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PATIENT IDENTIFICATION

Via Christi Adult Medicine

HISTORY AND PHYSICAL EXAMINATION

	Admit History & Physical / Family Medicine Resident
	Attending Physician: Primary Care Physician:
	CC: Information Source: Patient Other:
	History of Present Illness:







	Past Medical History: Past Surgical History:




	Medications on Admission:




	Imunizations: Pneumovax Influenza Tetanus < 10 y
	Allergies:
	Family History: DM HTN CAD CVA Asthma TB COPD CA ______________ Same as CC:

	Social History: Tobacco: EtOH: ILDU:
	Marital/Family Status: Religion/Cultural:
	Occupational History: OBHistory: G__P__LC__
	Review of Systems: gained/lost weight, f/c/ns, insomnia, fatigue, weakness, HA, vision change, nasal d/c, epistaxis, congestion,
	dec. drinking/eating, ear pain, sore throat, chest pain, palpitations, dyspnea, wheezing, syncope, hemoptysis, cough: dry, sputum
	n/v/d, constipation, dysphagia, reflux, hematemesis, abd pain, melena/hematochezia, jaundice, last BM _____, last urination: _____
	dysuria, hematuria, polyuria, polydipsia, polyphagia, nocturia, rash, pruritus, bruise/bleed, back pain, pain____________________
	All other systems negative (continued next page) Signature:

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Via Christi Adult Medicine

HISTORY AND PHYSICAL EXAMINATION


	History & Physical / Family Medicine Resident – continued
	VS: T BP P R SaO2 Wt Pain /10
	PE: Gen – Alert and oriented, NAD
	HEENT – NCAT, PERRLA, EOMI, TM Intact B, MMM, OP Clear
	Neck – Supple, No LAD
	Pulm – CTAB
	CV – RRR without Murmur
	Abd/GI – Soft, NT, ND, + BS, No HSM, No guarding or rebound
	Rectal – Heme +, Heme -
	GU -
	Ext – No c/c/e, strong periph pulses, cap refill < 2 sec
	Skin – No rashes noted, warm, dry
	Neuro – CNII-XII grossly intact, no focal deficits, strength/sensation equal B
	LAB Ca AST Protein Troponin T. Bili ALT Albumin CPK Alk Phos Globulin CKMB


	Radiology:


	Assessment/Plan:








	Code status: Proph: DVT GI
	Discussed with: Dictation # Signature:
Date/Time	I personally examined and interviewed the patient. I reviewed the chart, imaging, and labs. I discussed the patient with the family medicine resident, reviewed the note as above, and agree with the history, physical exam, assessment and plan of care as above, with the following additions or corrections: Preceptor Signature: