Reason given by the patient for seeking medical care “in quotes”
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other
related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med )
Chronic Illnesses/Major traumas
“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
Weight change, fatigue, fever, chills, night sweats,
Chest pain, palpitations, PND, orthopnea, edema
Delayed healing, rashes, bruising, bleeding or skin
discolorations, any changes in lesions or moles
Cough, wheezing, hemoptysis, dyspnea, pneumonia
Corrective lenses, blurring, visual changes of any
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, black tarry
Ear pain, hearing loss, ringing in ears, discharge
Urgency, frequency burning, change in color of
Contraception, sexual activity, STDS
Fe: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, throat pain
Back pain, joint swelling, stiffness or pain, fracture
SBE, lumps, bumps or changes
Syncope, seizures, transient paralysis, weakness,
paresthesias, black out spells Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, cold or heat intolerance
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, previous dx
Weight BMI Temp BP Height Pulse Resp General Appearance
Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first, then brighter later. Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
Pulses 3+ throughout. No edema. Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.
A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink
and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is
smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions appropriately.
Urinalysis – pending
Urine culture – pending
Wet prep – pending
o 1- o 2- o 3-
o Plan: ▪ Further testing ▪ Medication ▪ Education ▪ Non-medication treatments
Evaluation of patient encounter