Breasts Lumps; pain; discomfort; nipple discharge Negative Pulmonar y Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains Negative Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edema Negative G/I Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance Negative Urinary Frequency; nocturia; urgency; dysuria; hematuria; incontinence MALES : caliber of urinary stream; hesitancy; dribbling Negative G/U (General) Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposure Patient reports no sexual dissatisfaction, states that her and partner do not use protection from STD’s (only birth control) 4
Male G/U Discharge from or sores on penis; testicular pain/masses N/A Female G/U Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP Vaginal discharge; itching; sores; lumps Menopause; hot flashes; post- menopausal bleeding; Menarche age 12, LMP three weeks ago. Period lasts approximately seven days, patient reports no dysmenorrhea. No spotting between periods. Peripheral Vascular Claudication; leg cramps; varicose veins; hx of blood clots Negative Musculo- skeletal Muscle or joint pain; joint stiffness Negative Neuro Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements Negative Heme Hx of anemia; easy bruising or bleeding; blood transfusions Negative Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size Negative Psych Nervousness/anxiety; depression; memory changes; suicide attempts Patient reports some anxiety with normal life changes General Findings and Physical Exam General Observations Does patient appear to be their stated age? Appearance is appropriate to age Level of consciousness Alert and oriented to person, place, time, and situation Skin color Appropriate to ethnicity. Skin color appears slightly 5
rosy on cheeks, with no pallor or jaundice noted. Nutritional status Patient appears to be well nourished, with no apparent muscle wasting or cachexia Posture and position Patient is able to sit and stand upright without support, spine appears to be in proper alignment Obvious physical deformities No physical deformities noted, all extremities appear to be symmetrical and of even length. No involuntary movements noted or abnormal posturing Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Gait is smooth and even with no limping and patient does not require assistive devise. Patient is able to appropriately flex and extend all joints, no involuntary movements noted Facial expression Facial expression is symmetrical, no paralysis or facial ticking noted. Patient is able to move all facial muscles required for smiling, frowning, and raising eyebrows with no wincing Mood and affect Mood and affect is neutral and appropriate for
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- Fall '18