History and physical elements

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Sample elements of a comprehensive visit note

Chief complaint/reason for visit/admission/consult:

History of present illness:

Review of systems (14-point):
Gen: fatigue, fevers, chills, night sweats, change in appetite, change in weight
Eyes: change in visual acuity, double vision, red eye
ENT: change in hearing, tinnitus, vertigo, ear pain, sinus tenderness, sore throat, congestion, oral ulcers, change in taste, dysphagia, odynophagia
Allergy/immunology: rhinorrhea, sneezing, post-nasal drip
Respiratory: cough, sputum, hemoptysis, shortness of breath, wheezing
Cardiovascular: chest pain/tightness, palpitations, extremity edema, orthopnea, paroxysmal nocturnal dyspnea
GI: nausea, vomiting, diarrhea, constipation, melena, BRBPR, heartburn, stomach ache
GU: incomplete emptying, frequency, starting & stopping, urgency, weak stream, straining to start, nocturia, dysuria, hematuria, incontinence
Dermatology: rash, pruritus, ulcers, jaundice
Hematology/lymph: nose bleed, easy bruising, enlarged nodes
Musculoskeletal: back pain, foot pain, joint stiffness, joint pain, joint swelling
Endo: heat/cold intolerance, excess thirst
Psych: anxiety, insomnia, depression
Neuro: dizziness, fainting, tremor, headache, numbness/tingling, paralysis/weakness, memory changes

Past medical history:

Past surgical history:



Family history:

Social history:

Physical exam:

Performance status

General: NAD, alert, appears comfortable
Eyes: PERRL, sclerae anicteric, conjunctivae pink
ENT: OP clear, hearing nl, MMM, no oral ulcers
Neck: supple, thyroid non-tender
CV: RRR, no m/r/g, JVP __ , no carotid bruits, no LE edema, 2+ radials/DP/PT, <2s cap refill, ext WWP
Pulm: BCTA, equal expansion, nl inspiratory effort
Abd: soft, NT, ND, normoactive bowel sounds, no hepatomegaly, no splenomegaly
Skin: no rash, no ulcers, no induration/erythema
Lymph: no cervical, supraclavicular, axillary, inguinal lymphadenopathy
MS: normal muscle tone, no clubbing, no cyanosis
Neuro: fluent speech, oriented to name, place, month/year, intact attention, CNII-XII intact, intact sensation to light touch, 5/5 motor strength, intact reflexes, cerebellar: FNF, RAM, gait
Psych: nl mood & affect, good insight