Clinic History and Physical MedicalTemplate

New Outpatient Evaluation Patient Name DOB MRN Encounter Date
Review of Systems Chief complaint/Reason for consult Start Time Stop Time
Yes No
Constitution
Fatigue or Malaise
Fever or chills
History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Appetite changes
Eyes
Conjunctivitis
New eye pain
Blurred vision
ENT/mouth
Sore throat
Swollen uvula
E
Jaw pain
Respiratory
Dyspnea
Cough
Phlegm
Hemoptysis
Wheeze
Cardiovascular
Chest pain
Diaphoresis
Ankle edema
Syncope
Palpitations
Gastrointestinal
Nausea or vomiting
Weight changes
Diarrhea
Abdominal pain
PL
Allergies and Medications
Allergy List reviewed No drug allergies No food allergies History of life threatening allergic response to

Medications reviewed Medications reconciled with Nursing Home data
Past Medical History, Social History and Family History
Asthma
COPD
Diabetes
Hepatic Dysfunction
Obstructive Sleep Apnea
Seizure Disorder
Other
M
Genitourinary
Hematuria Congestive Heart Failure(CHF) HIV/AIDS Thyroid disease Hyper Hypo
Dysuria Coronary Artery Disease Hypertension Tuberculosis Treatment
Urethral discharge
Musculoskeletal Malignancy
Myalgias Adrenal Colon Leukemia/Lymphoma Melanoma Renal cell Thyroid Breast Lung Pituitary Prostate Testicular
Arthralgias Stage Treatment Surgical Resection Radioablation Chemotherapy Last Tx Radiation Last Tx
Joint swelling
Recent trauma Surgeries CABG Cardiac valve replacement Splenectomy Organ transplant Joint replacement Other
SA
Skin/Breasts
Masses
Social History / Risk factors
New skin lesions
Rash
No Yes Tobacco use Number Pack-Years __________
Neurologic
No Yes Quit tobacco use Quit date __________
Headaches Willingness to Quit Unwilling Considering Quit but resumed Within 1 month
Seizures Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade Buproprion or nortriptyline
Muscle weakness
Paresthesias No Yes Recreational drug use Route Inhalation Injection Ingestion
Endocrinologic No Yes Drug dependence Type Narcotics Benzodiazepines
Hair loss
Polydipsia No Yes Alcohol use ___ Drinks per Day Week
Tremors Ability to Perform Activities of Daily Living Vaccines
Neck pain Able Unable
Heme/Lymph Eating No Yes Influenza
Bathing
Bleeding gums
No Yes Pneumococcal
Unusual bruising
Dressing No Yes Pertussis
Swollen lymph nodes
Toileting No Yes Varicella
Allergy/Immunology
Nasal congestion Transfers
Rhinorrhea
Psychologic
Family Medical History
Agitation Asthma Coronary Artery Disease Renal Dysfunction Malignancy
Hallucinations CHF Pancreatitis Thrombotic disorder Other
COPD Peripheral Artery Disease Thyroid Disease
©MB and RR 2011 e-medtools.com Revised 1Feb2011 Health Care Provider Signature
Exam WNL = Within Normal Limits
NonInvasive Ventilator Constitutional
CPAP BiPAP Height in cm ________ Weight lb kg ________
Inspiratory Pressure _______

Temperature C F ________ Pulse Rate ________ AND Rhythm Regular Irregular
Expiratory Pressure _______
Medications Blood Pressure Sitting Standing Lying __________ / __________

Respiratory Rate__________

Optional Oxygen Saturation _____ % Cardiac Output _____ Systemic Vascular Resistance _____

E
Body habitus wnl Cachectic Obese Grooming wnl Unkempt
ENT
Within normal limits Edema or erythema present
Nasal mucosa, septum, and turbinates
Dentition and gums Within normal limits
Dental caries Gingivitis
Oropharynx Within normal limits Edema or erythema present Oral ulcers Oral Petechiae

Labs
\____/ ____ / ____ / ____ /

Neck
Resp
PL
Mallampati I II III IV
Neck Within normal limits Erythema or scarring consistent with recent or old radiation dermatitis
Thyroid Within normal limits Thyromegaly Nodules palpable Neck mass _____________________
Jugular Veins Within normal limits JVD present a, v or cannon a waves present
Chest is free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis
Scarring consistent with old, healed radiation dermatitis
Resp effort Within normal limits Accessory muscle use Intercostal retractions Paradoxic movements
Chest percussion Within normal limits Dullness to percussion Lt Rt Hyperresonance Lt Rt
/ \ \ \ \
M
Tactile exam Within normal limits Tactile fremitus Increased Decreased ________________________
Auscultation Within normal limits
Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub present
CV
Clear S1 S2 No murmur, rub or gallop Gallop Rub
Murmur present Systolic Diastolic Grade I II III IV V VI
Peripheral pulses palpable No peripheral edema Peripheral pulses Absent Weak
SA
GI
Radiology
CXR CT scan Other Abdomen Within normal limits Mass present LUQ RUQ LLQ RLQ ______________ Pulsatile
Liver and spleen palpation wnl Unable to palpate Liver Spleen Enlarged Liver Spleen
Lymph (2 areas must be examined)
Lymph node exam wnl Areas examined Neck Axilla Groin Other ___________________
Lymphadenopathy noted in Neck Axilla Groin Other ___________________
Musc
Muscle tone within normal limits, and no atrophy noted Tone is Increased Decreased Atrophy present
Gait and station wnl Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Extrem
Exam wnl Clubbing Cyanosis Petechiae Synovitis Rt Lt ________________________
Skin
No rashes, ecchymoses, nodules, ulcers
Neuro
Oriented NOT oriented to Person Time Place
Affect is within normal limits OR Patient appears Agitated Anxious Depressed
Additional Findings
Medical Decision Making Impression
Data Reviewed I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
ER Notes decision maker) understands their medical condition, their prognosis and the consequences of their Code
Old medical records Status decision.
Labs Code Status Patient is a FULL CODE
Radiology data DO NOT ATTEMPT Cardiac Resuscitation
Pathology DO NOT Intubate
Echocardiogram (ECHO)
Electrocardiogram (ECG) This patient has advanced health care directives. Their HCPOA is
Stress Test
Pulmonary Function Test
E
Operative/Procedure Notes
Care Coordinated with
Patient
HCPOA / Surrogate
Consultant(s)
Recommended Actions
Smoking cessation aids
Pneumonia vaccine
Influenza Vaccine
Recommended Diagnostics
12-lead Electrocardiogram (ECG)
Echocardiogram (ECHO)
Chest X-ray
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
PL
M

CBC with differential
PT, PTT, INR
Basic Metabolic Panel
Complete Metabolic Panel
TSH
HIV
SA
Hepatitis panel
Toxicology screen
Urinalysis
Urine electrolytes
Nasal or nasopharyngeal swab/wash
PPD
Quantiferon test
Serum Mycoplasma
Urinary antigen
Histoplasma Legionella
Culture
Sputum Blood Urine CSF

Consult
Follow Up Planned
Physician Signature
cc

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New Outpatient Evaluation Patient Name DOB MRN Encounter Date

Medications Blood Pressure Sitting Standing Lying /

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Clinic History and Physical MedicalTemplate

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New Outpatient Evaluation Patient Name DOB MRN Encounter Date

Medications Blood Pressure Sitting Standing Lying __________ / __________

\____/ ____ / ____ / ____ /

Potrebbero piacerti anche

Medications Blood Pressure Sitting Standing Lying /

\/ / / /