Data:

74 T.D African American male lives with wife, daughter and grandchildren retired 4 years
ago a as butcher with history of htn, dm, high cholesterol CHF CAD with 4 stents last placed
2018 stage 4 kidney disease, BPH. pt currently taking carvedilol 25mg 2x day ASA 81mg
daily Flomax 0.4mg daily, Isosorbide mononitrate 30mg ER daily Plavix 75mg daily nephro-
vite daily Hydralazine 25mg every 8 hours, glipizide 5mg 2x day nifedipine ER 30mg 2x day
Torsemide 20mg daily Novolog flex pen 5 units 3x day, Toujeo 10 units at night Omega 3-
acid 1grm capsule take 2 caps 2x day sodium bicarbonate 10 GR 3x day Atorvastatin 20mg
at night Lokelma 10grm 1 packet daily. NKDA or food allergies, height 5ft 8 inches weighs
170lbs Took flu vaccine 9/28/2023 covid vaccine 7/2021 and 8/2021. Last hospital
admission for pneumonia 9/20/21. Follow up with PMD and Cardiology every 3 to 4 months

FORMAT for HISTORY and PHYSICAL-the format for the write-up of the physical exam
follows below

Students Name:

Source of information:

Reliability:

CHIEF COMPLAINT-"pts own words" with a duration & time frame. Should be limited to one
complaint

HPI- Include SOCRATE(site,onset,character, radiation, associated symptoms, time course,

exacerbating/relieving factors,severity)

***Start with..This is a(age, race, sex) who presents today complaing of.................

****If there is no chief complaint, then the HPI is replaced with a "Wellness Health History"

Example:

This is a (age, race, sex) here today for an annual physical. Last physical was (date)
in this office. Denies major illness, hospitalizations, surgeries since last visit.
Reports feeling well today, denies health concerns.

PAST HEALTH HISTORY:

Medical:

Illnesses listed with year of diagnosis

Surgical:

Procedures listed with year of diagnosis

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Hospitalizations:

Reasons listed with year of diagnosis

Trauma/Injuries:

Diagnosis with year

Psychiatric:

Diagnosis with year

Medications:

Listed with year started

Allergies: denies to food, drugs, latex, environmental agents (if allergy present, then
document reaction)

Immunizations: (age appropriate)

Type Year: Td/Tdap, Chicken pox, MMR, polio, HPV, Zoster, Pneumonia PCV13, PCV 23,
Hepatitis A, B ,C

Documenting "UP TO DATE IS UNACCEPTABLE" You must include all immunizations that pt
has received. If patient is unsure of the immunizations that they have received document
what the patient states, example: patient reports "I am not sure" or Influenza Fall 2015,
patient unable to recall other immunizations or dates

Childhood illnesses

Transfusions:

year and if any reaction

Family History:

Mother: 55, alive DM2, HTN

Father: deceased age 50(MI)

Siblings: (if none document "NONE")

Children: (if none document "NONE")

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etc.

Family history should be modified according to age of patient. For example, in a geriatric
patient asking for the health of their grandparents is non-productive.

Social History:

Alcohol: quantified (8oz wine 3X/week)

Smoking: (include smokeless tobacco)

Number of packs smoked per day X years smoked = pack years

If an ex-smoker, year they quit and then pack years calculated

Recreational drugs:

Exercise: (type and frequency)

Education:

Occupation: if retired, what they did

Marital Status:

Lives with:

Review of systems:

General/Constitutional

Denies fever, chills, night sweats, rashes, lymphadenopathy, weight changes, excessive
fatigue, hours’ sleep/night.

**adjust according to patient response

Skin

HEENT

Head

3
Eyes

Ears:

Nose:

Throat:

Neck:

Lymphatics:

Breast:

Cardiac:

Respiratory:

Abdomen:

Urinary:

Reproductive Male:

Reproductive Female:

Extremities/peripheral vascular:

Musculoskeletal:

Endocrine:

Hematological: omit transfusions (already in the history)

Psychiatric:

Neuro:

PHYSICAL EXAM:

Vital signs:

B/P: 2 in each arm in 2 different positions- supine and standing

HR: include regular vs. irregular

Respirations: include regular or irregular

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Temp

Ht/Wt/BMI

General Survey: standardized format

This is a WD,WN (race, sex) who appears stated age. Recent and remote memory intact.
Speech clear. Gait steady. Dressed appropriately for the season. Answers congruent with
questions. In no acute distress. (modify according to patient status).

Integument:

HEENT:

Neck

Lymphatics:

Chest (Breast, Cardiovascular, Respiratory)

Abdomen

Back/spine

Extremities/peripheral vascular (pulses are listed and graded)

Musculoskeletal (muscle strength is graded)

Genitalia: Male or Female

Neurologic:

LAB/DIAGNOSTIC RESULTS:

(only for results you have- not what you plan to order)

SPECIAL ASSESSMENTS:

When recording results of special assessment , make sure to include the maximum score:

For Example- Folstein mini mental: 27/30

ASSESSMENT List all ICD 10 Codes in Priority order

1. Diagnosis ICD 10 code

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2. Diagnosis ICD 10 code

Plan:

1. Medications

2. Labs:

3. Diagnostics:

4. Referrals

5. Patient Education

6. Follow up

The plan must include rationales that are cited with a separate reference page from clinical
evidenced based guidelines for all areas above

**References (in APA format) must be current (within 5 years)

--------------------------------------------------------------------

Please review and follow the sample format for writing a History and Physical
examination below.

BP (seated, rt arm, lt arm) P R T WT HT BMI

Include other specifics that might be necessary(i.e orthostatic BP, pulse oximetry)

GENERAL SURVEY

This is a well developed, well nourished, white male, who appears stated age, speech clear,
alert and oriented x3, in no acute distress. (emaciated, cachexia, malnourished, disoriented,
in acute respiratory, cardiac, etc. distress)

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SKIN

Pink, Warm and dry with instant recoil (or with good turgor). No masses, lesions, scars. Hair
normal in distribution and consistency. No clubbing, cyanosis, pallor, deformities of nails.

HEENT

(Head Ears Eyes Nose and Throat. Include face, mouth, sinuses, and pharynx in this section).

Head normocephalic, atraumatic, with no masses or lesions. Hair normal (male, female)
distribution. Face symmetrical, light touch intact. Lashes and brows intact, no stare, ptosis,
or lid lag noted. Visual acuity 20/20 both eyes Color vision (red and green) intact. Fields
normal by gross confrontation. EOM's intact, no nystagmus, PERRLA (pupils, equal round
reactive to light and accommodation). Conjunctiva clear, sclera white, no defects of cornea
or iris. Normal globe tension, Corneal light reflex equal, corneal reflex intact, Cover test
negative (no strabismus). Red reflex present bilat. Disc margins sharp, AV ratio=2:3 (or
arterioles and venules normal) no AV nicking. No hemorrhages or exudates. Ears: no masses
or lesions of auricles, no discharge, external canal normal in appearance, no mastoid
tenderness, TM's pearly grey bilat. with good light reflex. No bulge or retraction noted.
Watch tick and whisper heard bilat. Weber - no lateralization, Rinne - AC>BC bilat. Nose
patent bilat. no discharge, no septal deviation or perforation. Can identify odors. No
maxillary or frontal sinus tenderness on palpation. Turbinate assessment; enlarged, or
reddened. No lesions or masses of lips, oral mucosa, gingiva, pink, moist. Teeth in good
repair. Tongue midline, no tremor, lesions, or masses noted. Pharynx pink, no tonsillar
enlargement or exudate, gag reflex present, uvula rises in midline on phonation.

NECK

Supple (or full ROM), No masses or lymphadenopathy. No jugular venous distention at 45

degrees. Carotid pulses equal with good upstroke, no bruits noted. Trachea midline, no
thyrodmegaly.

Lymphatics: Submandibular, submental, pre and post auricular, occipital, anterior, posterior cervical,
supraclavicular, axillary, inguinal epitrochlear non palpable

CHEST

Symmetrical, no bony deformities, AP diameter 2:1 (if normal and not increased), no
tenderness, or adenopathy noted. Lungs clear to auscultation and resonant, hyperresonant,
or dull to percussion Fremitus equal bilat. Breath sounds equal throughout.

Breasts symmetrical, no masses, nipple retraction, discharge, tenderness or

lymphadenopathy or skin changes.

Heart: no lifts, heaves or thrills noted PMI 5th LICS at MCL. Apical Rate 80/min. and regular
S1, S2 normal, no S3 or S4 noted A2>P2, No murmurs, rubs gallops, or clicks noted.

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ABDOMEN

Symmetrical, flat with no lesions, scars, herniations, or abnormal pulsations. Soft,

nontender, with normoactive bowel sounds positive in all four quadrants. No bruits or hums,
No organomegaly. Tympanic or dullness to percussion

BACK/spine

Normal curvature, nontender, mobility, no CVA tenderness.

MUSCULOSKELETAL: deformities, joint tenderness, edema, erythema, ROM Muscle strength

equal throughout.

EXTREMITIES/ PERIPHERAL VASCULATURE:

No clubbing, cyanosis, edema noted. Full ROM, Joints nontender, peripheral pulses intact
and equal throughout. (dorsalis pedis, posterior tibialis, radial, brachial, Popliteal, femoral,)

GENITALIA

MALE- Hair dist. normal, no lesions, ulcers, masses noted of penis, scrotum, or perineum.
Urethra without discharge. Spermatic cord, Epididymis, without masses or tenderness. No
lymphadenopathy. Prostate normal size, boggy, firm, nontender or tender, masses.

FEMALE- Hair dist. normal, no lesions, inflammation or ulceration noted. Bartholin's, Skene's
glands without discharge. Uterus :size, position, consistency, mobiity, tenderness. Cervix
pink, mobile, nontender and in (anteverted, retroverted, or midline) position. No adnexal
masses. Ovaries nontender (or not palpated) and cervix: firm smooth and moveable if
normal; abnormal hard (cancer) , soft(pregnancy).

RECTAL

Anal musculature strong, anal wink reflex intact, No lesions, masses, hemorrhoids noted,
guaiac negative. Stool color, consistency, blood, mucous, tenderness

NEUROLOGICAL

Alert and Oriented x3

Memory (recent and remote) intact

Appropriate behavior and speech

Cranial Nerves 1-12 grossly intact

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1-identifies alcohol

2-vision 20/20 both eyes color intact, visual fields by gross confront.

intact.

3,4,6,- EOM intact, no ptosis, nystagmus, PERRLA

5-sensation intact, jaw closure normal

7-face symmetrical, no weakness

8-hearing intact, whisper heard bilat. Weber - no lateralization,

Rinne- AC>BC

9,10-swallow and gag reflex intact, uvula rises in midline on

phonation.

11-head movement and shoulder shrug normal

12-tongue protrudes in midline, no tremor

Coordination intact, Romberg negative, gait normal

Motor function intact (no weakness tremors, atrophy)

Sensory function intact - Light touch, pinprick, vibratory sense

(128 or 256 cps)

Reflexes 2+/4+ intact throughout or use diagram. Plantars downgoing bliaterally