Physical Exam - Dr. Dang

Chief Complaint

Medical Note Template -- [Chief complaint]

History of present illness

[Provide detailed history of present illness]

HEENT

[Document relevant symptoms related to head, eyes, ears, nose, and throat]

Neck-thyroid

[Document symptoms related to neck and thyroid]

CVS

[Document cardiovascular system symptoms]

RESP

[Document respiratory system symptoms]

GI

[Document gastrointestinal symptoms]

GU

[Document genitourinary symptoms]

MSK

[Document musculoskeletal symptoms]

DERM

[Document dermatological symptoms]

Psychosocial

[Document relevant psychosocial history]

Past history - see CPP

[Refer to comprehensive past patient history in CPP]

Hepatitis

[Document history or screening for hepatitis]

TB

[Document history or screening for tuberculosis]

Malaria

[Document history or screening for malaria]

Family history

[Document relevant family medical history]

General appearance

[Describe general appearance]

Vital signs

BP = [Insert blood pressure] P = [Insert pulse] T = [Insert temperature]

HEENT examination

BP - [Document blood pressure if relevant] HEENT: [Describe head, eyes, ears, nose, throat exam] PERLA: [Document pupils equal, round, reactive to light and accommodation] Ears: external, internal, tympanic membrane [Describe findings] Nose: [Describe findings] Throat: [Describe findings] Teeth: [Describe findings]

Neck

Neck: [Describe neck exam] Nodes: [Describe lymph nodes] Thyroid: [Describe thyroid exam]

EOM

[Document extraocular movements]

Fundi

[Describe fundoscopic exam findings]

Cardiovascular system (CVS)

BP: [Insert blood pressure] PMI: [Describe point of maximal impulse] JVP: [Describe jugular venous pressure] S1: [Describe first heart sound] Heave: [Describe presence of heave] S2: [Describe second heart sound] Lift: [Describe presence of lift] Murmur: [Describe any murmurs]

Respiratory system (RESP)

[Describe respiratory exam findings]

Abdomen

LS: [Describe liver span] Spleen: [Describe spleen exam] Kidneys: [Describe kidney exam] Bowel sounds: [Describe bowel sounds] Rectal: [Describe rectal exam findings]

Genitourinary (G.U.)

Pelvic exam: External genitalia: [Describe findings] Cervix: [Describe findings] Uterus: size [Describe size] Ovaries: [Describe findings] Pap: [Describe Pap smear findings]

Musculoskeletal system (MSK)

Spine: [Describe spine exam] Arms: [Describe arm exam] Legs: [Describe leg exam]

Dermatological system (DERM)

Color: [Describe skin color] Texture: [Describe skin texture] Lesions: [Describe any lesions]