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H&PE

The patient presented with unspecified chief complaints and medical history. A review of systems found no significant positive findings. On physical exam, vital signs were normal and the general exam was unremarkable. Laboratory tests including a CBC, CK, troponin, ECG, and urinalysis were ordered. A chest x-ray was also ordered. The patient's history, medications, allergies, family history, and social history were also documented.

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Danielle
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285 views2 pages

H&PE

The patient presented with unspecified chief complaints and medical history. A review of systems found no significant positive findings. On physical exam, vital signs were normal and the general exam was unremarkable. Laboratory tests including a CBC, CK, troponin, ECG, and urinalysis were ordered. A chest x-ray was also ordered. The patient's history, medications, allergies, family history, and social history were also documented.

Uploaded by

Danielle
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Med-Source

H&PE

Name: Sex: Age / DOB:

Date:

CC: Meds:

HPI:

Allergies:

Gen: fevers / chills /sweats / wt / fatigue

Skin: rashes / scaling / moles


Birth Hx:
Head: HA / faint / seizures / LOC / concussion

Eyes: blurry / double / pain / drainage / yellow / red


PMH:
Ears: hearing / ringing / discharge / dizzy

Nose: epistaxis / discharge / abnl odors / sinusitis

Throat: sore / hoarseness / cavities / ulcers

Breast: soreness / lumps / pain / discharge

Lungs: wheezing /cough / hemoptysis / clubbing


Immunizations?
♥: chest pain / pressure /palpitations / murmur /
PSH: orthopnea / edema

Heme: easy bruising / easy bleeding

GI: abd pain / N / V / D / C / hemat -emesis -chezia /


color / freq. / jaundice/ liver dz

GU: dysuria / hematuria / freq / urgency / incontinence /


discharge / testicular swelling, lumps, pain / impotence

menstrual: LMP _____ menarche______ regular?

Fam Hx: MI / HTN / ♥ / Ca / DM / osteo Musc: pain / swelling / stiffness / ROM limitation / fx

Neuro: weakness / spasticity / tremor / involuntary

Psych: mood / anxiety /memory / sleep

Social Hx:

Tobacco______________ EtOH_________________ IVDU/other__________________


Med-Source
VS T: HR: BP: RR: Pox
H&PE
GEN:

HEENT::

RESP:

CV:

ABD:

GU:

MUSC: reflexes / sensory

SKIN:

CBC:

CK: CK-MB: RI: Troponin:

BC:

CXR:

ECG:

UA / UC:

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