EMD 703: Emergency Medicine • H&P Template · PDF fileEMD 703: Emergency Medicine...

EMD 703: Emergency Medicine • H&P Template

Name: Date: Attending:① Always start with the patient’s age, chief complaint

andvital signs

CC: Age: BP:Blood Pressure: circle any abnormalities Heart Rate: Resp Rate:Temp: O2 Sat: Pain:② List must not miss diagnoses for

CC④ pertient Hx factors to DDx ⑦ pertinent PE to DDx

1.2.3.4.5.

③ Good description of CC ⑤ Past Historical Facts ⑥ Review of Sys (circle or slash)Character: PMHx: CNST: wt loss / fever / chills / weak / fatigue

Onset: HEENT: vis ∆ / hear ∆ / congest / sore throat

Location: SKIN: No rash or itching.

Duration: CV: c-pain or press / palpt / edema

Radiation: PSHx: RESP: SOB / cough / sputum

Exacerbators: GI: naus / vom / diar / abd pn / bleeding

Alleviators: GU: dysuria / preg / LMP / sex act

Diff Today: NEURO: ha / diz / sync / numb / weak / atax

Meds: MUSC: back pain / joint pain

HEME: bleeding / bruising

LYMPH: nodes

Soc Hx: PSYCH: depr / anx / SI / HI

Allg: ENDO: sweat / temp intol / polyur / polydips

PMD: ALLG: hives / eczema

⑧ Now rank your DDx ⑨ What tests do you need for eachDx

⑩ Make a guess now

1. What’s the Dx?2.3. What’s the disposition?4. admit observation discharge5.

⑪ Results ⑫ Final diagnosis & dispo