NameDateSexAgeDOBPlace of BirthSUBJECTIVEH.docx

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Name: Date: Sex: Age/DOB/Place of Birth: SUBJECTIVE Historian: Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes” Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) HPI: (must include all components) Medications: (List with reason for med ) PMH: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations: Family History (Please identify all immediate family) Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Cardiovascular Skin Respiratory Pediatric SOAP Note Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight Temp BP Height Pulse Resp General Appearance and parent‐child interaction Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Musculoskeletal Neurological Psychiatric In-house Lab Tests – document tests (results or pending) Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment) Diagnosis · Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials) · Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives · Primary diagnosis · Is #1 on list of differentials · Evidence for primary diagnosis should be supported in the Subjective and Objective exams. PLAN including education · Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature. · Include EB rationale for all aspects of your treatment plan: · Vaccines administered this visit · Vaccine administration forms given · Medication-amounts and mg/kg for medications · Laboratory tests ordered · Diagnostic tests ordered · Patient education including preventive care and anticipatory guidance · Non-medication treatments · Follow-up appointment with detailed plan of f/u *ALL references must be Evidence Based (EB) .

Education

Respiratory
Pediatric SOAP Note
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE (plot height/weight/head circumference along with
noting percentiles) Attach growth chart
Weight
Temp
BP
Height
Pulse
Resp
General Appearance and parent‐child interaction
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary

Musculoskeletal
Neurological
Psychiatric
In-house Lab Tests – document tests (results or pending)
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc)
with results and rationale
For adolescents (HEADSSSVG Assessment)
Diagnosis
· Include at least three differential diagnoses with ICD-10
codes. (Includes Primary dx and 2 differentials)
· Document Evidence based Rationale for ROS and each
differential with pertinent positives and negatives
· Primary diagnosis
· Is #1 on list of differentials
· Evidence for primary diagnosis should be supported in the
Subjective and Objective exams.
PLAN including education
· Plan: Treatment plan should be for the Primary Diagnosis and
based on EB literature.
· Include EB rationale for all aspects of your treatment plan:
· Vaccines administered this visit
· Vaccine administration forms given
· Medication-amounts and mg/kg for medications
· Laboratory tests ordered
· Diagnostic tests ordered
· Patient education including preventive care and anticipatory
guidance
· Non-medication treatments
· Follow-up appointment with detailed plan of f/u
*ALL references must be Evidence Based (EB)

NameDateSexAgeDOBPlace of BirthSUBJECTIVEH.docx

This document provides an introduction to pediatrics and history taking in pediatrics. It defines pediatrics as the branch of medicine dealing with the care of children and adolescents. The goal of pediatrics is to enable children's survival, health, growth, development and intellectual achievement. History taking in pediatrics requires listening to the caregiver, understanding the chief complaint, and gathering information on the present illness, past medical history, family history, development, nutrition, and socioeconomic factors. A thorough pediatric history takes a skilled, sympathetic approach tailored to the unique needs of children and families.

All clinico social formats

Devandiran Shankar

This case summary provides details of an under-5 child presenting with failure to gain weight. The key details include: 1. The child's birth history, including preterm delivery, low birth weight, and initiation of breastfeeding. 2. History of the current complaints of failure to gain weight, fever, cough and respiratory difficulty. 3. Past medical history noting recurrent infections, hospitalizations, and treatment history. 4. Socioeconomic factors like family income, ration card status, mother's antenatal and birth history are also documented. 5. A comprehensive history is taken to understand the physical, nutritional and social determinants influencing the child's health and development.

Concept Map.docx

write4

This concept map summarizes key components of a patient's medical history and hospital course. It includes sections for the patient's chief complaint, medical and surgical history, social history, diagnostic test results, admitting diagnosis, medical management and orders, priority nursing diagnoses, assessments, interventions, and discharge planning. The concept map is structured with 14 domains to guide the collection and documentation of relevant clinical information to develop an individualized plan of care for the patient.

Concept Map.docx

write22

Concept Map.docx

write22

Health history and care plans.docx

4934bk

This document contains sections for collecting a 65-year-old African American woman's health history, including biographical data, living arrangements, present health issues, vital signs, health beliefs and practices, medications, activities of daily living, past medical history, allergies, immunizations, surgical history, sexual history, family history, psychosocial history, review of body systems, and safety concerns. The interviewer is asked to submit the health history and narrative summary as one document and the genogram as a separate attachment.

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.x-3

AlleneMcclendon878

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. x-3 Student Checklist Ball: Seidel’s Guide to Physical Examination, 8th Edition Chapter 05: Mental Status Student Checklist Adult Examination Checklist Mark data, when appropriate, to indicate the following: If normal, * if abnormal, O if absent. Subjective Data __Alertness __Emotional status __Orientation __Time __Place __Person __Analogies (similarities) __Abstract reasoning (fable, proverb) __Arithmetic calculations __Writing ability __Motor skills __Memory __Immediate __Recent __Remote __Attention span (short commands) __Judgment/decision making (hypothetical situation) __Voice __Quality __Pace __Loudness __Articulation __Comprehension __Coherence (perceptions clearly conveyed) __Mood and feelings __Thought processes (logical) __Perceptual distortions (hallucinations) Objective Data Observation __Alertness __Grooming __Body language __Emotional status __Attention span __Coherence __Voice __Quality __Pace __Loudness __Articulation __Comprehension __Mood and feelings __Thought processes __Perceptual distortions Testing __Orientation __Time __Place __Person __Analogies __Abstract reasoning __Arithmetic calculations __Writing ability __Motor skills __Memory __Immediate __Recent __Remote __Attention span 5-2 Student Checklist Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Detail those data marked as abnormal: Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance). PMHx: inc ...

Otterbein University Graduate Studies in Nursing 6830 2021 Tina Jones.docx

sdfghj21

This document provides instructions for a nursing student, Tina Jones, to complete a comprehensive health history write-up assignment for her Nursing 6830 course at Otterbein University. It outlines the required sections and formatting for the assignment, including sections on the patient's chief complaint, history of present illness, medications, allergies, past medical history, family history, social history, and a review of systems. It also provides a grading rubric for evaluating the assignment.

This document provides guidance on conducting pediatric interviews. It outlines key areas to focus on during a pediatric history, including presenting illness, past medical history, pregnancy/birth history, development, and family/social history. Specific questions are provided for each area. The document emphasizes building rapport, focusing the history based on the situation, and considering language/culture. It also notes the importance of directly observing the child and prioritizing confidentiality during adolescent interviews.

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE PEDIATRIC FILLABLE SOAP NO.docx

JUST36

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE PEDIATRIC FILLABLE SOAP NOTE TEMPLATE PEDIATRIC FILLABLE SOAP NOTE TEMPLATE STUDENT NAME: DATE OF ASSIGNMENT: 05/11/2020 Patient Initials: J.T. Date of Encounter: 05/06/2020 Sex: Male Age/DOB/Place of Birth: 12yo, DOB: 05/03/2008, Miami, FL SUBJECTIVE Historian: Patient J.T. Present Concerns/CC: “My throat has been hurting recently” Reason given by the patient for seeking medical care “in quotes” Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) Patient is sexually inactive, a student at a local middle school, spends his time at home due to the COVID-19 pandemic, otherwise he enjoys playing videogames with his friends all day. The patient spends all of his time at home recently due to the pandemic but would otherwise go out with her family and friends sometimes. HPI: (must include all components - OLD CARTS) Patients throat began to hurt 2 days ago. It worsened over the past day, but he states that it is now around the same as yesterday. He states that he can still swallow food and drink, but it hurts when it passes his throat. It is present at all times of day, from when he wakes up, to when he goes to bed. The pain is localized at the back of this throat. It is dull and described as a 3/10. His mother has given him a honey and lime mixture that he states helps for a short while. Medications: (List with reason for meds) Patient not currently taking any medication PMH: Allergies: Dog hair, cat hair Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: None Immunizations: All vaccines up to date with the exception of the most recent influenza vaccine. Family History (please identify all immediate family) Mother: 32 years old, no current health problems Father: 34 years old, no current health problems Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status) Middle school student. Does not work. Lives with his parents and 2 brothers, one 6, the other 2 years old. Parents are married. Does not drink alcohol. Does not use recreational drugs, does not use tobacco products, does not smoke, does not vape. The patient states feeling safe at home with his family. Review of Systems (ROS) General Denies fevers, chills, nausea, and vomiting Cardiovascular Denies chest pain, pressure, palpitations Skin Denies lesions, itching, or redness. Respiratory Denies shortness of breath, denies cough, denies difficulty breathing Eyes Denies blurred vision, denies visual loss, denies double vision Gastrointestinal Denies nausea and vomiting, denies abdominal pain, denies diarrhea, and bloody stools. Ears Denies hearing loss, pain, or dra.

Linkedlifelines

Bruce Wolffenbuttel

LifeLines is a population-based study in northern Netherlands that aims to understand why some people age healthily while others develop impairments or diseases early in life. It focuses on multifactorial diseases influenced by both genes and environment. The study collects extensive data on over 55,000 grandparents, 75,000 parents, and 35,000 children to analyze genetic and environmental factors related to aging and diseases like heart/blood vessel conditions and psychiatric illnesses. Data is collected through questionnaires, medical records, yearly physical measurements and tests, and biobanking to enable genomic and advanced biomarker research. The long-term multi-generational cohort study takes a systems biology approach to integrate information from various sources to better understand disease determinants, modifiers

Cadth 2015 e1 deal prader willi cadth

CADTH Symposium

This document summarizes a workshop on developing clinical care guidelines for growth hormone treatment in Prader-Willi syndrome. The workshop brought together over 40 experts, including endocrinologists, geneticists, clinicians with an interest in growth hormone research, patient advocates, and methodologists. It utilized a multi-criteria decision analysis framework to develop the guidelines, taking into account scientific evidence, disease impact, safety, and other criteria. The goal was to produce consensus guidelines that integrated evidence, values, and ethics to guide policy and clinical practice around this complex treatment decision.

History taking in Medicine

drnooruddin

The document provides guidance on how to conduct a thorough patient history, including how to structure the history taking session and how to approach each component of the history. It discusses taking the chief complaint, history of present illness, past medical history, drug history, family history, and social history. For each component, it provides tips on what information to obtain and how to record it in the patient's own words. It also describes doing a review of all body systems to check for any associated symptoms.

CardiologyEndocrine Case Study Course Student Learning Outcom.docx

annandleola

Cardiology/Endocrine Case Study Course Student Learning Outcomes Upon completion of the case study, students will be able to … 1. Apply the principles of pharmacology relative to pharmacotherapeutics across age levels including the effect of race, gender, ethnic group, and special populations. 2. Describe the uses, actions, effects and nursing implications of general classifications of drugs and selected specific drugs. 3. Investigate media resources and information technologies to enhance knowledge base of pharmacology. 4. Analyze the responsibilities of the nurse when administering drugs. 5. Apply pharmacological research to nursing practice. Purpose The purpose of this case study is to apply concepts from pharmacology and pathophysiology, national guidelines, and evidenced based clinical practices in the management of chronic disease. Remember this paper must follow APA guidelines for font, in text citations, reference list etc. No abstract is needed. Provide headings for the different questions in your paper. Setting This case study takes place in a primary care setting in a small rural hospital clinic that provides health care services to predominately Latino field workers and their families. The rural clinic serves children and adults for all medical needs including well care, acute care, and chronic conditions. Some clients have seasonal insurance, state health insurance, or no insurance. Many live below poverty level according to the federal guidelines. Most do not own a vehicle. Most do not speak English; so, a translator is provided at each visit. The clinic is one hour from the nearest city where higher level of care can be offered to patients in need of specialty care. The clinic is staffed by one family medicine physician, an internist, two nurse practitioners, an RN, two LVNs, a lab tech, eight MAs and support staff. Once a week a cardiologist, podiatrist, pain specialist, orthopedist and ophthalmologist service the clinic. There is an on-site lab and a pharmacy two blocks away. There are two ambulances servicing the entire south end of the county with poor availability for emergencies. Client Jose is a 47 year old morbidly obese Latino male who presents to the clinic for follow up evaluation of headaches, dizziness, ringing in his ears and frequent urination. He reports having a headache that “comes and goes” with ringing in his ears and sometimes he sees spots. Jose has taken acetaminophen and states that seems to help. Due to his work schedule of six 12 hour days, Jose has not had preventive care. He reports fatigue and is depressed regarding his current income situation. Jose has just been laid off for the season and will lose his insurance in 30 days until the restart of the harvesting season in March. He is concerned about paying for any health care that may go beyond his benefit period. Jose lives with his pregnant wife, who does not work, and their seven children in a three bedroom one bath house that they share.

SOAP NOTE SAMPLE FORMAT FOR MRCNameDateTime AgeS.docx

pbilly1

SOAP NOTE SAMPLE FORMAT FOR MRC Name: Date: Time: Age: Sex: SUBJECTIVE CC: “ .” HPI: . Current Medications: PMHx: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries Family History Social History ROS General Cardiovascular Skin Respiratory Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE Weight lb Temp - BP Height 5’1 Pulse Respiration General Appearance Skin HEENT Cardiovascular Respiratory Gastrointestinal Genitourinary 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 clothes. Maintains eye contact. Answers questions appropriately. Lab Tests Special Tests- No ordered at this time. Diagnosis Differential Diagnoses Diagnosis Plan/Therapeutics · Plan: · Medication – · Education – · Follow-up – References .

Patient InitialsPt. Encounter NumberDateAgeSex Al.docx

JUST36

Patient Initials: Pt. Encounter Number: Date: Age: Sex: Allergies: Advanced Directives: SUBJECTIVE CC: HPI: Describe the course of the patient’s illness: Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment: Current Medications: PMH Medication Intolerances: Chronic Illnesses/Major traumas: Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: Family History: Social History: ROS General Cardiovascular Skin Respiratory Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE Weight BMI Temp BP Height Pulse Resp PHYSICAL EXAMINATION General Appearance Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Musculoskeletal Neurological Psychiatric Lab Tests Special Tests Diagnosis · Primary Diagnosis-  Evidence for primary diagnosis should be documented in your Subjective and Objective exams. o Differential Diagnoses- Include three diagnoses PLAN including education o Plan:  Further testing  Medication  Education  Non-medication treatments · Referrals  Follow-up visits References .

Calculation of dose in pediatrics by syeda shiza aleem

PARUL UNIVERSITY

The most important aspect for selection of a drug and establishment of the proper pediatric dosage is the acknowledgment that the pediatric patient is not just a small adult. Newborns, children and adolescents have different physiological, pharmacokinetic and pharmacodynamic parameters compared to adults. The differences are mainly related to the changes occurring during growth and maturation and require individual dosages. Thus, guidelines of specific dosages and useful means for calculation of pediatric dosages must be developed in order to enhance the effectiveness and therapeutic limit and prevent serious adverse effects

Kin 188 Pre Participation Physical Examinations

JLS10

The document discusses pre-participation physical examinations (PPE) for athletes. The goals of a PPE are to evaluate an athlete's general health, detect any medical conditions that could increase injury risk, and establish baseline health measurements. A PPE typically involves collecting a medical history, conducting a physical exam checking various body systems, and clearing the athlete for participation or making recommendations. The physical exam covers vital signs, musculoskeletal/neurological functions, and screening for common health issues. Laboratory tests are not usually required but may be used if issues arise during the exam.

Internal medicine

shakeeljutt

The document provides an overview and examples of various note formats used in internal medicine, including formats for history and physical exams, progress notes, admission and discharge orders, and specialty notes. It includes mnemonics, equations, and classifications to guide note writing. The document aims to familiarize medical students with the structure and components of different types of notes commonly written in internal medicine.

internal medicine.pdf

DOREEND3

The document provides an overview and examples of various note formats used in internal medicine, including formats for history and physical exams, progress notes, admission and discharge orders, and specialty notes. It includes mnemonics, equations, and classifications to guide documentation. Sections cover topics such as cardiology, gastroenterology, pulmonary medicine, and intensive care unit notes.

Taking history in any medical cases in clenics

z2mtqw4gq9

The document provides guidance on taking a patient's medical history. It explains that taking a thorough patient history is important for systematically recording all relevant medical information. It outlines the key components of a patient history, including personal details, chief complaint, present illness history, review of systems, past medical history, family history, medication history, social history, and other relevant details. The document provides examples of questions to ask within each section and notes important points such as using open-ended questions and avoiding leading questions. It also provides tips for handling special situations and challenges that may arise during a patient interview.

PEDIATRIC HISTORY.ppt

MishiSoza

The document provides guidance on taking a pediatric history, including focusing the history on the chief complaint, birth and medical history, developmental milestones, vaccinations, family history, and social factors. It also outlines the approach to performing a physical examination of children, with tips on techniques for different age groups and examining individual body systems in a sensitive manner. The goal is to obtain relevant information to identify health issues while maintaining the comfort, safety and dignity of pediatric patients.

HISTORY TAKING and it's importance in daily medicine

plixflixstudio

The document discusses guidelines for taking a patient's medical history. It recommends introducing oneself to the patient, explaining the purpose of questions, and obtaining consent before asking questions. A thorough history should follow a standard pattern, including the patient's name, age, marital status, occupation, address, presenting complaints, past medical history, family history, and personal habits. Taking a complete history can provide 80% of the information needed for diagnosis. The interviewer should maintain a friendly, gentle, and confident manner throughout.

DETERMINENTS OF HEALTH by RAM NAIK

Ram Naik M

The document discusses the spectrum of health and diseases and the determinants of health. It states that health lies on a continuum from positive health to death. The determinants of health include both uncontrollable factors like genetics and gender as well as controllable factors like diet, smoking, and exercise. Biological determinants discussed include body weight, genetics, hormones, blood pressure, cholesterol, and glucose regulation. Behavioral determinants include physical activity and social relationships. Social determinants discussed are socioeconomic status, housing, work, and unemployment.

Analyze the subjective portion of the note. List additional inform.docx

amrit47

Analyze the subjective portion of the note. List additional information that should be included in the documentation. Analyze the objective portion of the note. List additional information that should be included in the documentation. Is the assessment supported by the subjective and objective information? Why or why not? Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis? Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. GENITALIA ASSESSMENT Subjective: CC: “I have bumps on my bottom that I want to have checked out.” HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner during the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed. PMH: Asthma Medications: Symbicort 160/4.5mcg Allergies: NKDA FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys) Objective: VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs Heart: RRR, no murmurs Lungs: CTA, chest wall symmetrical Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia. Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, negMcBurney Diagnostics: HSV specimen obtained Assessment: Chancre Episodic/Focused SOAP Note Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. HPI : This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: L.

Paediatric_Clerkship-1.pdf

NasriMungwana1

This document provides a template for documenting a pediatric patient history and physical exam. It includes sections for identifying information, chief complaint, history of present illness, review of systems, past medical history, antenatal/natal/neonatal history, immunization history, dietary history, developmental history, family social history, and a physical exam. The physical exam section includes assessing the patient's general appearance, vital signs, and examination of specific body systems and features.

Name Pt. Encounter Number Date Age Sex SUBJ.docx

pauline234567

Name: Pt. Encounter Number: Date: Age: Sex: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” HPI: 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, and surgeries or past diagnostic testing related to the present illness. Medications: (List with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?” Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease? Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Weight change, fatigue, fever, chills, night sweats, and energy level Cardiovascular Chest pain, palpitations, PND, orthopnea, and edema Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB Eyes Corrective lenses, blurring, and visual changes of any kind Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools Ears Ear pain, hearing loss, ringing in ears, and discharge Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDs Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis Breast SBE, lumps, bumps, or changes Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx OBJECTIVE 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 and then brighter later. Skin Skin.

Key points of obstetrics and gynaecological history

Naila Memon

This document contains a template for taking a thorough medical history. It includes sections for collecting the patient's biodata, chief complaints, history of present illness, obstetric history, gynecologic history, past medical history, family history, medications, allergies, social history, and systems review. The template provides guidance on the key information to collect under each section to fully understand the patient's history and current medical concerns.

NETWORKING SYSTEMS .docx

NameDateSexAgeDOBPlace of BirthSUBJECTIVEH.docx

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