pleasant and appropriate, in acute distress, well nourished/developed/emaciated/older than stated age, AA&O (alert, awake and orientated);
VS: BP, P, Resp, Temp;
HEENT: EOMI, PERRLA, sclerea clean, CN II-XII unremarkebal, no facial droop, tongue moist, ear canal clean;
Neck: no lymphadenopathy, supple, lumps, no bruits over carotides, thyroid gland not enlarged;
lungs: clear to A&P, no crackles, ronchi, wheezes, no coughing up phlegm;
Heart: S1S2, no murmurs, no addit HS, RRR, no SOB; JVD sign negativ, ;
Abdomen, soft and nontender, no masses on palp, no ascites, no hepatic/spleen enlargement, no CVAT; no recent change in bowl habits,
Extrem: no edema, pulses , pop, pes; strenght equal 4+/5 bs, sens equal bs, coarse proprioception intact, vibration sensation grossly intact, no claudication history;
neuro: A&Ox3 (time/place/self); DTRs 2+ bs, Babinski ., higher coordination ; ...;
etc etc
finally: A&P (assessment and plan in SOAP (subjective, objective, assessment (tentative diagnosis), plan)
