H & P

History

CC:


HPI:

Associated S&S's
Onset
Provocative
Palliative
Previous
Quality
Region
Radiation
Risk factors
Severity
Temporal
Tx's

PMH:

Disorders:


Operations:


Medications:


Allergies:


Trauma
Immunizations
Transfusions


FHx:


Social Hx: - EOM, home, sppts, finances, insur, relig


ADL's (crucial to self-care)
Dressing
Eating
Ambulation
Toileting
Hygiene

Instrumental ADL's (enable independent living)
Shopping
Housekeeping
Accounting
Food preparation
Transportation

Habits: - ATD, eat, sleep, exercise, hobbies


Review of Systems:

General: No recent weight change, weakness, fatigue, fever, night sweats.

Skin: No noticeable color changes, pruritus, petechiae, infections, rashes, sores, changes in moles, changes in hair or nails.

Eyes: Last eye exam was . No pain, excessive tearing, double vision, floaters, loss of visual fields, history of glaucoma or cataracts.

Ears: No hearing loss, vertigo, tinnitus, or infections.

Nose and sinuses: No frequent colds, nasal stuffiness, hay fever, nosebleeds, sinus trouble, obstruction, discharge, pain, change in ability to smell, post-nasal drip, or history of nasal polyps.

Mouth and throat: No soreness in mouth, dryness, pain, sore tongue, pyorrhea, sore throat, hoarseness. No problem with dental caries, chronic mouth ulcers, or bleeding gums.

Neck: No lumps, goiter, or neck pain.

Lymphatics: No swollen nodes in neck, axillae, epitrochlear, or inguinal areas.

Breasts: No discharge, pain, or enlargement of breasts. No Hx of abnormal mammogram.

Cardiovascular: No history of heart disease or murmur. No chest pain or palpitations. No DOE, orthopnea, PND, edema, nocturia.

Pulmonary: No cough, dyspnea, wheezing, hemoptysis, pleuritic chest pain, cyanosis of lips or nail beds, Hx of TB exposure, Hx of positive TB skin test, Hx of pneumonia, or Hx of known environmental exposure.

Gastrointestinal: No dysphagia, odynophagia, hematemesis, food intolerance, rectal bleeding, melena, hernias abdominal pain. No nausea, vomiting, constipation, diarrhea, or change in bowel habits. No jaundice or gallbladder problems.

Urinary: No feeling of incomplete emptying, terminal dribbling, frequency, urgency, nocturia. No decreased stream, hesitancy, intermittency, straining. No dysuria, suprapubic pain, CVA tenderness, or history of urinary tract infection. No hematuria. No Hx of stones. No incontinence.

Genital tract: No penile discharge or history of STD. No testicular pain, swelling, or scrotal mass. No infertility, impotence, change in libido, sexual difficulties.

Endocrine: No thyroid problems, heat or cold intolerance. No excessive urination, thirst, or hunger.

Hematologic: No history of anemia or easy bruising.

Musculoskeletal: No joint pain, tenderness, stiffness, swelling, effusion, or limitation of motion. No Hx of arthritis or gout.

Neurologic: No unusual headaches or recent head injury. No paralysis, local weakness, numbness, tingling, tremors, or muscle atrophy. No syncope, vertigo, dizziness, or seizures. No changes in mental status, confusion, or memory loss.

Psychiatric: No anxiety, depression, insomnia, hypersomnia, phobias.

Physical Exam:

General appearance: Ambulatory & in no apparent distress. Well developed & well-nourished.

Vital Signs:

BP supine: /, standing: /
pulse and regular
respiration
temperature (oral) C
Height
Weight
BMI

Skin: Texture & turgor normal. No jaundice, pallor, edema, or cyanosis. No concerning skin lesions or loss of hair.

H&N: Normocephalic. No evidence of trauma. Scalp & hair distribution normal. Maxillary & frontal sinuses non-tender. Neck supple. Trachea midline. No thyroid enlargement, masses, or tenderness. Carotid pulses 2/4 bilaterally with normal upstroke and no bruits. No JVD.

Eyes: No ptosis, icterus, or conjunctival or scleral erythema or injection. Corneas clear. Visual acuity using hand-held chart 20/20 bilaterally. No visual field deficits by confrontation. EOMs intact and without nystagmus. Pupils equal, round, briskly reactive to light & accommodation directly and consensually. Ophthalmoscopy reveals red reflexes and sharp optic discs; no copper wiring, AV nicking, soft or hard exudates, or hemorrhages.

Ears: Hearing intact to whisper test. Pinnae and mastoid processes non-tender. Normal Weber and Renne. TMs & external auditory canals without erythema or exudates.

Nose, mouth, & throat: Nasal septum midline & without discharge. Lips, gums, & tongue without lesions. Dentition without obvious caries. Tonsils & posterior pharynx without erythema or exudates. Uvula midline & mobile.

Lymph nodes: No palpable or tender occipital, post-auricular, posterior cervical, supraclavicular, anterior cervical, deep cervical, tonsillar, pre-auricular, submandibular, or submental nodes. No palpable or tender inguinal, axillary, or epitrochlear nodes.

Breasts: No dimpling, peau d'orange, nipple inversion, or discharge. Nontender to palpation. No masses.

Chest: Bilaterally symmetrical movements with respiration. No chest wall deformities. Resonance on percussion. Normal breath sounds without crackles or wheezes.

Heart: PMI palpable in 5th left intercostal space at midclavicular line, approximately 1 cm in diameter. No heaves or thrills. Regular rhythm with normal S1 and S2. No S3, S4, clicks, murmurs, or rub.
Pulses: Carotid, brachial, radial, femoral, dorsalis pedis, and posterior tibial pulses 2/4 bilaterally. Popliteal pulses not palpable bilaterally. No carotid or abdominal bruits.

Abdomen: Thin, non-protuberant abdomen without scars or abnormal contour. Normal bowel sounds. No bruits. Tympany on percussion. Liver percussed at 10 cm at right midclavicular line, with smooth liver edge one cm below costal margin. Spleen not palpable. No masses or hernias.

Genitalia: Normal male distribution of pubic hair. No visible penile or scrotal lesions or discharge. No testicular tenderness, atrophy, or masses.

External: Normal female distribution of pubic hair. No masses, lesions, or swelling. Perineum intact with healed episiotomy scar. Urethral meatus intact without erythema or discharge. No vaginal discharge.
Speculum: Vaginal mucosa pink and moist with rugae present. No unusual odors. Profuse thick, white, curdy discharge. Cervix pink with horizontal slit midline; no lesions or discharge.
Bimanual: Cervix smooth, firm, mobile. No CMT. Uterus midline, anteverted, firm, smooth, non-tender, not enlarged. Ovaries not palpable. No adnexal tenderness.
Rectovaginal: Septum intact. Sphincter tone normal. Anal ring smooth & intact. No masses or tenderness.

Rectal: No anal lesions, hemorrhoids, fissures, or fistulae. Normal sphincter tone. Prostate smooth, symmetrical, and normal consistency; not tender or enlarged; no palpable nodules. Rectal vault without palpable lesions.

Musculoskeletal:

Back/Spine: Mobility, curvature, posture normal. No point or CVA tenderness.

Extremities: Upper & lower extremities symmetrical. Muscle strength 5/5 throuhout. No atrophy. No cyanosis, clubbing, or edema. Full range of motion in all joints without obvious deformity, tenderness, abnormal warmth, erythema, crepitus, swelling, or effusions.

Neurologic:

Mental Staus: Oriented to person, place, & time.
Cerebellar: Finger-to-nose & heel-to-shin normal. Rapid alternating movements of hands & feet normal bilaterally.
Cranial nerves: II intact by direct & consensual light & accomodation reflexes, & visual acuity; III, IV, VI intact by extraocular movements; V1, V2, & V3 sensory component intact by light touch & pin prick; and motor component of V intact by contraction of masseter & temporalis bilaterally; VII intact by contraction of facial muscles; VIII with grossly normal auditory acuity; IX & X intact by midline elevation of uvula & gag reflex; XI intact by sternocleidomastoid and shoulder shrug tests; XII intact by midline tongue protrusion.
Gait & station: Negative Romberg. Normal gait. Heel-toe tandem walk intact. Able to walk on toes only and on heels only.
Muscle strength: 5/5 in upper & lower extremities. No atrophy or fasciculations. No pain on palpation.
Sensation: Pinprick, vibratory sensation, & joint position sense intact in all distal extremities.
Reflexes: Deep tendon reflexes 2/4 in biceps, triceps, brachioradialis, patellar, & ankle bilaterally. Plantar responses down-going bilaterally.


Laboratory:

ECG:

Imaging:

Problem List:

1.
2.
3.
4.

Plan:



Pediatric Hx
Ped PMH form

Prenatal Hx
Prenatal care
G & P at birth
Age at birth
Medical problems during pregnancy
Meds taken during pregnancy
Hospital stays


Birth Hx
Weight
APGARs
Term?
Labour (spont or induced)
Delivery (SVD, forceps, C-section)
Complications (resuscitation, jaundice)
Hosp stay


Feeding


Developmental Hx

Milestone	Approximate age (normal)
Social smile	1 month
Sit	7 months
Vocal babble	9 months
Pull to stand	9 - 10 months
Pincer grasp	12 months
Walks alone	13 months
Three or four words	18 months
Hand preference	18 months
Many words	24 months

Social Hx

Personality
Ways of comforting self
Expression of anger/frustration
Cooperation/obedience
Fears
Self-satisfaction/degree of happiness
Reaction to change
Relationship to other children
Number of close friends
School performance
Child?s opinion of school
What do you like best about this child?
What concerns you most about this child?

Pediatric Px
General: Alert & active. Good colour. Respirations easy. Well-hydrated. Well-nourished.

Normal ranges for vital signs


Age group	RR	HR	Systolic BP	Weight (kg)	Weight (lbs)
Newborn	30-50	120-160	50-70	2-3	4.5-7
Infant (1-12 months)	20-30	80-140	70-100	4-10	9-22
Toddler (1-3 yrs)	20-30	80-130	80-110	10-14	22-31
Preschooler (3-5 yrs)	20-30	80-120	80-110	14-18	31-40
School age (6-12 yrs)	20-30	70-110	80-120	20-42	41-92
Adolescent (≥ 13 yrs)	12-20	55-105	110-120	>50	>110

Canadian Task Force on Preventive Health Care (CTFPHC)

U.S. Preventive Services Task Force (USPSTF)

Merck Manual

Criteria for Rheumatic Diseases

DSM IV TR

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ATPIII Guidelines on Cholesterol Management

JNC7 Guidelines on Htn

BMI Calculator

PubMed

ICD decoder

Medical Dictionary