history and physical exam template pdf Monday, May 31, 2021 8:45:04 PM

History And Physical Exam Template Pdf

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Published: 31.05.2021

Having a healthy lifestyle and taking measures to prevent illness whenever possible is the best way to ensure a long and healthy life. Talking about taking measures to prevent illness, one of the best things you can do to keep the diseases at bay is get physically examined every now and then.

History & Physical Exam

The patient is a year-old right-handed woman with a history of chronic headaches who complains of acute onset of double vision and right eyelid droopiness three days ago. When she looked up at the clock on the wall, she had a hard time making out the numbers. At the same time, she also noted a strange sensation in her right eyelid. She went to bed and upon awakening the following morning, she was unable to open her right eye.

When she lifted the right eyelid with her fingers, she had double vision with the objects appearing side by side. The double vision was most prominent when she looked to the left, but was also present when she looked straight ahead, up, down, and to the right, and went away when she closed either of her eyes. She also noted that she had pain in both of her eyes that increased if she moved her eyes around, especially on looking to the left. Smith also notes that for the past two to three weeks, she has been having intermittent pounding bifrontal headaches that worsen with straining, such as when coughing or having a bowel movement.

The headaches are not positional and are not worse at any particular time of day. She rates the pain as 7 or 8 on a scale of 1 to 10, with 10 being the worst possible headache.

The pain lessened somewhat when she took Vicodin that she had lying around. She denies associated nausea, vomiting, photophobia, loss of vision, seeing flashing lights or zigzag lines, numbness, weakness, language difficulties, and gait abnormalities. She has never taken anything for these headaches other than ibuprofen or Vicodin, both of which are partially effective. The last headache of that type was two months ago. Her visual symptoms have not changed since the initial presentation. She denies previous episodes of transient or permanent visual or neurologic changes.

She denies head trauma, recent illness, fever, tinnitus or other neurologic symptoms. She is not aware of a change in her appearance, but her husband notes that her right eye seems to protrude; he thinks that this is a change in the last few days. The patient lives with her husband and year-old daughter in a 2-story single-family house and has worked as a medical receptionist for 25 years. She denies tobacco or illicit drug use and rarely drinks a glass of wine. Her mother had migraines and died at the age of 70 after a heart attack.

Her maternal grandfather had a stroke at age She states that she had an upper respiratory infection with rhinorrhea, congestion, sore throat, and cough about 6 weeks ago. She denies fever, chills, malaise, weight loss, neck stiffness, chest pain, dyspnea, abdominal pain, diarrhea, constipation, urinary symptoms, joint pain, or back pain.

Neurologic complaints as per HPI. The patient is obese but well-appearing. Temperature is There is no tenderness over the scalp or neck and no bruits over the eyes or at the neck. There is no proptosis, lid swelling, conjunctival injection, or chemosis. Cardiac exam shows a regular rate and no murmur. Mental status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming.

Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 4 mm and briskly reactive to light. When the patient is looking to the left, the right eye does not adduct.

When the patient is looking up, the right eye does not move up as well as the left. She develops horizontal diplopia in all directions of gaze especially when looking to the left.

There is ptosis of the right eye. Convergence is impaired. CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact. Motor: There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally. Plantar responses are flexor. Sensory: Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes. Coordination: Rapid alternating movements and fine finger movements are intact.

There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal or extraneous movements. Romberg is absent. Gait is steady with normal steps, base, arm swing, and turning. Heel and toe walking are normal. Tandem gait is normal when the patient closes one of her eyes. These range in size from 1 to 10 mm and do not enhance after administration of gadolinium. There are no signal abnormalities in the brain stem or in the corpus callosum.

No abnormalities in orbits, sinuses, or venous structures. In summary, the patient is a year-old woman with longstanding headaches who has had an acute onset of pupil-sparing partial third nerve palsy on the right involving levator palpabrae, superior rectus, and medial rectus associated with a bifrontal headache.

Because this is an isolated third nerve palsy without involvement of other cranial nerves or orbital abnormalities, the lesion is localized to the nerve itself, e. However, other potentially serious causes of third nerve palsy must be excluded. If a third nerve palsy is due to a compressive lesion, the pupillary fibers will generally become involved within about one week of the onset of symptoms. So the fact that her pupil is normal in size and reactive to light weighs against the diagnosis of a compressive lesion such as an aneurysm or tumor, but does not eliminate the possibility.

The MRI does not show evidence of a mass lesion, but an aneurysm cannot be completely excluded without an angiogram. Another potentially serious cause of the third nerve palsy is meningitis. The patient is afebrile, has no meningeal signs, is well-appearing, and has been stable over three days, making bacterial meningitis highly unlikely, but atypical meningitis including fungal, Lyme, sarcoid or carcinomatous meningitis are possibilities. Finally, the patient may have a vascular lesion of the third nerve due to unrecognized diabetes.

The appearance of the MRI abnormalities is non-specific. The lesions are potentially explainable by migraines, but are also consistent with hypertension or a vasculopathy. The patient denies a history of hypertension, is not currently hypertensive, and has no risk factors for vascular disease, but the possibility of a genetic disorder such as CADASIL cannot be excluded given the lack of paternal history. Problem 1. R IIIrd nerve palsy. The patient will undergo a cerebral angiogram to evaluate for an aneurysm, particularly a posterior communicating aneurysm.

Patient has been informed of risks and benefits of this procedure and it is scheduled for AM. She will be kept NPO for the procedure. A lumbar puncture will be performed with opening pressure assessed and CSF sent for cell count and differential, protein, glucose, cultures and cytology.

She will have her glucose and hemoglobin A1C drawn to evaluate for diabetes. She will have close observation for possible neurologic worsening including neuro checks every 4 hours for first 24 hours. She will be given an eye patch for comfort to eliminate the diplopia.

Problem 2. She will be given a trial of naprosyn mg po bid; if this is ineffective, she may require narcotic analgesia while her evaluation is being completed. If the cerebral angiogram and lumbar puncture are negative and her headache does not improve, she may be a candidate for IV dihydroergotamine treatment. Despite the infrequency of her migraines, the occurrence of a debilitating migraine with neurological deficits warrants the use of a prophylactic agent.

A tricyclic antidepressant would be a good choice given her history of depression. Problem 3. The patient denies current symptoms and will continue Zoloft at current dose. Department of Neurology. Toggle navigation. Postdoctoral Research Opportunities. Evidence-Based Stroke Management Series. History of present illness: Mrs. Past medical history: Migraine headaches, as described in HPI.

There is no history of diabetes or hypertension. Medications: Zoloft 50 mg daily, ibuprofen mg a few times per week, and Vicodin a few times per week. Allergies: None. Social history: The patient lives with her husband and year-old daughter in a 2-story single-family house and has worked as a medical receptionist for 25 years.

Family history: Her mother had migraines and died at the age of 70 after a heart attack. Review of systems: She states that she had an upper respiratory infection with rhinorrhea, congestion, sore throat, and cough about 6 weeks ago.

General physical examination: The patient is obese but well-appearing. Neurologic examination: Mental status: The patient is alert, attentive, and oriented.

Encounter Forms

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Download encounter forms to help ensure accurate documentation for asthma, diabetes, hypertension, and other conditions common in primary care. Sign Up Now. FPM Toolbox Encounter Forms Download encounter forms to help ensure accurate documentation for asthma, diabetes, hypertension, and other conditions common in primary care. Return to main toolbox page. Want to use this article elsewhere? Get Permissions.

Forget about scanning and printing out forms. Use our detailed instructions to fill out and e-sign your documents online. SignNow's web-based application is specifically developed to simplify the management of workflow and improve the process of competent document management. Use this step-by-step instruction to fill out the History and physical template form quickly and with excellent precision. By using SignNow's complete platform, you're able to execute any needed edits to History and physical template form, make your personalized digital signature within a couple of fast steps, and streamline your workflow without leaving your browser. Find a suitable template on the Internet.

Physical Examination

The History portion contains the chronology of what is wrong with the patient - often the "what is wrong with the patient" is called the " chief complaint " and is often abbreviated "CC" in the History documentation in the medical record. For example, a patient may report that there is blood in her sputum and this has been present for a period of one week. The physician will often write: CC: "Patient reports blood in sputum for a period of one week. Following the chief complaint, the physician will also document any other pertinent History about the patient's medical, behavioral, and psycho-social aspects. The Physical Exam includes both objective and subjective assessments of the patient's physical being.

In a physical examination , medical examination , or clinical examination , a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms. Together, the medical history and the physical examination help to determine a diagnosis and devise the treatment plan. This data then becomes part of the medical record. The routine physical , also known as general medical examination , periodic health evaluation , annual physical , comprehensive medical exam , general health check , preventive health examination , medical check-up , or simply medical , is a physical examination performed on an asymptomatic patient for medical screening purposes.

FREE 9+ Sample Physical Exam Forms in PDF

Department of Neurology

A Physical Exam or a Physical Assessment is an important means of preventive medicine for everyone regardless of race, age, sex, or level of activity. Physical Examinations are a means to screen for a disease, an ailment, or a condition and enables medical practitioners to assess its future medical risk. A Physical Examination is a process wherein a medical practitioner goes through the body of a patient and checks for any sign of disease. Physical Exams are recommended for everyone, especially among individuals above the age of

A physical examination is a routine test your primary care provider PCP performs to check your overall health. A PCP may be a doctor, a nurse practitioner, or a physician assistant. The exam is also known as a wellness check. The physical exam can be a good time to ask your PCP questions about your health or discuss any changes or problems that you have noticed. There are different tests that can be performed during your physical examination. Depending on your age or medical or family history, your PCP may recommend additional testing. A physical examination helps your PCP to determine the general status of your health.

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for seeking care. HPI (history of present illness) - PQRST PMH (past medical /surgical history) general OBJECTIVE (Physical Exam - sample recordings).


Physical examination

2 Comments

Gislena S. 01.06.2021 at 22:48

The patient is a year-old right-handed woman with a history of chronic headaches who complains of acute onset of double vision and right eyelid droopiness three days ago.

Psychantersea 05.06.2021 at 13:47

A physical exam form is a blank form and format with guided lines that tells you what to fill up on each blank space, and gives you this ready format to make a complete report of the physical examination of a candidate who is ready to apply for something, go somwhere or getting ready for some special work or purpose.

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