Template/ Format for Complete Write up

Submitted by sypark on Tue, 09/09/2008 - 2:34pm

Template /Format for Complete Write up

The following is a template that you can adapt and use for your complete write ups for ICM II.  It is helpful to put it on some kind of a card or “cheat sheet” and take it with you to remind you of the various parts of the history, (and review of systems!) and the physical exam.

Format for Complete Write up

Problem List

Identifying Information/Chief Complaint

History of Present Illness

organized by problem

Past Medical History

childhood illnesses and immunizations

medical problems

surgeries/trauma

pregnancy history/sexual history

Medications/Habits and Risk Factors

medications

allergies

habits/risk factors

cigarettes

alcohol

drugs (IV, other)

transfusions

travel

other exposures

preventive health

regular source of care

health maintence

diet

exercise

Family History

genogram

general review

Social History

upbringing/education/military

cultural/ethnic background

occupation(s)

current life situation

living situation

relationships (family, friends), social support

finances/insurance

stresses, satisfactions, interests

religion/spiritual support

Review of Systems

General: fevers, sweats, weight change, exercise tolerance, “energy” level.
Derm: rashes, pruritus, changing moles, lumps, lesions.
HEENT:

Head: headache, trauma.

Eyes: vision, glasses, diplopia, inflammation, pain.

Ears: hearing, tinnitus, vertigo, pain.

Nose: epistaxis, obstruction, sinusitis.

Mouth: dental care, dentures, sores, sore throat.
Breast: lumps, discharge, pain, swelling.
Respiratory: dyspnea, pleuritic pain, cough, sputum (description), wheezing, asthma, hemoptysis, cyanosis, snoring, apnea, history of TB exposure, PPD
Cardiovascular: chest pain, angina, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, peripheral edema, history of murmur, palpitations, claudication, leg cramps
Gastrointestinal: appetite, odynophagia, dysphagia, heartburn, nausea, vomiting, hematemesis, jaundice, abdominal pain, melena, hematochezia, diarrhea, constipation, change in bowel habits or color of stool, hemorrhoids
Genitourinary: dysuria, nocturia, hematuria, frequency, urgency, hesitancy, urinary incontinence, vaginal or urethral discharge, sores, dyspareunia, testicular pain, swelling
Musculoskeletal: joint or back pain, swelling stiffness, deformity (list affected joints), muscle aches, locking of joints
Neurological: dizziness, involuntary movements, syncope, loss of coordination, motor weakness or paralysis, memory changes, speech, seizures, paresthesias
Psychiatric: depression, sadness, sleep disturbance, crying spells, anorexia or hyperphagia, anhedonia, suicidal/homicidal ideation, loss of libido, anxiety, eating disorders (anorexia nervosa, bulimia, dissatisfaction with body image), hallucination, delusions, behavioral changes
Hematologic: known anemia, easy bruising, heavy bleeding
Endocrine: polyuria, polydipsia, head/cold tolerance,
Functional Status (optional): Activities of Daily Living (ADLs): bathing, ambulating, toileting, transfer, eating, dressing.  Instrumental ADLs: shopping, cooking, mode of transportation, telephone use, laundry, housekeeping, responsibility for meds/finances.

Physical Examination

General: general appearance, apparent state of health, nutrition, development, stature, gross deformities, skin coloration, level of distress

Vital Signs: pulse and regularity, BP (orthostatics and bilateral pressures if indicated), temperature, respiratory rate

Skin: texture, rashes, lesions (characterize including description, number, location, distribution), pigmentation, nails

HEENT: Head: shape, hair distribution, lesions; Eyes: visual acuity, visual fields, conjunctivae and sclerae, pupils, fundoscopic exam; Ears: hearing, discharge, auricular pain, appearance of tympanic membranes. Nose: obstruction, mucosa discharge. Mouth: sores, dentition, mucosa, tongue, gums, floor of mouth; appearance of tonsils, pharynx, uvula, palate

Neck: flexibility, masses, thyroid, tracheal deviation

Lymphatics: cervical, submandibular, supraclavicular, axillary, epitrochlear, inguinal, femoral, (characterize size, number, consistency, mobility, tenderness)

Breasts: appearance, asymmetry, tenderness, masses, nipple discharge

Pulmonary/Chest: Inspection: symmetry, spinal deformities, spine or CVA tenderness, tracheal deviation; Palpation: fremitus, tenderness; Percussion: clarity, symmetry, diaphragmatic excursion;  Auscultation: character of breath sounds, adventitious sounds (crackles, rubs, wheezes, egophony, vocal fremitus)

Cardiovascular: Neck Veins: level, wave, CVP, changes with respiration.  Heart: Inspection.  Palpation: PMI, lifts, heaves.  Auscultation: rate, rhythm, S1, S2, murmurs (grade, location, radiation, timing (systolic, diastolic) maneuvers), rubs, gallops.  Pulses: carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibialis. (Note strength, character, bruits.)

Abdomen: Inspection: distended/flat/scaphoid, abnormal movements, dilated veins, striae, scars; Ausculation: bowel sounds, bruits, rubs; Palpation: tenderness, guarding, rebound, ascites, masses, liver, spleen, aortic aneurism; Percussion: distention, organ size, shifting dullness

Genital: External: development, sores, scars.  Male: hydrocele, variocele, testicular masses, tenderness, urethral discharge, hernias, circumcision.  Females: appearance of vulva, perineum, vaginal walls, cervix, and vaginal discharge; cervical motion tenderness, size and position of uterus and adnexa, abnormal masses.

Rectal: external lesions, hemorrhoids, sphincter tone, fissures, prostate (size, texture, nodules, tenderness), masses, stool (color, consistency), fecal occult blood test.

Extremities: Inspection: deformity, nodules, clubbing, edema, symmetry, skin color, temperature, texture; joint  ROM, effusions, erythema, tenderness, synovial thickening

Neurological: Mental status: level of consciousness, orientation, mood/affect, speech (naming, repetition, fluidity), recall (registration, short term, long term), attention, commands, abstractions, judgement, insight, delusions, hallucinations.  Cranial nerves: pupils (symmetry, reactivity, size), corneal reflex, extra-ocular movements, facial sensation, movement and symmetry, air and bone sound conduction, gag reflex, shoulder shrug, sternocleidomastoid strength, tongue movement.  Motor: atrophy, tone, fasciculations, tremor, strength (0-5 scale), pronator drift.  Sensory:  light touch, pain, temperature, vibration, proprioception.  Reflexes: DTR’s (symmetry, 0-4 scale), Babinski.  Cerebellar function: rapid alternating movements, finger to nose, heal to shin.  Gait:  steadiness, symmetry.  Romberg.

Summary

one sentence

Branching Diagram

Discussion