Patient’s Name: __________________ BP: ____________ HR: _________ RR: ___________ Temp: ___________

C.C. ________________________________________________________________________________

 

HPI:

Transition Question

Review of systems (ROS): This is a check list, do NOT write anything

PAIN LIQOPRAAA Location Intensity Quality Onset (duration & Frequency) Precipitating event • Progression • Previous episodes Radiation Alleviating Aggravating Associated symptoms

NO PAIN DOC PA FAA Describe what happened? Onset Constant/intermittent

Adults

Pediatrics

THEN FR CS PUB SAW ID

FEVER CUD SAD

Trauma/Travel recently Headache Edema Nausea/Vomiting (onset, color,

Precipitating event • Progression • Previous episodes Alleviating factors

frequency)

Fever/chills/Night sweat/Fatigue Racing of / Rash

Frequency Aggravating factors Associated symptoms

Chest pain/Cough (sputum, odor, color, blood)

SOB Pain in joints Urinary problem Bowel problem (abdominal pain, Diarrhea, Constipation, onset, color, blood, frequency)

Sleep problem Appetite Weight (how much? Time? Intentional?)

tiona Transi

PMH: Adults PAM HITS FOSS Past Medial History Allergies Medication Hospitalization in the past I’ll contacts Trauma Surgery TQ Family Hx OB/GYN (LMP RTV CS PAP) LMP, Menarche, Period lasts? Regularity? Tampons (# per day), Vaginal discharge, Itching, Dryness, Cramps, Spotting? (Intermenstrual / Post coital), Pregnancy (# of times? Complication), Abortion/Miscarriage Pap Smear (Last pap? Abnormal?),

Sexual Hx (with who? # of partners? Men or women? Protection? # of partners since last year?)

Social Hx (WHARTED) - Work - Home - Alcohol (ask CAGE) - Recreational drugs (Name? Last time used, method of use?) Tobacco (#pack per day, Educate)

- Exercise - Diet

Day care (Sick contacts?) Eating habits Appetite Last Check up (was it normal?)

Sleep/ Seizure (loss of bowel or urine, loss of consciousness) Activity (awake, playful, how does he looks?) Dehydration (dry mouth, shrunken eyes, soft or shrunken spots over the head “fontanelles”)

Diagnostic work-up • • • • • •    

Visit www.medical-institution.com for USMLE Step 2 CS Mnemonics & Physical Examination videos

 

URI, runny nose, cough, chest pain, SOB, difficulty swallowing) Urination (increase or decrease, #dippers, odor, color, dysuria) Diarrhea (onset, frequency, color, blood, mucus)

DDx: 1. 2. 3.

PAM IF BIG DEALS Past Medial Hx, • Past Surgical Hx • Previous hospitalization • Prenatal Hx Allergies Medications

Birth Hx Immunization Growth & Development

Cry / Chest symptoms/Cold (recent

Infection (recent infection) Dizziness (if yes, Vision problem?)

lQ

Pediatrics

Ill contacts Family Hx

Fever Ear pulling Vomiting (onset, color, frequency) Eyes / Ear discharge Rash / Rhinorrhea

 

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