7/23/2019 Chief Complaint format
1/3
Chief complaint:
History of present illness:
Past Medical HistoryDM ( ) years ___ HPN( ) years ___
CA ( ) years ___ TB ______Stroe _______ resid!al
___________Admission ________________S!r"ery
________________#amily h$ (HTN% TB% Cancer CAD% Bleedin"Disorders%
Sicle Cell% dia&etes% anemia% asthma%consan"!inity)
___________________________________________________
'iin" Arran"ement(sm*dpartner)
__________________________________________________
_
+esidence (ho!se% apt,% shelter% homeless-safety meas!res)
Ho!se-
_______________________________Se$!al history ( if
appropriate)
_________________.cc!pation
________________________________/nironmental /$pos!res
____________________Trael
History______________________________Diet and /$ercise
___________________________
/d!cation (hi"hest leel attained)_____________________
Ci"s ( ) No ( ) yes _____ pac year
/t.H ( ) No ( ) 0es amo!nt _______
7/23/2019 Chief Complaint format
2/3
1llicits: ( ) No ( ) 0es type _________
Aller"ies: ( ) N2DA .ther __________
Meds:
PHYSICAL EXAMINATION (Please describe yourfndings!i"al
Signs#Ht,___________ 3t,___________ BM1__________/+ Temp____
P______BP_______ ++____ o4 ______3ard Temp____ P_____BP_______
++____ o4 _____$eneral A%%earance#
&&&&&&&&&&&&&&&&&&&&&&&&&&&'
S)in and Subcu"aneous Tissue
Inspection (rashes, lesions, ulcers)Palpation (induration,
subcutaneous nodules,tightening)
* Eyes'ids and con5!nctiae (discharge, icterus,
ptosis,edema)P!pils and irisesOptic discs and posterior segments
(size, Cup to disc ratio,
appearance, vessel changes, exudates, hemorrhages)
+ Ears,Nose,T-roa"/$ternal ears% nose (scars, lesions,
masses,foreign body)
.toscopic e$am (external auditory canals,tympanic
membranes/mobility)No si"ni6cant6ndin"s,Hearin" (whispered voice,
Rinne and Webber test)Nose (Nasal Mucosa, septum, turbinates)
. Nec) .erall appearance (masses, symmetry, trachealposition,
crepitus)Thyroid (enlar"ement% tenderness% mass)'ymph nodes
/es%ira"oryInspection/respiratory effort and rhythm (shape,
intercostal
retractions, use of accessory muscles,)Palpation of chest (chest
movements, tactilefremitus, tenderness)
Perc!ssion of the chest (dullness, hyperresonance)A!sc!ltation
of l!n"s (breath sounds, adventitioussounds, rubs)
0 Cardio1ascularNec 7einsPalpation of the heart (M! location,
si"e, thrills)
A!sc!ltation: (normal sounds, abnormal
sounds,murmurs)/$amination of:
Carotid arteries (pulses, bruits, amplitude)A&dominal Aorta
(si"e, bruits)#emoral arteries (pulse, amplitude, bruits)Pedal
P!lses (pulse, amplitude)/$tremities (edema, varicosities)
2 $as"roin"es"inal1nspectiona!sc!ltation of a&domen
(masses,appearance of abdominal wall)Palpationperc!ssion of lier%
spleen% and "enerala&domen (enlargement% irre"!larities%
ascites%masses)/$amination for presencea&sence of hernia
(inguinal, femoral, ventral)/$amination of an!s% perine!m%
rect!m (incl!din"
patency% sphincter tone% hemorrhoids% rectalmasses *hen
indicated)
3 4ac)5 E6"re7i"ies5 Musculos)ele"al8ait1nspectionpalpation of
di"its% nails (clubbing,cyanosis, in#ammation, petechiae,
ischemia,infections, nodes)
1ncl!de for each area:1nspectionpalpation +an"e of Motion
Sta&ility
M!scle Stren"th 9 Tone
8 Neurological'eel of conscio!sness%hi"her f!nctions and
speechTest of cranial neres *ith notation of de6citsCN 1
(.lfactory) smell mint leaesto&accoCN 11 (.ptic) is!al ac!ity 9
f!nd!scopicCN 111 (.c!lomotor) p!pillary reaction CN 17(Trochlear)
p!pillary reactionCN 7 (Tri"eminal) clench teeth% open 5a*%CN 71
(A&d!cens) /.MCN 711 (#acial) raise
eye&ro*fro*nsho*teethsmilep!; cheeCN 7111 (Aco!stic) *hisper
test-CN 1< (8lossopharyn"eal) hoarseness% ton"!emotCN <
(7a"!s) sayin" =ah%= 9 note palate and!!la moe !p*ardCN
e$es%stren"th% tone% 9 cere&ral f!nctionSensation (touch, pain,
vibration, proprioception $%abins&i)Cere&ellar
si"ns8aitA&normal moements (tremors, choreoathetoid,dystonia,
tics)
1mpression:
______________________________
Basis
____________________________________
Plan
____________________________________
Di;erentials:
?,____________________________________
4,____________________________________
@,
____________________________________
