Chief Complaint Reason for admission or the patient s own words HPI Includes relevant facts from throughout

presentation COLD REARS SIT PMH/SH Chronic/acute Hospitalizations, surgeries, accidents Menstruation/obstetrical Include health maintenance issues (PAP, mammogram) Immunizations Allergies Type of reaction that occurs Medications Herbal/alternative medicines FH Social History y Living situation y Smoking/Alcohol/drugs y Sexual y Occupational y Pets y Travel y Exposure to children y Exposure to TB/transfusions/toxins ROS (include relevant info from this in HPI) y General: fever, weight changes, malaise, chills, night sweats y Skin: rash, lesions, lumps y Head: trauma, headaches, hair loss y Eyes: glasses, blurry vision, floaters y Ears: tinnitus, hearing loss, discharge, vertigo y Nose: epistaxis, rhinorrhea

y y y y y y y y y y y y

Mouth/Throat: lesions, sores, bleeding gums, hoarseness/voice changes, sore throat, swollen neck Neck: pain, masses, decreased ROM Respiratory: cough, hemoptysis, dyspnea Cardiovascular: HTN, tachy/brady, murmurs, angina, exertional dyspnea GI: NVD (nausea, vomiting, diarrhea), appetite, pain, dyspepsia, melena Genitourinary: frequency/polyuria, hematuria, dysuria, incontinence, urgency, dysparenuria, STDs Endocrine: heat/cold intolerance, polydipsia, polyphagia, thyroid, DM Hematologic: anemia, bruising, poor wound healing, excessive bleeding, clots Lymphatic: Lymphadenopathy Musculoskeletal: OA, pain, stiffness, weakness, aches Neurologic: parasthesias, tremors, paralysis, syncope Psychiatric: depression, anxiety, suicidal thoughts, delusions, hallucinations

Physical Exam y Vital Signs o BP o Pulse o Respiration (use of accessory muscles or pursed lips) o Temperature o PulseOx, oxygen requirement (liters of O2 necessary to keep saturation about 95%) General Appearance o Age, appearance (relative to age), obese/cachectic/well-nourished, comfort level Head o Normocephalic, atraumatic Eyes o Size and reactivity of pupils o Visual field o Color of sclera o Extraocular movements o Appearance of conjunctiva (pink/pale/normal) o Fundoscope exam o Convergence/accomodation Ears o External appearance o Otoscope exam o Appearance of tympanic membrane (visualized light reflex and clear of hazy, presence of effusion) o Auditory acuity Nose o Appearance of nasal septum (midline/deviated)

y y

y y y

o Mucosa o Polyps o Sinus tenderness Mouth/Throat o Unusual findings o Pharynx o General dental health Neck o JVD o HJR o Bruits o Lymphadenopathy o Thyroid palpation o Carotid pulses o ROM o Tracheal deviation Axilla o Lympadenopathy Breast Exam o DON T Lungs o Auscultate o Percuss o Symmetry o Shape of ribcage o Fremitus o Egophony o Accessory muscle use Cardiovascular o PMI o R/L upper sternal border o R/L lower sternal border o Apex o Heave o Peripheral pulses Abdomen o Distention o Scars/markings o Ausultate 4 quadrants o Bowel sounds/bruits o Percuss liver span and spleen o Assess fluid wave and shifting dullness o NO rectal Genital o NO

y y

y y

y y y y y

Back o Spinal appearance, tenderness, o Costovertebral angle (CVA) tenderness Extremity o Pulses, color, warmth, edema (pitting or non) Musculoskeletal o ROM of joints o Reflexes o Bulk and tone of muscles o Knee extension against resistance o Dorsiflexion of toe against resistance o Plantarflexion of foot against resistance Skin o Rashes o Turgor o Temperature of extremities o Pigmentation o Hair distribution Neurological o Self, place, date CN Exam o II- papillary light reflex o III, IV, VI- extraocular movements, ptosis, nystagmus  PERRLA- pupils equal, round and reative to light and accommodation o V- light touch, corneal reflex, clench jaw o VII- raise eyebrows, frown, tightly close eyes, show upper and lower teeth, puff out cheeks o VIII- Rinne, Weber o IX, X- Ahhhhh o XI- shrug shoulders, turn head o XII- stick out tongue DTR o Patellar, biceps, triceps, ankle, babinski Finger to nose, thumbs up, active OK, finger abduction Romberg Pronation/supination Gait