History and Physical Template.docx - History and Physical Template Chief Complaint Age Handedness Gender Problem and its duration Usual state of

History and Physical Template.docx - History and Physical...

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Unformatted text preview: History and Physical Template Chief Complaint: Age: Handedness: Gender: Problem and its duration: Usual state of health (baseline): “At baseline….” normal, active, fully functional residual mild _____ hemiparesis, can ambulate Relevant risk factors: HTN, CAD (stroke), DM, ____ +/- assist device”; oriented to self, transfers Obesity, smoking by lift Pertinent negative symptoms: Imaging if that was reason for the consult: Historian? ________ Quality? __________ Hospital Course: vital signs: Review of Systems — Constitutional: Eyes: HENT: Respiratory: Cardiovascular: Gastrointestinal: Genitourinary: Integument/breast: Hematologic/lymphatic: Musculoskeletal: Neurological: Behavioral/Psych: Endocrine: Allergic/Immunologic: early exam: Concisely and chronologically describe treatments: General Exam: which prompted medical attentions symptoms VS: BP:____ HR: ____, T: ____, P:______ response to therapy: (Timeline) * orthostatic vital signs: syncope, passing out symptom evolution: spells, hypotension. Past Medical History: Location: General Appearance — General current, treated, pertinent Quality/severity: observations: well nourished, well Chronology: Surgicalin History: developed, distress or not, appearance when it first beganfor stated age, etc. extremity: mode Lower of onset0/5: no contraction right leg straight and don’t let me Allergies Lift andup Adverse Reactions: mode of endingpush it downfemoral L3 1/5: muscle flicker, but no movement type of agent and reaction, severity, and Cardiovascular — Examine 1/+ item such Knee extensionfemoral L3,4 duration2/5: movement possible, but not against Knee flexionSciatic S1 dose dependent. aswhether auscultation of the carotids, frequencyKnee SGN L4-5 gravity (test the jointabduction: in its horizontal Medications —Adduction: ideally includes name, dosage, auscultation of the heart, palpation for L2-4 Knee Obturator Mental Status: plane) settingFoot dorsiflexion: DP, L5 route of administration (default assumption is peripheral pulses aggravating and alleviating factorsFoot plantar flexion: Tibial S1,S2 3/5: movement possible against gravity, Level conscious: oral), frequency, and whenDPN: started Toe dorsiflexion L5 if relevant treatmentbutOphthalmologic not against resistance by attempt the — Should and link to medical problems Attention: W-O-R-L-D fwds/bckwds associated symptomscomment the and appearance of the optic OR Months fwds/bckwds Reflexes: + upon Babinski Graspreflex 0: absent overall courseFamily Hx: +/- though neuro dz, +/- vessel neuro risk disc at minimum, blood and factors Orientation: effect on normal activitiesBiceps C5, C61+: trace, Age/ Cause ofDeath1st Degree Relatives Cranial Nerves: or seen only with Full name (musculo) Location history of similar symptomsreinforcement CNMother: II:previous visualUpper fields, pupillary reaction & extremity: Brachioradiali C6 (radial) Date (month, day, year) s accommodation Father: out 2+: normal Hands straight/ Don’t let me bend CN III, IV, VI: EOM, convergence Triceps C7 (radial) Language: Fluency, content Siblings: fingers– extensionC7 radial nerve Patellar L4 (femoral) Naming- watch, pen, hair CN&VII: smile, + puff cheeks, raise Gait Station Coordination — frown, 3 : brisk Ulncar T1 Finger adduction: Repetition: TATATA, PAPAPA, GAGAGA Sensation: eyebrows, shut eyesabduction: while examiner Finger Ulnar T1 Natural gaitHistory: noting fingerposture, to nose stance, maneuver Social max education, Both arms/legs Thumb abduction planeoccupation, palm/ opposition: attempts to open Recent Memory: hat, bike, Chicago 3, 5 Pinprick or Temp Median, T1 speed, stride length, rapid alternating arm swing, movements turns. CNfront/back VIII: finger rub (eyes closed) minutes Motor: atrophy/ fasciculations? Inspection: Hands Touch Wrist ext- Radial nerve, C6 Remote Memory: borntheir eyes. Vibration Drift: hold up both presidents, arms and close Younger heeltandem to shingait, testing heel (orand foot tapping if a CN IX patients: & X: articulation, say “ah” Wrist flexionmedian ulnar, C6-C8 when/where? fine movements: rapid finger tapping, rapid hand pronation Position CN XI:toe shoulder shrug & neck strengthmovements Elbow flexionmusculocutaneous C5, C6 walking, walking. screen). Note adventitious supination (as in screwing in a light bulb), rapidRomberg hand/foot tapping Elbow Extension radial nerve C7 against resistance *visuospatial neglectobject. (line bisection and against the function, floor or other such abduction as tremor,@ chorea Arm shoulder- Axillary C5 line cancellation), construction, calculation, ...
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  • Winter '14
  • vital signs, Brachial plexus, radial nerve, extensionC7 radial nerve, mild _____ hemiparesis

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