HISTORY IDENTIFYING DATA:
name, age, race, sex; referring physician or clinic.
SOURCE AND RELIABILITY:
Name and reliability
of informant (patient, old chart, relative).
HISTORY OF PRESENT ILLNESS (HPI):
Describe the course
of the patients illness, including when it began, character of the symptoms; location where the symptoms began; aggravating
or alleviating factors; pertinent positives and negatives, other related diseases; past illnesses or surgeries, past diagnostic
PAST MEDICAL HISTORY (PMH):
Past diseases, surgeries,
hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, COPD, MI,
Cancer, TB. In children include birth history, prenatal history, immunizations, type of feedings.
Medical problems in relatives;
specifically ask about problems similar to patients illness. Asthma, MI, heart failure, hypertension, CA, TB, diabetes, kidney
Alcohol, smoking, drug usage. Marital status and children;
employment and home situations; exposure to carcinogens or environmental agents. In children include: Sleep, play habits,
grade in school.
REVIEW OF SYSTEMS (ROS):
General: Weight gain or
loss, appetite loss, fever, chills, fatigue, night sweats.
Skin: Rashes, bruising, skin discolorations.
Head: Headaches, dizziness, tenderness, lumps or masses; history of seizures, head trauma.
Eyes: Visual changes, visual acuity, visual field deficits, diplopia, inflammation.
Ears: Tinnitus, vertigo, pain, discharge.
Nose: Nose bleeds, discharge, sinus diseases.
Mouth & Throat: Dental diseases, hoarseness, sore throat, pain.
Respiratory: Cough, shortness of breath, sputum (color, amount), chest pain; history of PTB; vaccination
for influenza or pneumococcus. Positive Purified Protein Derivative (PPD Testing).
Cardiovascular: Chest pain, orthopnea, paroxysmal nocturnal dysonea; dyspnea on exertion, claudication,
Gastrointestinal: Odynophagia, dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, melena, hematochezia,
constipation, bloody stool, change in bowel habits, jaundice.
Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge, impotence, testicular masses,
Gravida/para, abortions, LMP (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding;
last pelvic exam and pap smear, breast masses, self-examination, mammography.
Endocrine: Polyuria, polydipsia, polyphagia, skin or hair changes, cold or heat intolerance, hormonal
Musculoskeletal: Joint pain or swelling, arthritis, myalgias.
Skin: Easy bruising, bleeding tendencies.
Neuropsychiatric: Weakness, seizures, paresthesias, memory changes, emotional depression disturbances.
PHYSICAL EXAMINATION Vital Signs:
Temperature, heart rate, respiratory rate, blood pressure (right and left arm, sitting and standing
Rashes, scars, moles; capillary refill (in seconds).
Cervical, supraclavicular, auxiliary, inguinal nodes; size, mobility, tenderness, consistency.
Bruising, tenderness. In pediatric patients check fontanelles.
Pupils equal round and react to light and accommodation (PERRLA); extra ocular movement intact
(EOMI); visual fields and acuity. Fundoscopy (fundi, papilledema, arteriovenous nicking, hemorrhages, or exudates), conjunctiva;
scleral icterus, ptosis.
Discharge, acuity, tympanic membranes (dull, shiny, intact, injected, bulging).
Discharge, exudates, polyps. Pediatrics: Nasal flaring.
Mouth & Throat:
Mucus membrane color and moisture level; oral lesions, dentitions, tonsils, erythema.
Jugular venous distention (JVD), thyromegaly, lymphadenopathy; range of motions, masses, bruits, hepatojugular
Equal expansion, tactile fremitus, percussion, auscultation, rhonchi, crackles, rubs, breath sounds,
egophony, whispered pectoriloquy.
Point of maximal impulse (PMI), thrills (palpable tubulance); regular rate & rhythm (RRR), first
& second heart sounds (S1 & S2); gallops, murmurs (grade 1-6), pulses (grade 0-2+).
Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia.
Contour (flat, scaphoid, obese, distended); scars, bowel sound, tenderness, organomegaly, masses, liver
span; splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle tenderness (CVAT), inguinal
External lesions, hernias, scrotum, testicles, varicoceles.
Vaginal mucosa, cervical discharge; uterus size & masses, adnexa, ovaries, suprapubic tenderness.
Joint swelling, range of motions, edema (grade 1-4+); cyanosis, clubbing, edema (CCE);pulses (radial,
ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homans sign,; cyanosis, varicosities.
Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; presence or absence of
stool in rectal vault, prostate (nodules, tenderness, size).
Mental status & affect; cranial nerves 1-12; gait, strength (graded 0-5); touch sensation, pressure,
pain, position & vertigo; deep tendon reflexes (graded 0-4+) (biceps, triceps, patellar, ankle); Romberg’s test
(ability of patient to stand erect with arms outstretched and eyes closed).
Cranial Nerve Exam:
II: Visions & Visual fields;
III, IV, VI: Pupil responses to light; positional
& pursuit eye movements, ptosis.
V: Facial sensation, ability to open jaw against resistance, corneal reflex.
Close eyes tightly, smile, shows teeth.
VIII: Watch tick, Weber test; Rinne’s Test.
IX, X: Palette moves in
midline when patient says ah, speech.
XI: Shoulder shrug & turns head against resistance.
XII: Stick out tongue
in midline. Heel to skin test.
Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine),
CBC (hemoglobin, hematocrit, WBC count, platelets, differential); X-rays, ECG, Urine Analysis (UA), liver function tests (LFTs).
MINI-MENTAL STATUS EXAM
What is the
year, day of the week, date, month? = 5 points
What is barrio, town, city, country, hospital, floor? = 5 points
Repeat: 3 objects: apple, book, coat = 3 points
Spell WORLD backwards
= 5 points
Recall 3 objects = 3 points
Name a pencil
& a watch = 2 points
Repeat, No ifs, ands or buts = 1 point
Three stage command:
this paper in your right hand, fold it in half, and put it on the floor= 3 points
Close your eyes. = 1 point
Write a sentence = 1 point
Copy two overlapping pentagons = 1 point
TOTAL SCORE 30 POINTS
Mild Intellectual Impairment: 20-25
Moderate Intellectual Impairment: 10-20
Intellectual Impairment: 0-10
PROBLEM-ORIENTED PROGRESS NOTE
List each problem separately (heart failure, pneumonia, hypokalemia). Retain number
of each problem throughout hospitalization and address each problem daily in progress note. Give post- operative day number,
antibiotic day number if applicable.
Write how the patient feels in the patients own words; and give observations about
Vital signs, physical exam for each system, laboratory data.
Evaluate each numbered problem separately, and discuss the progress of each problem.
For each numbered problem, discuss any additional orders, changes in drug regimen or plans
for discharge or transfer. Discuss conclusions of consultants.