H and P for PDA

Here's a typed up H and P for a PDA. You can put in on a Palm PDA as a memo or a Dataviz Documents to Go file. Fill in the details during the patient encounter, and then synch it with a desktop for printing. Feel free to make adjustments and post them as comments on this site.

H and P
Patient Name:
Hospital Unit:
Time of Admission:
Informant:
Birthdate:
Age:
Sex:

CC:
Reason for Admission:

History of Present Illness:






Past Medical History:

Past Surgical History:

Injuries/Disabilities:
Medications:




Herbal Meds:
Immunizations:
Allergies:
Drugs:
Food:
Family History:
Social History:

Review of Systems:
General: ( ) weight loss ( ) fever ( ) night sweats ( ) weakness/fatigue ( ) appetite
Endocrine: ( ) heat intolerance ( ) decreased energy ( ) thyroid/reanl dz ( ) polydipsia ( ) polyuria
Lympatics: ( ) lymphadenopathy
Skin: ( ) itching ( ) pale ( ) palmar creases
Hematology: ( ) anemia ( ) bruising ( ) bleeding
Head: ( ) seizures ( ) trauma ( ) loss of conscioussness ( ) headache ( ) vertigo ( ) dizziness
Eyes: ( ) visual changes ( ) blurred vision ( ) loss of vision ( ) discharge
Ears: ( ) discharge ( ) ear pain ( ) tinnitus ( ) ototoxic drug history ( ) hearing loss
Nose: ( ) discharge ( ) rhinorrhea ( ) epistaxis
Mouth and Throat: ( ) lip cracking ( ) gum soreness ( ) gum hypertrophy ( ) dryness ( ) thirst ( ) excessive salivation ( ) throat pain ( ) hoarseness
Cardiorespiratory: ( ) SOB ( ) valvular disease ( ) orthopnea ( ) dyspnea on exertion ( ) nocturia ( ) edema ( ) paroxysmal nocturnal dyspnea ( ) cough ( ) cyanosis ( ) hemoptysis
Gastrointestinal ( ) dysphagia ( ) abdominal pain ( ) vomiting ( ) hematemesis ( ) melena ( ) hematochezia ( ) change in appetite ( ) diarrhea ( ) constipation ( ) jaundice
Genitourinary: ( ) change in bladder function ( ) change in amount ( ) dysuria ( ) hematuria ( ) discharge
Neuropsychiatric: ( ) weakness ( ) motor/sensory deficit ( ) depression ( ) anxiety
Pain:


Physical Exam
General Appearance:
Vital Signs:
Temperature: Oxygen Saturation: Blood Pressure:
Respiratory Rate: Pulse Rate:
Skin/Nails:
Head:
Eyes:
Ears:
Nose:
Throat/Mouth:
Neck:
Lymph:
Pulmonary:
CV:
Abdomen:
Breasts:
Rectal:
Genitals:
Peripheral pulses:
Musculoskeletal:
Neurologic:
Mental Status
CN I
CN II
CN III,IV, VI
CN V, VII
CN VII
CN VIII
CN IX, X
CN XI
CN XII
Cerebellar
DTRs

Labs:




Assessment:

Problem List:

Differential Diagnosis:

Diagnostic Plan:

Therapeutic Plan: