Medical Notes

HISTORY

IDENTIFYING DATA:
Patients 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 testing.

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.

MEDICATIONS:

ALLERGIES:
Penicillin?

FAMILY HISTORY:
Medical problems in relatives; specifically ask about problems similar to patients illness. Asthma, MI, heart failure, hypertension, CA, TB, diabetes, kidney diseases, hemophilia.

SOCIAL HISTORY:
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, extremity edema.

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, penile discharge.

Gynecological:

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 therapy.

Musculoskeletal: Joint pain or swelling, arthritis, myalgias.

Skin: Easy bruising, bleeding tendencies.

Lymphatics: Lymphadenopathy.

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 height), weight.

Skin:

Rashes, scars, moles; capillary refill (in seconds).

Lymph Nodes:

Cervical, supraclavicular, auxiliary, inguinal nodes; size, mobility, tenderness, consistency.

Head:

Bruising, tenderness. In pediatric patients check fontanelles.

Eyes:

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.

Ear:

Discharge, acuity, tympanic membranes (dull, shiny, intact, injected, bulging).

Nose:

Discharge, exudates, polyps. Pediatrics: Nasal flaring.

Mouth & Throat:

Mucus membrane color and moisture level; oral lesions, dentitions, tonsils, erythema.

Neck:

Jugular venous distention (JVD), thyromegaly, lymphadenopathy; range of motions, masses, bruits, hepatojugular reflex (HJR).

Chest:

Equal expansion, tactile fremitus, percussion, auscultation, rhonchi, crackles, rubs, breath sounds, egophony, whispered pectoriloquy.

Heart:

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+).

Breast:

Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia.

Abdomen:

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 masses.

Genitourinary:

External lesions, hernias, scrotum, testicles, varicoceles.

Pelvic Exam:

Vaginal mucosa, cervical discharge; uterus size & masses, adnexa, ovaries, suprapubic tenderness.

Extremities:

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.

Rectal Exam:

Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; presence or absence of stool in rectal vault, prostate (nodules, tenderness, size).

Neurological:

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:

I: Smell
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.
VII: 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.

Labs:
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

Orientation:
What is the year, day of the week, date, month? = 5 points

What is barrio, town, city, country, hospital, floor? = 5 points

Registration:
Repeat: 3 objects: apple, book, coat = 3 points

Attention/Calculation:
Spell WORLD backwards = 5 points

Memory:
Recall 3 objects = 3 points

Language
Name a pencil & a watch = 2 points
Repeat, No ifs, ands or buts = 1 point

Three stage command:
Take this paper in your right hand, fold it in half, and put it on the floor= 3 points

Written Command:

Close your eyes. = 1 point
Write a sentence = 1 point

Visual Spatial:

Copy two overlapping pentagons = 1 point

TOTAL SCORE 30 POINTS

Normal: 25-30
Mild Intellectual Impairment: 20-25
Moderate Intellectual Impairment: 10-20
Severe Intellectual Impairment: 0-10