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Scut Sheet

The document contains a patient's history and physical exam findings. It includes the patient's chief complaint, history of present illness, review of systems, past medical history, social history, medications, vital signs, physical exam findings, and planned labs, imaging, and other tests. The physical exam documents the patient's eyes, ears nose and throat, neck, heart, lungs, abdomen, neurological system, muscles and skin.

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florezstephanie
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1K views

Scut Sheet

The document contains a patient's history and physical exam findings. It includes the patient's chief complaint, history of present illness, review of systems, past medical history, social history, medications, vital signs, physical exam findings, and planned labs, imaging, and other tests. The physical exam documents the patient's eyes, ears nose and throat, neck, heart, lungs, abdomen, neurological system, muscles and skin.

Uploaded by

florezstephanie
Copyright
© © All Rights Reserved
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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A/P CC: Name

HPI: MRN
RM #
Admit Date

ROS Fam Hx
Constit: f/c, wt loss, nt sweats, fatigue
Eyes: eye pain, vision
ENT: in hearing, congestion, rhinorrhea, sore
throat, swallowing diff
CV: chest pain, SOB, palpitations, PND, orthopnea,
edema, calf pain
Resp: SOB, cough Social Hx
GI: n/v, diarr/constip, abd pain, blood in stool, Alcohol (last drink?)
hematemesis Tobacco
GU: burning, hematuria, urgency, frequency, Illicit Substances
nocturia, incont Living
Neuro: H/A, syncope, numb, tingling, weak Employment
MSK: musc/jt pain, weak, jt stiffness Married/Single/Divorced
Derm: rashes, itching Home Meds
Meds (abx, pain, sedation, prophylaxis) Endo: heat or cold intolerance, polyuria,
polydipsia, polyphagia
Heme: bleeding, bruising, blood clots

PMHx/PSurgHx

Allergies
Vitals / I&O Phys Exam labs (CBC, BMP, other, imaging)

/ Subj Other labs (LFTs, Micro) To do


CBC

VS:
Tmax Phys Exam:
HR Eyes: PERRL, EOMI, pallor, icterus
BP ENT: moist mem, oral ulcers, hearing BMP
Neck: LAD, thyromegaly
RR CV: JVD, carotid bruit, RRR, m/r/g, periph pulses
Resp: CTAB, wheezing/rhonchi, resp effort Imaging (CXR, Echo, CT, MRI)
O2
Abd: ND/NT, +BS, guarding, rebound, organomeg
I/O Neuro: CN2-12 intact, numb, tingling, reflexes
MSK: muscle tone and ROM
Skin: rashes, ulcers Ca P Mg

/ Subj Other labs (LFTs, Micro) To do


CBC

VS:
Tmax Phys Exam:
HR Eyes: PERRL, EOMI, pallor, icterus
BP ENT: moist mem, oral ulcers, hearing BMP
Neck: LAD, thyromegaly
RR CV: JVD, carotid bruit, RRR, m/r/g, periph pulses
Resp: CTAB, wheezing/rhonchi, resp effort Imaging (CXR, Echo, CT, MRI)
O2
Abd: ND/NT, +BS, guarding, rebound, organomeg
I/O Neuro: CN2-12 intact, numb, tingling, reflexes
MSK: muscle tone and ROM
Skin: rashes, ulcers Ca P Mg

/ Subj Other labs (LFTs, Micro) To do


CBC

VS:
Tmax Phys Exam:
HR Eyes: PERRL, EOMI, pallor, icterus
BP ENT: moist mem, oral ulcers, hearing BMP
Neck: LAD, thyromegaly
RR CV: JVD, carotid bruit, RRR, m/r/g, periph pulses
Resp: CTAB, wheezing/rhonchi, resp effort Imaging (CXR, Echo, CT, MRI)
O2
Abd: ND/NT, +BS, guarding, rebound, organomeg
I/O Neuro: CN2-12 intact, numb, tingling, reflexes
MSK: muscle tone and ROM
Skin: rashes, ulcers Ca P Mg

/ Subj Other labs (LFTs, Micro) To do


CBC

VS:
Tmax Phys Exam:
HR Eyes: PERRL, EOMI, pallor, icterus
BP ENT: moist mem, oral ulcers, hearing BMP
Neck: LAD, thyromegaly
RR CV: JVD, carotid bruit, RRR, m/r/g, periph pulses
Resp: CTAB, wheezing/rhonchi, resp effort Imaging (CXR, Echo, CT, MRI)
O2
Abd: ND/NT, +BS, guarding, rebound, organomeg
I/O Neuro: CN2-12 intact, numb, tingling, reflexes
MSK: muscle tone and ROM
Skin: rashes, ulcers Ca P Mg

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