Medical Skills Course

History and Physical Exam Form Student Name: _________Cong

(Hospital visit) PHan_______

Do not write Patient name Date of History and Physical:

02/08/2017

Chief Complaint (CC): Use patients own words (eg. My leg has been
hurting)
I started having left leg pain since last Wednesday

Clinical Presentation: What Clinical Presentation best fits this patients

situation:
High fever with leg pain

Source and Reliability: Patient, family member, caregiver, etc.

Pain

History of Present Illness (HPI): Include clear timeline, progression of

symptoms presented chronologically, pertinent positives and negatives
related to presenting complaint, relevant associated symptoms, and
pertinent PMH.

This is a 24 year old patient coming in to the hospital 02/07/2017 with complaining left
leg pain starting Wednesday 02/01/2017. Patient stated that the lesion started like a
pimple on his left shin then began to get bigger and redder over the week time period.
He also stated that on 02/06 he started feeling nauseous and dizzy and had cold
sweat. He checked his temperature and it was 105.1. At the emergency room, he was
determined to have cellulitis of left low leg and was taken to surgery to drain the
abscess. The fluid from the abscess was sent for screening and the result was positive
for HIV.

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History and Physical Form Medical Skills Course

Past Medical History: past (and ongoing) medical conditions and surgical
procedures. Include date of diagnoses or duration of illness.
Childhood Illnesses: None

Medical Illnesses:
None

Surgical Procedures: Drainage of abscess 02/07/17

Hospitalizations: 02/07/2017 for left leg cellulitis

Obstetric history: N/A

Family History: include all conditions for first degree relatives, hereditary
conditions in other family members. Include approximate age of diagnosis of
that condition. Include Pertinent negatives related to HPI(such as negative
Family history for heart disease in CP case)
Father has diabetes mellitus

Social History: education, occupation, living situation, support system,

ethnic/cultural, spiritual, hazards/exposures. Include social factors affecting
care
Full time truck driver student.
Lives with two uncles.

Risk Behaviors: tobacco, alcohol, drugs, sexual Hx, diet, violence, high risk
activities
Smoke 3-4 cigarette a day.
Drink once a month socially, 3-4 drinks.

Not sexually active. But has sex with men only.

Last sexually encounter was 12/2016.

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 History and Physical Form Medical Skills Course

Poor dietary habit, eats once a day, usually fast food.

Denies recreational, IV drug use.

Medication list: include dose, interval, and reason for taking the medication.
Include OTC and herbal remedies. Use generic names.
Ceftriaxone 1gm IV /q8h cellulitis
Docusate 100mg PO BID prevent constipation
Vancomycin 1gm IV q12h cellulits

Drug Allergies or Adverse Drug Events: name the drug and describe the
reaction

NKDA, NKFA/
Preventive Care:
Vaccinations: flu Pneumovax
N/A

Review of Systems: instruct the patient to answer yes or no. Use everyday
terms. If present, please enter a (+) in the box. If negative, please enter a (-) In
the box. Add additional information and/or explain positive findings in the space
provided.
GENERAL- change in overall health - weight change (+) fever other or
explanation:
SKIN: - rash - lumps - itching - dryness - Other or explanation: None
NECK: - swollen glands - lumps - pain or stiffness - other or explanation: None
HEAD: - headache - history of head injury - dizziness or lightheadedness - other or
explanation: None
EYES: - pain - redness - double vision - blurred vision/loss of vision - other or
explanation: None
EARS: - hearing loss - earache - tinnitus - vertigo - other or explanation: None
NOSE: - discharge - stuffiness - frequent colds - nosebleeds - other or
explanation: None
MOUTH: - toothache - bleeding gums - lesions - other or explanation: None
THROAT: - sore throat - hoarseness - difficulty swallowing - other or
explanation: None
NECK: - swollen glands - lumps - pain or stiffness - other or explanation: None
RESPIRATORY: - cough - shortness of breath -wheezing - other or explanation:
None
CARDIOVASCULAR SYSTEM: - chest discomfort - swelling - palpitations - heart
trouble
other or explanation: None

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 History and Physical Form Medical Skills Course

BREAST: - pain - lumps - discharge - other or explanation: None

GASTROINTESTINAL SYSTEM: - heartburn - abdominal fullness - pain (+) nausea -
vomiting
- diarrhea - constipation - blood in stool - other or explanation: Nauseated for 3
days
URINARY SYSTEM: burning with urination - frequency - urgency - incontinence -
nocturia
- hematuria - urinary infections - stones - other or explanation: None
GENITAL SYSTEM: - lesions - rashes - pain - discharge - abnormal bleeding
Women: Last menstrual period; ; birth control method: N/A
;
Men: - pain - discharge - lesions - other or explanation: NOne
ENDOCRINE SYSTEM: - sensitivity to heat or cold - abnormal sweating - thirst -
urine flow
other or explanation: None
MUSCULOSKELETAL SYSTEM: (+) pain (+) tenderness (+) swelling - stiffness of
joints other or explanation: Left shin swollen and painful since 02/01/2017
HEMATOLOGIC: - anemia - bruising - past transfusions - other or explanation:
None
NEUROLOGICAL SYSTEM: - weakness, - difficulty speaking, - numbness, - tingling -
memory loss
- other or explanation: None
PSYCHIATRIC: - changes of mood - feeling down or depressed - nervousness -
confusion - problems sleeping - other or explanation: None

Physical Examination (PE): remember to wash your hands

General appearance:

Vital Signs: BP_114/77 P_97____ RR _20____ T__100___O2 sat ______ + Room

air Supplemental O2_____ __

Height_5ft 7________ Weight _132 lbs_______

Skin (inspect as you examine each area):

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History and Physical Form Medical Skills Course

HEENT:
Eyes (include inspection, visual fields, extra-ocular muscles, pupillary
reaction):
PERRLA, conjunctiva pale, sclera not icteric, EOMI, Visual fields intact to confrontation

Mouth/Throat (include inspection, palate elevation, tongue protrusion):

Mucosa pink and moist with no lesions, normal palate elevation and
tongue protrusion

Facial sensation:
Intact to light touch

Strength of facial muscles: Normal upper and lower face

Neck / Thyroid (include shoulder shrug, lymph node palpation, and palpation
of thyroid):

Shoulder shrug 5/5 bilaterally

No lymphadenopathy in the anterior cervical, posterior cervical, or supraclavicular
areas Thyroid normal size with no nodules or abnormalities palpable

Chest & Lungs (include inspection, auscultation, and percussion):

Clear to auscultation and percussion. No wheezes no crackles.

Heart & Vascular (assess JVP, palpate carotids, palpate apical impulse,
auscultation):
No JVD noted with head at 30
Carotid pulses palpable and equal bilaterally, normal upstroke
Heart: RRR with no murmurs or gallops appreciated; apical impulse palpable at 5th
intercostal space in the mid-claviclar line

Abdomen (include inspection, auscultation, palpation, and assessment of

liver) :
Normoactive bowel sounds
Soft and nondistended with no scars or striations
No pulsatile masses, no abdominal bruits auscultated
Liver edge palpable just beneath the right costal margin, spleen not palpable Tender to
deep palpation in epigastric region and left upper quadrant;
No rebound tenderness; No guarding;

Lymph Nodes (Axillary and Inguinal):

Did not palpate inguinal lymph nodes due to patients pain and discomfort
No palpable axillary lymph nodes

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History and Physical Form Medical Skills Course

Extremities and Musculoskeletal (inspect muscles, joints and assess edema

and pulses):
No joint swelling noted in elbows, wrists, hands, knees, ankles.
Positive for pedal edema on left leg. non-pitting 3+
Dorsalis Pedis and Posterior Tibial pulses 2+

Neurological:
Mental status (Note level of consciousness, orientation and speech during
the interview):

Awake, Alert and oriented X 3

Clear, coherent speech

Muscle stretch
reflexes

Strength and tone: Upper Extremities (graded from 0 to 5):

5/5

Strength and tone: Lower Extremities (graded from 0 to 5):

5/5

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History and Physical Form Medical Skills Course

Sensation: Intact sensation upper and lower extremities

Gait: Did not assess due to patient discomfort

Pertinent laboratory and other test results:

WBC 9.8
HB/HCt 15/42
Cr 1.2
Bun 12
ALK 141
Na 134
K 3.5
Cl 99
Anion Gap 13

Summary Statement: In one sentence, summarize the key elements from the
patients history, physical exam and diagnostic studies (if applicable).
This is a 24 year old patient with HIV and currently getting treatment for left
lower leg cellulitis. Patient had drainage surgery for abscess and is now on
antibiotic therapy.

Assessment:
List the patients Primary problem first under #1.
Include up to 3 possible diagnoses related to the presenting problem under
A, B, and C.
List the relevant points from the history, physical examination and pertinent
diagnostic tests (if applicable) under each of the possible diagnoses. In
addition, list other active problems that also need monitoring and
management under # 2 and # 3.
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History and Physical Form Medical Skills Course

# 1 Primary Problem: ______Cellulitis for left lower leg________________________

A) Diagnosis:________Nausea and vomiting

_____________________________________

History Finding(s): Physical Findings:

Nauseated for 3 days Nauseated

B) Diagnosis: _____________Left lower leg cellulitis __________________________.

History Finding(s): Physical Findings:

1. painful left shin 1. Fever 105
2. Nauseated 2. Swollen and red left
shin
3. Fever 3. Elevated WBC on
admission
4. Dizziness

C) Diagnosis: ________HIV_________________________________________.

History Finding(s): Physical Findings:

1. Left leg infection 1. Positive HIV
screening.
2. Having sex with men

Problem #2 (include another active problem that needs monitoring and

management):
Psychosocial problem in dealing with newly diagnosis of HIV

Problem #3 (include another active problem that needs monitoring and

management):
Nausea

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History and Physical Form Medical Skills Course

Diagnostic Plan (describe how you will begin to investigate the presenting
problem listed above under #1, including initial diagnostic tests and
imaging.
1. Continue with current antibiotic treatment.
2. Follow up with CT scan of left leg for potential osteomyelitis
3. Consult Heme to address HIV diagnosis.
4. HIV and safe sex practice education
5. Refer to HIV support programs
6. Smoking cessation education

REV 11/20/2013 GW, REV 11/04/2014 MDF, REV 6/9/2015 GW, MDF, SG, LG, IE, REV 10/12/2016 TTH.