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Sample Complete History and Physical

This is a sample of an extensive history and physical. Even though it's extensive it's still not entirely complete. Feel free to download and add to it and study from it as long as you gimme some cred. ***DISCLAIMER*** this isn't meant to be used as professional medical advice

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hugosays
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3K views

Sample Complete History and Physical

This is a sample of an extensive history and physical. Even though it's extensive it's still not entirely complete. Feel free to download and add to it and study from it as long as you gimme some cred. ***DISCLAIMER*** this isn't meant to be used as professional medical advice

Uploaded by

hugosays
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as TXT, PDF, TXT or read online on Scribd
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Name

CC
Where? When did it start? why did it happen?
Quality? Quantity? (pain 0-10; SOB/cough NYHA I-IV) Radiation?
when is it worse? duration, frequency(laying down, day time, night time, standing
up; exercising/ambulating)
What makes it better?
what makes it worse?
Have u taken anything for it? (aspirin, tylenol, nyquil, Ben gay)

PMH: Recent hospitalizations/illnesses, Immunizations, Psych;


DM/HTN/CA/Asthma/Thyroid
Meds:
Allergies:
PSH:
Blood Transfusions: blood type
Social: EtOH (how much/hz/kind), nicotine, drugs. Sex, living accomodations, diet,
exercise

ROS
General: Fever, chills, wt loss/gain, night sweats, fatigue weakness
Skin: Nail changes, itching, hair loss, rashes, bumps
Head: Trauma, HA, nausea, dizziness
Eyes, Visual changes/blurry vision, tearing itching
Ears: Hearingloss, tinnitus, ringing, vertigo, aches, discharge
Nose/Sinuses: Rhinorrhea, stuffiness, sneezing, itching, allergies, bleeding
Mouth: Bleeding gums, hoarseness, voice changes, sore throat,
Neck: Swollen neck, tenderness,
Breast: skin changes (color/txtr), lumps, pain, discharge, self exams
Cardiac: CP, palpitations, dyspnea on exertion, orthopnea, PND, edema
Pulm: SOB, wheezing, cough, phlegm, hemoptysis, asthma, TB
GI: N/V/D/Constipation, hematemesis, dysphagia, BM changes, hematochezia, melena,
color, hemorrhoids, abdominal pain, hepatitis
GU: Hz, hesitancy, urgency, polyuria, polydypsia, nocturia, incontinence, stones,
infx
Genitals: General: STDs, hetero/homo, problems, function, contraception
M:discharge, sores, pain, masses, hernias; F:Menarche, regularity, last period,
itching, discharge, sores, gestations/complx/abortions, birth control, menopause
Vascular: Leg edema, claudication, varicose vv, DVTs
MS: weakness, pain, stiffness, ROM, instability, redness, swelling, arthritis,
gout
Neuro: numbness, paraesthesias, twitching, fainting, LOC, seizures
Hem: anemia, bruising, bleeding, petechia, purpura
Endo: heat/cold intolerance, excessive sweating, DM, thyoid probs
Psych: depression, bipolar, concentration/memory anxiety

Physical Exam:
VS: BP, P, R, T, Ht, Wt
General: state of health, hygeine, affect

Skin: scars, rashes, bruises, tattoos, nail stippling

Head: size, shape, trauma, hair distribution, bumps, bleeding


NCAT, good hair distribution,no scars or bleeding
Eyes: pupils, symmetry, conjunctival injection, scleral icterus, fundal
papilledema, hemorrhage, lid edema, extraocular movements, visual field acuity,
discharge, whisp test
PERRLA, no redness or cataracts, ...
Ears: symmetry, tenderness, discharge, external canal, TM patency/inflammation
Nose: symmetry, tenderness, discharge, bleeding, dryness, turbinate inflammation,
sinus tenderness
Mouth: hygeine, dentures, erythema, exudate, tonsilar enlargement
Neck: masses, ROM, spine, trachea, thyroid
Breasts: skin color, symmetry, dimpling, tenderness, discharge,
Heart: rate, rhthm, murmurs, rubs, gallops, clicks, bruits
Pulm: symmetry w/ respirations, fremitus, tympany/dullness to percussion,
auscultation (wheezing, crackles, rales, stridor, egophony; bronchial vs
vesicular), diaphragmatic excursion
Abd: scars, striae, shape (scaphoid, flat, protruberent, pannus), bowel sounds
(none, active), renal bruits, percuss for liver and spleen span, stroke for
peritonitis, palpate for masses/hernias, palpate for hepatosplenomegaly/kidneys,
rebound tenderness; murphy's sign
GU: M: inspect for edema, rashes, ulcers, bumps, discharge, induration, palpate
for tenderness, hernias; F: inspect for ulcers, warts, bumps, dryness, redness,
inflammation, patency of urethra/vagina; Speculum-cervix color, bleeding,
friability; digital exam-palpate for cervical motion tenderness, ovarian/uterine
masses, vaginal support, rectovaginal fistulas
Rectal: tone, prostate (consistency, lumps), colon texture (smooth, ridges,
polyps), feces (amount, consistency)
MS: atrophy, weakness, ROM, stability, redness, swelling, tenderness, spine
deviation (midline, scoliosis), strength (5/5)
Vasc: pulses (carotid, radial, femoral, popliteal, posterior tibial, dorsalis
pedis), JVD (waves-a,x,c,y,v)
Lymph: cervical, supra/infra clavicular, axillary, inguinal
Neuro: twitching, CN 2-12 (I smell; II visual acuity, fields, fundoscopic exam;
III/IV/VI eyelid opening extraocular movements, direct/consensual light reflexes,
wisp test(VI); V sensation forehead, cheek, jaw, masseter muscle; VII eyebrow
raise, eyelid close, smile, frown, pucker, taste; VIII auditory, Rinne (air vs
bone [mastoid] conduction), Weber [tuning fork on head-->air], Oculocephalic
reflex [dolls eye maneuver], oculovestibular reflex [ear canal distribution], IX,
X palate elevation, swallowing, posterior taste, phonation, gag reflex; XI lateral
head rotation, neck rotation, neck flexion, shoulder shrug; XII tongue protrusion
and lateral movement), DTR (1+ - 5+; achilles tendon, babinski, patellar, biceps,
tendon, trapezius), cerebellar (heel to shin, rapid alternating movements, finger
to nose), clonus, rigidity; GCS (3-15)
Psych: MMSE (Time-year, season, month, day/date/president, Place-state, county,
city, hospital, country; Retistration-remember 3 things; Concentration-Serial 7's;
Recall-repeat 3 objects; Language-Repeat "no ifs ands or buts"; Name 2 objects;
follow 3 step command; Read and obey CLOSE YOUR EYES; Write a sentence; Copy a
design) mood, SIGECAPS, DIGFAST, S/H I, A/V H

** PMH-Past Medical History; GI-Gastrointestinal; GU-Genitourinary; MS-


Musculoskeletal; Hem-Hematology; Endo-Endocrine; VS-Vital signs, BP-blood
pressure, P-pulse, R-respiratory rate, T-temperature; NCAT-normocephalic
atramatic; PERRLA-pupils equal round reactive to light and accomidation; JVD-
jugular venous distension; MMSE-Folstein Mini Mental Status Exam

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