Chief complaint at admission and beyond
HPI: 6 core questions
A. Duration – longer better
B. Pattern – better or worst, AM or PM, when
C. Alleviating/ Provoking factors
D. Associated symptoms
E. What does the patient think the diagnosis is
How can I help you?
PMH – Is it possible you can be pregnant?
Medications and Allergies
FH: HTN, diabetes, cancer, stroke, heart attack, high lipids, arterial disease
SH: sheltered, somebody else to care for them, occupation
Habits: EtOH, smoking, rec. drugs, gay/straight/bi
ROS: fatigue, weight-loss/ gain
Vital signs – BP (120/80), P (60-100), Temp (abnormal is 100.5 and above),
O2 sat (95% or greater), RR (12-20x), Pain scale(0/10)
Skin: No lesion, warm, dry, color, spots
Nodes: no cervical, axillary, supraclavicular or inguinal adenopathy,
(posterior, occipital, submandibular, anterior jugular, elbow)
HEENT: supple, no thyromegaly or JVD.
No carotid bruits, hearing, vision,
teeth, runny nose, pupil equal, round, reactive to light, saliva
Chest: clear to auscultation and percussion. Cough, shortness of breathe, chest
Breasts: symmetric with no masses or nipple discharge.
Axillary tail normal
Cardiac: PMI (enlarged means congestive heart failure) in the mid-axillary
RRR (regular rate and rhythm) S1 (mitral) and
2(aortic valve); no S3 (pulmonary) or S4 (CHF).
No mumurs or rubs.
systolic ejection murmur heard bet at the base without radiation, ending well
before S2, heart pace, skip beats, fatigue with exercise
Abdomen: no distension, cars or abnormal pulsations.
Bowel sounds present.
No masses or tenderness.
(if tender, localize and identify whether there is
voluntary or involuntary guarding), size, heart burn, eating, change in bowel
Genitourinary: normal (un)circumsized male.
No testicular masses.
refused), sexual dysfunction, urinary consinence
Rectal – normal sphincter tone, heme negative stool, no masses or tenderness,
prostate smooth without nodules
Extremities: no clubbing, cyanosis (not enough O2) or edema
Neurologic Examination: alert and oriented times 4 (person, place, time, and
Cranial nerves 2-12 intact.
Motor: normal tone and symmetric
Sensory: intact to light touch.
Reflexes 2+ and symmetric with down-