Internal Medicine History and Physical Page 1 of 2 - BINOCULAR

[Pages:2]Internal Medicine History and Physical

Page 1 of 2

Chief Complaint: ____________________________________________________ Date: ________________ Time: ________________

History of Present Illness:_____________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

Review of Systems:

General: fatigue weight loss fever chills night sweats

Eyes: visual change pain redness

ENT: headaches hoarseness sore throat epistaxis sinus symptoms hearing loss tinnitus

yes no [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

CV: chest pain edema PND orthopnea palpitations claudication

Resp: cough SOB wheezing hypersomnolence

GI: abdominal pain stool changes nausea/vomiting diarrhea heartburn blood in stool

yes no [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

Other ROS: ___________________________________________

[ ] Unobtainable due to __________________________________

GU: dysuria frequency hematuria discharge menstrual problems

Musc-skel: arthralgia arthritis joint swelling myalgias backpain

Heme/Lymph: bleeding brusing clotting transfusions lymph node swelling

yes no [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

yes no

Endo: polyuria

[] []

polydypsia

[] []

polyphagia

[] []

heat/cold intolerance [ ] [ ]

Derm: rash

[] []

pruritis

[] []

Neuro: weakness

[] []

seizures

[] []

paresthesias

[] []

tremor

[] []

syncope

[] []

Psych: anxiety

[] []

depression

[] []

hallucinations

[] []

All/Imm: hayfever

[] []

bee sting allergy

[] []

[ ] All other ROS reviewed and were NORMAL.

Past Medical History:_________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________

Past Surgical History: ______________________ __________________________________________ __________________________________________

Family History: ____________________________ __________________________________________ __________________________________________

Social History: _____________________________ __________________________________________

Cigs [ ] No [ ] Yes Pack-yrs: _________________ EtOH [ ] No [ ] Yes Amount: __________________ Illicits [ ] No [ ] Yes Type: ____________________

Allergies: [ ] NKDA Other: ____________________

Medications: ______________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________

Regional Medical Center at Memphis

INTERNAL MEDICINE HISTORY & PHYSICAL

PAGE 1 of 2 FORM NO. 6024.013 (Rev. 11/05)

Addressograph/Patient ID

Internal Medicine History and Physical

Page 2 of 2

Physical Exam

T _______ RR _______ BP___________ HR _______ Wt _______ (lbs) Ht _______ (in) BMI _______ O2 Sat _______ on _______

Eyes

[ ] nl conjunctiva & lids

ENT External [ ] no scars, lesions, masses

Neck External [ ] no tracheal deviation

Pupils Fundus Vision Abnormals:

[ ] equal, round, & reactive [ ] nl discs & vessels [ ] acuity & gross fields intact

Otoscopic Hearing Oropharynx Abnormals:

[ ] nl canals, tympanic membranes [ ] nl to finger rub [ ] nl teeth, tongue, palate, pharynx

Palpation Thyroid Abnormals:

[ ] no masses or crepitus [ ] no `megaly or tenderness

GI Palpation [ ] no masses or tenderness

Resp

Skin

[ ] no rashes, lesions, ulcers

Auscultation Percussion Anus/rectum

Abnormals: CV Palpation Auscultation Carotids JVD Pulses Edema Abnormals:

[ ] no hep/splenomegaly [ ] nl bowel sounds [ ] no shifting dullness [ ] no abnormality or masses [ ] heme negative stool

[ ] PMI nondisplaced [ ] no murmur, gallop, or rub [ ] nl intensity w/o bruit [ ] no jugulovenous distension [ ] 2+/= femoral & pedal pulses [ ] no pedal edema

Effort Percussion Palpation Auscultation

Abnormals:

[ ] nl without retractions [ ] no dullness or hyperresonance [ ] no fremitus [ ] CTAB w/o W, R, or R

Neuro

Orientation Cranial nerves Sensory

[ ] A&O to person, place, time [ ] CN II-XII intact [ ] nl sensation throughout

Reflexes

[ ] 2+ + and symmetrical throughout

Abnormals:

Chest/Breast Lymph nodes Genitourinary

Psych Abnormals:

[ ] nl turgor [ ] nl inspection & palpation [ ] no axillary, inguinal, cervical,

or submandibular LAD [ ] nl external genitalia [ ] nl vaginal tone, mucosa [ ] no cervical motion tenderness [ ] nl penis & scrotal contents [ ] nl prostate size and texture [ ] nl cognition [ ] MMSE ___________ [ ] nl mood and affect

Musculoskeletal

Inspection ROM Strength Tone ( if normal)

Abnormals:

Other:

[ ] no apparent distress

Upper extrem

[ ]

[ ]

[ ]

[ ]

Lower extrem

[ ]

[ ]

[ ]

[ ]

Gait

[ ] nl gait and station

X-ray:

EKG:

Other:

Assessment & Plan: _______________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Signature: _________________________________ Date: _____________________________________

Attending MD [ ] I've examined the patient. [ ] I've reviewed with housestaff and agree with the above. Signature ____________________________ Date: ____________

Regional Medical Center at Memphis

INTERNAL MEDICINE HISTORY & PHYSICAL

PAGE 2 of 2 FORM NO. 6024.013 (Rev. 11/05)

Addressograph/Patient ID

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