Internal Medicine History and Physical

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Chief Complaint: ____________________________________________________

Date: ________________
Time: ________________
History of Present Illness:_____________________________________________________________________
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Review of Systems:
General: fatigue
weight loss
fever
chills
night sweats
Eyes: visual change
pain
redness
ENT: headaches
hoarseness
sore throat
epistaxis
sinus symptoms
hearing loss
tinnitus

yes
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[ ] Unobtainable due to __________________________________

no
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CV: chest pain

edema
PND
orthopnea
palpitations
claudication
Resp: cough
SOB
wheezing
hypersomnolence
GI: abdominal pain
stool changes
nausea/vomiting
diarrhea
heartburn
blood in stool

yes
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no
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GU: dysuria
frequency
hematuria
discharge
menstrual problems
Musc-skel: arthralgia
arthritis
joint swelling
myalgias
backpain
Heme/Lymph: bleeding
brusing
clotting
transfusions
lymph node swelling

yes
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no
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Endo: polyuria
polydypsia
polyphagia
heat/cold intolerance
Derm: rash
pruritis
Neuro: weakness
seizures
paresthesias
tremor
syncope
Psych: anxiety
depression
hallucinations
All/Imm: hayfever
bee sting allergy

Other ROS: ___________________________________________

[ ] All other ROS reviewed and were NORMAL.

Past Medical History:_________________________

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Allergies:

Past Surgical History: ______________________

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Family History: ____________________________
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Social History: _____________________________
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Cigs [ ] No [ ] Yes Pack-yrs: _________________
EtOH [ ] No [ ] Yes Amount: __________________
Illicits [ ] No [ ] Yes Type: ____________________
Regional Medical Center at Memphis
INTERNAL MEDICINE HISTORY & PHYSICAL
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FORM NO. 6024.013 (Rev. 11/05)

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Other: ____________________

Medications: ______________________________
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Addressograph/Patient ID

Internal Medicine History and Physical

Physical Exam

T _______

RR _______ BP___________ HR _______ Wt _______ (lbs) Ht _______ (in)

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BMI _______

O2 Sat _______ on _______

Eyes

[ ] nl conjunctiva & lids

ENT External

[ ] no scars, lesions, masses

Neck External [ ] no tracheal deviation

Pupils

[ ] equal, round, & reactive

Otoscopic

[ ] nl canals, tympanic membranes

Palpation

[ ] no masses or crepitus

Fundus

[ ] nl discs & vessels

Hearing

[ ] nl to finger rub

Thyroid

[ ] no megaly or tenderness

Vision

[ ] acuity & gross fields intact

Oropharynx

[ ] nl teeth, tongue, palate, pharynx

Abnormals:

Abnormals:
GI

Abnormals:

Palpation

[ ] no masses or tenderness

Resp

Skin

[ ] no rashes, lesions, ulcers

[ ] no hep/splenomegaly

Effort

[ ] nl without retractions

Auscultation

[ ] nl bowel sounds

Percussion

[ ] no dullness or hyperresonance

Chest/Breast

[ ] nl inspection & palpation

Percussion

[ ] no shifting dullness

Palpation

[ ] no fremitus

Lymph nodes

[ ] no axillary, inguinal, cervical,

Anus/rectum

[ ] no abnormality or masses

Auscultation

[ ] CTAB w/o W, R, or R
Genitourinary

[ ] nl external genitalia

[ ] heme negative stool

[ ] nl turgor

or submandibular LAD

Abnormals:

Abnormals:

[ ] nl vaginal tone, mucosa

[ ] no cervical motion tenderness

CV Palpation

[ ] PMI nondisplaced

Neuro

Auscultation

[ ] no murmur, gallop, or rub

Orientation

[ ] A&O to person, place, time

Carotids

[ ] nl intensity w/o bruit

Cranial nerves

[ ] CN II-XII intact

JVD

[ ] no jugulovenous distension

Sensory

[ ] nl sensation throughout

Pulses

[ ] 2+/= femoral & pedal pulses

Reflexes

[ ] 2+ + and symmetrical throughout

Edema

[ ] no pedal edema

Abnormals:

[ ] nl prostate size and texture

Psych

[ ] nl cognition
[ ] MMSE ___________
[ ] nl mood and affect

Abnormals:

Abnormals:
Musculoskeletal

Gait

[ ] nl penis & scrotal contents

Inspection

ROM

Strength

Upper extrem

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Tone ( if normal)
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Lower extrem

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Abnormals:

Other:

[ ] no apparent distress

[ ] nl gait and station

X-ray:

EKG:

Other:

Assessment & Plan: _______________________________________________________________________________

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Signature: _________________________________

Attending MD

[ ] Ive examined the patient.

Date: _____________________________________

[ ] Ive reviewed with housestaff and agree with the above.

Signature ____________________________ Date: ____________

Regional Medical Center at Memphis

INTERNAL MEDICINE HISTORY & PHYSICAL
PAGE 2 of 2
FORM NO. 6024.013 (Rev. 11/05)

Addressograph/Patient ID