Patient History Skeleton

ID: One sentence summary

CC: Pt presents with
HPI:
Hospital Course:
PMH:
Medical Hx:
1)
Hospitalizations:
Surgical Hx:
Medications:
Immunizations:
Allergies:
FHx:
Mother:

SHx:
Review of Systems:
General:
Skin:
HEENT:
Respiratory:
Cardiovascular:
Gastrointestinal:
Urinary:
Genital:

Endocrine:
Musculoskeletal:
Neurological:
Psych:
Physical Exam:
Vital Signs:
P: /min on R/L artery; regular rate and rhythm
BP: on R/L arm, supine/sitting up.
RR: /min with normal depth and effort.
Pain: /10
General appearance:
Example: Pt is a ; appears to be stated age, with a normal/fit body habitus. He is alert and
oriented x 4, well-nourished and well-developed. He is calm and cooperative and is in no acute
distress. Pt has good hygiene, no breath or body odor, skin tone is normal.
Cardiac:
Example: No central/peripheral cyanosis, clubbing, or pallor. JVP was 3 cm above the sternal
angle at 30. PMI approximately located in the midclavicular 5LICS, with a 1cm diameter. S1
and S2 normal, with no S3, S4, murmurs, clicks, or frictions rubs. No evidence of bruits in
carotid arteries, abdominal aorta, or renal arteries.

LT
RT

Carotid
2+
2+

Brachial
2+
2+

Radial
2+
2+

Femoral
2+
2+

Popliteal
2+
2+

Post. Tib.
2+
2+

D. Pedis
2+
2+

Abdominal:
Example: Pt has no stigmata of liver disease (palmar erythema, spider angiomata, asterixis, or
ascites). Normal bowel sounds in all 4 quadrants. No tenderness, guarding, or rebound on
palpation of all 4 quadrants. Liver percusses to 7 cm in the midclavicular line; edge not felt.
Spleen and kidneys not felt. No palpable masses. No CVA tenderness. No evidence of bruits;
abdominal aorta palpated to 3.5 cm.
Neuro:
Mental Status Exam:
Orientation
Appearance
Behavior

Attitude
Rapport
Speech and Language
Mood
Affect
Thought Processes/Associations
Thought Content
Cognitive
Concentration
Abstraction
Serial Sevens
Memory
Insight
Judgment
Cranial nerves:
CN I:
CN II:
CN III, IV, VI:
CN V:
CN VII:
CN VII:
CN IX, X:
CN XI:
CN XII:
Motor:
Example: No involuntary movements or atrophy. Normotonic in all four extremities. Strength of
all muscles 5/5.
Sensory: Example: Pinprick, light touch, position sense, vibration intact in lower extremities.
Coordination: Example: Finger-to-nose, heel-to-shin, rapid alternative movements, finger tap
intact.
Reflexes:
LT
RT

Biceps
2+
2+

Triceps
2+
2+

Brachioradialis
2+
2+

Patellar
2+
2+

Achilles
2+
2+