H&P Card

Chief Complaint
reason for visit
pts own words
Hx of Present Illness (HPI)
1st paragraph: “Mr. X is a __ year old M/F with a past medical hx of _____ who presents with a ___ day hx of _________.

Pertinent positive ROS (pts words)
Pain: LQD MASCOT
– Location (site & radiation)
– Quality (sharp, burning, dull, aching, etc)
– Duration (constant, intermittent, etc)
– Modifiers (alleviating, aggravating)
– Assoc sxs (fever, chills, etc)
– Severity (0-10)
– Context (sig factors affecting CC – known exposures, risks, etc)
– Onset (acute, gradual, began when)
– Timing (frequency, time of day, patterns)

2nd paragraph (medical terms):
– relevant facts/risk factors from PMH, FMHx, Social hx that are related to CC

Last paragraph (medical terms):
– pertinent negative ROS

Pain Mnemonic
DOCS ARE FIT
Duration
Onset
Character
Site
Associated symptoms
Radiation
Exacerbating/ relieving symptoms
Frequency
Intensity
Timing
Mnemonic for rest of Full
CIAO MS. HIT PFam, LSD Mt caIIS
CIAO MS. Fam, LSD Mt caIIS stands for?
Childhood illness
Illnesses as an adult
Allergies
OBGYN

Medications
Surgical History

Hospitalizations
Injuries
Toxic exposures/ transfusions

Psychiatric History
Family History

Life, Stressors, Drugs

Maintenance
ca
Immunization
Issues of Safety
Screening

Past Medical History (PMH) 2 kids, 6 adult
Childhood:
1- sig illnesses
2- hospitalizations

Adult:
1- Medical Illnesses: current status, year of dx
2- OB/Gyn Hx: menarche/menopause, pregnancy hx (G-Ptpal)
3- Hospitalizations
4- Accidents/injuries
5- Transfusions/toxic exposures (& when)
6- Psyc hx (dates, dx, hosp, tx)

Past Surgical History (PSH)
list in chronological order w/ dates
Medications
current meds
herbal supplements
OTC

– name, dose, route, frequency, reason

Allergies
medicine, reaction, & year
Family History

– 14 dx to ask

age, dx, alive/deceased, cause of death

HTN
CHD (<55 yo males, <65 females) Hyperlipidemia Stroke DM Thyroid or renal disease Cancer Arthritis Anemia or blood disorders TB, asthma, or lung disease HA Seizures Mental illness, suicide Alcoholism & drug addictions Father, Paternal GF & GM Mother, Maternal GF & GM Siblings Children

Social History – 3 things
Life Experiences (7)
– birthplace
– childhood home situation
– childhood trauma (physical, emotional, verbal, sexual)
– education (last grade)
– job hx
– military service
– overseas travel

Current Stressors/Support (8)
– residence/home situation
– marital status & family
– sexual hx (HIV risk factors)
– occupation
– financial status
– leisure activities
– hobbies
– religious affiliation &/or beliefs

Habits (7)
– tobacco (PPD, total pack years)
– alcohol (type & amount)
– drugs (what & last time)
– caffeine
– diet
– exercise
– sleep patterns & effectiveness

Life Experiences (7)
1- birthplace
2- childhood home situation
3- childhood trauma (physical, emotional, verbal, sexual)
4- education (last grade)
5- job hx
6- military service
7- overseas travel
Current Stressors (8)
Current Stressors/Support (8)
– residence/home situation
– marital status & family
– sexual hx (HIV risk factors)
– occupation
– financial status
– leisure activities
– hobbies
– religious affiliation &/or beliefs
Habits (7)
– tobacco (PPD, total pack years)
– alcohol (type & amount)
– drugs (what & last time)
– caffeine
– diet
– exercise
– sleep patterns & effectiveness
Health Maintenance – 3 things
SIS: safety, immunizations, screening
dates & results if completed/known

Immunizations (7)
TPISHTH
– tetanus
– prevnar/pneumovax
– infulenza
– shingles (zostavax)
– high risk vaccines
– travel shots (Hep A, Hep B series)
– HPV

Safety Issues (3)
– seatbelts, helmets
– sunblock
– smoke detectors

Screening Tests (6)
– cholesterol
– colonoscopy
– mammogram
– dexa scan
– Pap smear
– PPD

Immunizations (7)
– tetanus
– prevnar/pneumovax
– infulenza
– shingles (zostavax)
– high risk vaccines
– travel shots (Hep A, Hep B series)
– HPV
Safety Issues (3)
– seatbelts, helmets
– sunblock
– smoke detectors
Screening Tests (6)
– cholesterol
– colonoscopy
– mammogram
– dexa scan
– Pap smear
– PPD
ROS – General (8)

w/in last 2-4 weeks

fever
chills
night sweats
recent unexplained weight changes
weakness
fatigue
non-refreshed sleep
chronic pain
ROS – Endocrine (7)
thyroid problems
heat/cold intolerance
hyperhidrosis
polydipsia
polyphagia
polyuria
change in glove or shoe size
ROS – Skin (7)
rash
dryness
pruritis
hives/wheals
changes of hair or nails
unusual or new skin lesions that are changing in color or growing, intensely itching, bleeding, or painful
ROS – Head (5)
HA
tramua
dizziness
lightheadedness
scalp lesions
ROS – Eyes (9)
last eye exam
glasses/contacts
hx of glaucoma or cataracts
eye pain
redness
discharge
vision changes: loss, diplopia, scotoma, halo, flashes, blurring
photophobia
ROS – Ears (7)
tinnitus
hearing problems
phonophobia
earache
vertigo
infections
discharge
ROS – Nose/Sinuses (8)
frequent hay fever
colds
itching
rhinorrhea
congestion
sinus pressure/pain
epistaxis
snoring
ROS – Mouth/Throat (11)
date of last dental exam
dentures or dental appliances
loose or missing teeth
recurrent infections
bleeding gums
ulcers
soreness
dry mouth
altered taste
hoarseness
dysarthria
ROS – Neck (5)
lumps
swollen glands
thyroid goiter
pain
stiffness
ROS – Breasts (5)
lumps
pain
nipple discharge
skin changes (rashes, dimpling, swelling)
self-exam routine
ROS – Respiratory (11)
cough
sputum production (color, quantity)
hemoptysis
dyspnea
pleurisy
wheezing or coughing spasms
hx of asthma
TB (or exposure to TB)
PPD status
recurrent respiratory infections
hx of sleep apnea
ROS – Cardiac (10)
chest pain
dyspnea on exertion (DOE)
paroxysmal nocturnal dyspnea (PND)
orthopnea
palpitations
blood pressure problems (high, low)
syncope or pre-syncope
hx of rheumatic fever
hx of heart murmur
past testing plus results
ROS – Vascular (6)
edema
claudication
cyanosis
varicose veins
clots
cramps
ROS – GI (18)
anorexia
unplanned weight loss
dysphagia
heartburn
nausea
vomiting
hematemesis
abdominal pain
excess gas/belching
food intolerances
jaundice
liver or gallbladder problems
antacid/laxative use
change in bowel habits (constipation, diarrhea)
melena
hematochezia
ribbon-like stools
hemorrhoids
ROS – Genital (5, F5, M4)
discharge
rashes
lesions/lumps
STIs & tx
sexual
– decreased libido
– anorgasmia
– satisfaction
– function
– problems
– HIV risks

Females:
– menses: LMP (1st day) & pattern (interval, duration, intensity)
– bleeding issues: amenorrhea, metrorrhagia, menorrhagia, menopause
– pain: dysmenorrhea, dyspareunia, PMS
– vaginal: soreness or sores, lumps, pruritus, DES exposure (pre 1971)
– contraception: hx, success, satisfaction

Males:
– penile sores
– testicular pain/mass
– hernias
– erectile dysfn

ROS – Urinary (9, M4)
frequency
urgency
dysuria
polyuria
nocturia
hematuria
recurrent infections
nephrolithiasis
incontinence

Males:
– difficulty starting stream
– dribbling
– hesitancy
– decreased force/caliber of stream

ROS – Hematologic/Lymphatic (4)
abnormal bleeding/bruising
anemia
past transfusions or rxns
new lymphadenopathy
ROS – Musculoskeletal (3)
back pain
gout
arthralgias or myalgias
– location
– swelling
– warmth
– redness
– pain
– tenderness
– limiations: locking, laxity, or deformity
– stiffness
– weakness
– timing
– duration
– hx of any trauma
ROS – Neurologic (10)
HA
fainting
syncope
seizures
tremors
involuntary movements
ataxia
paralysis
paresis
paresthesia
ROS – Psychiatric (14)
loss of memory
loss of quality sleep
constant worrying
nervousness
panicky
crying
feeling sad, down
depressed
hopeless
helpless
hx of suicide attempts
difficulty concentrating
feeling overwhelmingly happy or energetic
change in bx or speech patterns/thoughts
PE – Vitals
Temperature
Pulse
RR
BP
Height
Weight
BMI
PE – General Appearance
“Awake, alert, appropriately groomed & dressed well developed & well-nourished [race/gender] looking their stated age, who is cooperative, nontoxic, non-ill appearing & in no acute distress”.
PE – Head
hair pattern
scalp
skull
face
PE – Eyes
Function followed by structure, out to in

visual acuity (DVA & NVA)
visual fields to confrontation
EOMI
lids, lashes, & eye alignment
conjunctivae (palpebral & bulbar)
sclera
cornea
anterior chamber/lens
pupils (PERRLA, size, shape)
fundi
– vessels
– disc
– cup to disc ratio
– exudates
– hemorrhages
– AV nicking
– papilledema

PE – Ears
hearing
– whispered voice at 6 ft
– finger rub at 6 in
– Weber lateralization
– Rinne (AC>BC)

auricle
– helix
– antihelix
– tragus
– pinna
– pain w/ movement

external canal
– cerumen
– swelling
– bondy growths

TM
– color
– light reflex
– bony landmarks
– mobility
– perforation

PE – Nose
sinuses
septum
mucosa
turbinates
discharge