Name: Pt. Encounter Number:

Date: Age: Sex:

SUBJECTIVE

CC: Reason given by the patient for seeking medical care “in quotes”

HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location

where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other

related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.

Medications: (List with reason for med )

PMH

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart

disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”

Family History

Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with:

lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

ETOH, tobacco, and marijuana. Safety status

ROS

General

Weight change, fatigue, fever, chills, night sweats,

and energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, and

edema

Skin

Delayed healing, rashes, bruising, bleeding or skin

discolorations, and any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia

hx, and TB

Eyes

Corrective lenses, blurring, and visual changes of

any kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis,

hemorrhoids, eating disorders, ulcers, and black,

tarry stools

Ears Ear pain, hearing loss, ringing in ears, and

discharge

Genitourinary/Gynecological Urgency, frequency burning, change in color of

urine.

Contraception, sexual activity, STDs

Female: last pap, breast, mammo, menstrual

complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or

discharge, dental disease, hoarseness, and throat

pain

Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture

hx, and osteoporosis

Breast SBE, lumps, bumps, or changes

Neurological Syncope, seizures, transient paralysis, weakness,

paresthesias, and black-out spells

Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night

sweats, swollen glands, increase thirst, increase

hunger, and cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal

ideation/attempts, and previous dx

OBJECTIVE

Weight BMI Temp BP

Height Pulse Resp

General Appearance Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.

Slightly somber affect at first and then brighter later.

Skin

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs

intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive

light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two

seconds. Pulses 3+ throughout. No edema.

Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Genitourinary

Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal

distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.

A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink

and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.

Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.

No adnexal masses or tenderness. Ovaries are nonpalpable.

(Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)

(Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is

smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm).

Musculoskeletal Full ROM seen in all four extremities as the patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though

clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis—pending

Urine culture—pending

Wet prep—pending

Special Tests

Diagnosis

o Include at least three differential diagnosis

o Final diagnosis

 Evidence for final diagnosis should be documented in your Subjective and

Objective exams.

PLAN including education

o Plan:

 Further testing

 Medication

 Education

 Nonmedication treatments

 Follow-up