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H&P Template - v2

The document is a medical examination report detailing a patient's physical exam findings, past medical and surgical history, and review of systems. It includes vital signs, general observations, and assessments across various body systems. Additionally, it outlines the patient's social history and differential diagnoses, along with a plan for further evaluation or treatment.

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nvincecr
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292 views1 page

H&P Template - v2

The document is a medical examination report detailing a patient's physical exam findings, past medical and surgical history, and review of systems. It includes vital signs, general observations, and assessments across various body systems. Additionally, it outlines the patient's social history and differential diagnoses, along with a plan for further evaluation or treatment.

Uploaded by

nvincecr
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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Name: Admit Date:

DOB: MRN: Physical Exam:


Age/Gender: CC:
Vitals HR: BP: Temp: O2: Weight: BMI:
HPI:
General NAO, Alert, Awake, and Oriented X4, W0WN
Head / Neck NCAT, Supple, JVD, LAD, carotid bruit, thyromegaly

Ears TM intact
Eyes EOMI. PERRL, anieteric sclera, conj injection
Nose

Oropharynx

Respiratory CTAB, no r/r/w, egophany/tactilc fremitus


Past Medical History: Medications CV RRR, no m/r/g, PMI, Cap Refill <2secs
Diagnosis Date Name
Abdomen soft, non-distended/non-tender, +BS nl x4, rebound/guarding
No cyanosis/clubbing/edema, normal ROM, joint swelling or erythcma
GU

Skin Intact, rashes, lesions, erythema


Past Surgical History:
Procedure Date Neurologic CN II-XII intact, no focal deficit, normal gait
Labs:
Allergies:

Past Family History: Social History: Differential: Other Test / Labs:


Diagnosis Live/Work:
Diet/Exercise:
EtOH:
Tobac./Drugs:
Sex/OB:
Psych:
Assessment Plan
Review Of Systems:
General Respiratory GI Urinary Endocrine Skin

Weight Loss Cough NVD Frequency Temp Intol. Dryness


Sputum Urgency Polyuria Rash
Night Sweats Hemoptysis Abdo Pain Hesitancy Polydipsia Itching
Fevers/Chills SOB GERD Pain Neuropathy Jaundice
Sleep Change Wheezing Bleeding Bloody/Dark New Growth Notes:
HEENT: CV: GU: MSK: Neuro: Other: To Do Notes

Headache Pain w/ Sex Joint Pain Weakness


Hearing Orthopnea Discharge Joint Swell Dizziness
Vision Diaphoresis Itching LBP Tremors
Chest Pain Irr. Period Myalgia Memory
Sore Throat Edema Lesions Dec. ROM Ataxia

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