MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN
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1 MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN PA: PRECEPTOR: MARYWOOD STAFF: PATIENT ID: AGE: SEX: DATE: Chief Complaint: History of Present Illness: 1
2 Medications: Allergies: Past Medical History (note dates, menstrual and pregnancy history, immunization status, and childhood diseases) Previous Surgeries: 2
3 Patient s last physical exam: Has the patient ever has positive findings on any of the following: EKG X-Ray Ultrasound Blood, Urine Tests Skin Tests Family History: Social History: 3
4 Review of Symptoms: Brief statement for each. A or none is not acceptable. Describe in detail if +. GENERAL Weight Change Fever-Chills Weakness Fatigue Sweating Night Sweats Vertigo SKIN Nail Changes Rash-Eruptions-Pigment Hair Changes Moles-Lesions Itching Headache HEAD Trauma Wears Glasses Vision Blurring Photophobia EYES Diplopia Scotoma Inflammation Tearing Deafness Drainage EARS Tinnitus Pain 4
5 Sinusitis Polyps NOSE Epistaxis Obstruction Teeth Dentures Gums Breath MOUTH & THROAT Pain Taste Swallowing Wheezing Dyspnea Hemoptysis RESPIRATORY Chest Pain Cough Sputum Lumps Discharge BREASTS Pain Changes CARDIOVASCULAR Palpitation Blood Pressure Pain Problems Dyspnea Cyanosis Orthopnea Edema Murmurs Claudication 5
6 Appetite Indigestion Nausea-vomiting Gas Pain Hematemesis Jaundice Hernia GASTRO-INTESTINAL Stool shape, color Constipation Cathartics Diarrhea Melena Hemorrhoids Abdominal Girth Dysuria Nocturia Hematuria GENITO-URINARY Frequency Urgency Incontinence History of any STD s Discharge Pain SEXUAL HISTORY Impotence Epididymitis Sores PREGNANCY-MENSTRUAL HISTORY Gravida/Para/Abortions Cycle/Duration/Amount Menopause Sterility Last Pelvic Exam-PAP Use of Contraception Smear Dysmenorreah, Spotting Irregularity 6
7 Goiter Diabetes ENDOCRINE Hormone Therapy (exclude BCP) Drugs Foods Pollens Other Reactions ALLERGIC Eczema Asthma Hives Trauma BONES, JOINTS & MUSCLES Pain-Arthritis NEUROLOGIC Syncope Coordination Gait Sensation Convulsions Paralysis-Strength Anemia Bleeding Tendency BLOOD-LYMPHATIC Lymph Node Enlargement PSYCHOLOGIC Memory Anxiety Mood Emotional Disturbances Sleep Pattern Drug, Alcohol Problems 7
8 PHYSICAL EXAMINATION Blood Pressure: RA & LA Sitting Standing Lying Down Repeat Blood Pressure x3 during exam if initial BP elevated. Results: Pulse: Rate Rhythm Respirations: Rate Rhythm Temperature: AX PO Ear Rectal Weight Height General Appearance: General Examination: (All items should be examined! No mark will be interpreted as not examined. Describe abnormal findings in detail.) Temperature Texture-Color Hair SKIN Nails Lesions Turgor Configuration HEAD Lymph Nodes EYES Visual Acuity OD OS Cornea Ocular Tension OD OS Pupils (equality, light reaction) Visual Fields Accommodation Movement Fundi Lids- Conjuctivae 8
9 EARS Pinna Hearing-Air Canals-Drums Bone Conduction NOSE Configuration Septum Mucosa Sinuses MOUTH-THROAT Lips-Breath Mucosa Teeth-Gums Tonsils-Pharynx Tongue Uvula NECK Motion Trachea Thyroid Lymph Nodes Carotids Neck Veins CHEST Shape-Symmetry Masses Breasts Lymph Nodes LUNGS Resonance Dullness Breath Sounds Fremitus 9
10 CARDIAC Apical Impulse- Cardiac Sounds- (character, (rate & rhythm) position) Thrills ABDOMEN Shape Organs, Liver, Spleen, Kidney Scars Sounds Tenderness Lymph Nodes Guarding- Rigidity GENITALIA MALE: FEMALE: Penis Perineum-Vagina Hernia Cervix-Uterus Scrotum-Testes Adnexa-Ovaries RECTUM Sphincer Tone Prostate Masses Guaiac MUSCULOSKELETAL SYSTEM-EXTREMITIES Spine Muscle Bulk Extremities Varicosities Joint Exam Pulses: R L Bruits: R L Radial Femoral Popliteal Post Tibial Dorsalis Pedis 10
11 Mental Status Speech Gait Cranial Nerves Motor System Reflexes: R L Biceps Knee Ankle Sensory System Position- Vibratory Sense Coordination (List tests used) Pathologic Reflexes (List ones used) NERVOUS SYSTEM 11
12 ASSESSMENT (Number) Include impression with rule-outs and chronic problems: 12
13 PLAN (Number, Diagnostic, Therapeutic, Patient Education) one for each assessment: 13
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