Concept Map

Initials: TJ

Age: 28

Gender: FEMALE

Height

Weight

BP

HR

RR

Temp

SPO2

Pain

Allergies

3/10

Medication: PCN (hives, rash)

Food: NKA

Environment: CATS (sneezing, itchy, watery eyes, runny nose)

History of Present Illness (HPI)

Chief Complaint (CC)

CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom

O nset

L ocation

D uration

C haracteristics

A ggravating Factors

R elieving Factors

T reatment

Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Medication

(Rx, OTC, or Homeopathic)

Dosage

Frequency

Length of Time Used

Reason for Use

Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.

Type II Diabetes diagnosed at 24 Asthma since childhood(hospitalized at 16) Irregular periods with heavy bleeding and painful cramps Obesity Tetanus booster 1 year ago No flu vaccine Last pap smear 4 years ago

Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.

Patient does not smoke cigarettes or use any tobacco products Social drinking 1-2 times a weak Past use of marijuana at the age of 20-21 Single Not sexually active at this time Never married No children Lives with mother and sister Currently enrolled in school Hobbies include church, watching TV (documentaries), reading Total number of sexual partners 3 Prefers male partners LIVES INDEPENDENTLY SINCE AGE 20 LIVES AT HOME TO HELP SUPPORT FAMILY EMPLOYEED AS A SUPERVISOR AT ….. CAR/CELLPHONE/COMPUTER ACTIVE IN CHURCH LOVES HANGING OUT WITH FRIENDS NO PETS STRESSOR BALANCING WORK, SCHOOL, DEATH OF FATHER PLANS ON GETTING MARRIED AND HAVING CHILDREN DRINKS DIET COKE DIET/BREAKFAST/LUNCH/DINNER

Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

The patient’s father is diseased, he died from a motor accident last year. He had a history of hypertension, type II diabetes, and hyperlipidemia.The mother has hypertension and hyperlipidemia. Ms. Jones’ younger sister has asthma. Her paternal grandma has high blood pressure, paternal grandpa died from colon cancer. The grandfather also had a history of diabetes type II. Her maternal grandmother has also been diagnosed with hyperlipidemia and high blood pressure.The patient’s maternal grandfather also had a history of hyperlipidemia and hypertension.

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.

Constitutional

Skin

HEENT

☐Fatigue Click or tap here to enter text.

☐Weakness

☐Fever/Chills Click or tap here to enter text.

☐Weight Gain Click or tap here to enter text.

☐Weight Loss Click or tap here to enter text.

☐Trouble Sleeping Click or tap here to enter text.

☐Night Sweats Click or tap here to enter text.

☐Other:

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☐Itching Click or tap here to enter text.

☐Rashes Click or tap here to enter text.

☐Nail Changes Click or tap here to enter text.

☐Skin Color Changes Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

☐Diplopia Click or tap here to enter text.

☐Eye Pain Click or tap here to enter text.

☐Eye redness Click or tap here to enter text.

☒Vision changes Pt states blurry vision when reading for long periods. Vision right eye 20/40.

☐Photophobia Click or tap here to enter text.

☐Eye discharge Click or tap here to enter text.

☐Earache Click or tap here to enter text.

☐Tinnitus Click or tap here to enter text.

☐Epistaxis Click or tap here to enter text.

☐Vertigo Click or tap here to enter text.

☐Hearing Changes Click or tap here to enter text.

☐Hoarseness Click or tap here to enter text.

☐Oral Ulcers Click or tap here to enter text.

☐Sore Throat Click or tap here to enter text.

☐Congestion Click or tap here to enter text.

☐Rhinorrhea Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

Respiratory

Neuro

Cardiovascular

☐Cough Click or tap here to enter text.

☐Hemoptysis Click or tap here to enter text.

☐Dyspnea Click or tap here to enter text.

☐Wheezing Click or tap here to enter text.

☐Pain on Inspiration Click or tap here to enter text.

☐Sputum Production

Choose an item.

Choose an item.

Choose an item.

☐Other: Click or tap here to enter text.

☐Syncope or Lightheadedness Click or tap here to enter text.

☒Headache Started 2 days ago after MVA.

☐Numbness

☐Tingling

☒Sensation Changes

LLE

☐Speech Deficits Click or tap here to enter text.

☐Other: PT

☐Chest pain Click or tap here to enter text.

☐SOB Click or tap here to enter text.

☐Exercise Intolerance Click or tap here to enter text.

☐Orthopnea Click or tap here to enter text.

☐Edema Click or tap here to enter text.

☐Murmurs Click or tap here to enter text.

☐Palpitations Click or tap here to enter text.

☐Faintness Click or tap here to enter text.

☐OC Changes Click or tap here to enter text.

☐Claudications Click or tap here to enter text.

☐PND Click or tap here to enter text.

☐Other: Click or tap here to enter text.

MSK

GI

GU

PSYCH

☒Pain Neck pain due to MVA that happened 1 week ago, pt rates pain 3/10

☒Stiffness Neck

☐Crepitus Click or tap here to enter text.

☐Swelling Click or tap here to enter text.

☒Limited ROM Choose an item.

☐Redness Click or tap here to enter text.

☐Misalignment Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐Nausea/Vomiting Click or tap here to enter text.

☐Dysphasia Click or tap here to enter text.

☐Diarrhea Click or tap here to enter text.

☐Appetite Change Click or tap here to enter text.

☐Heartburn Click or tap here to enter text.

☐Blood in Stool Click or tap here to enter text.

☐Abdominal Pain Click or tap here to enter text.

☐Excessive Flatus Click or tap here to enter text.

☐Food Intolerance Click or tap here to enter text.

☐Rectal Bleeding Click or tap here to enter text.

☐Other:

Click or tap here to enter text.

☐Urgency Click or tap here to enter text.

☐Dysuria Click or tap here to enter text.

☐Burning Click or tap here to enter text.

☐Hematuria Click or tap here to enter text.

☐Polyuria Click or tap here to enter text.

☐Nocturia Click or tap here to enter text.

☐Incontinence Click or tap here to enter text.

☐Other: Click or tap here to enter text.

☐Stress Click or tap here to enter text.

☐Anxiety Click or tap here to enter text.

☐Depression Click or tap here to enter text.

☐Suicidal/Homicidal Ideation Click or tap here to enter text.

☐Memory Deficits Click or tap here to enter text.

☐Mood Changes Click or tap here to enter text.

☐Trouble Concentrating Click or tap here to enter text.

☐Other: Click or tap here to enter text.

GYN

☐Rash Click or tap here to enter text.

☐Discharge Click or tap here to enter text.

☐Itching Click or tap here to enter text.

☐Irregular Menses Click or tap here to enter text.

☐Dysmenorrhea Click or tap here to enter text.

☐Foul Odor Click or tap here to enter text.

☐Amenorrhea Click or tap here to enter text.

☐LMP: Click or tap here to enter text.

☐Contraception Click or tap here to enter text.

☐Other:Click or tap here to enter text.

Body System

Positive Findings

Negative Findings

General

Obese

Skin

No itching or skin rash.

HEENT

Denies headache at this time. Denies history of trauma before this accident. Eyes: denies wearing corrective lenses. Vision left eye: 20/20. Ears: Weber midline. Negative conductive hearing loss to left and right ears. Negative tinnitus, hearling loss, vertigo, earache or discharge. Nose/Sinuses: Ability to discriminate between odors intact. Negative rhinnorhea, stuffiness, sinus pressure or epistaxis.Neck: No swelling noted bilaterally. Sternocleidomastoid and trapezius strength normal against resistance.

Respiratory

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Neuro

Decreased sensation in feet bilaterally Right eye vision Left eye vision

Denies tingling, numbness, tremors, paralysis, weakness, fainting, seizure, or blackouts. No bladder or bowel dysfunction. No changes in sleeping patterns, concentration, appetite or coordination, appetite. Mental statues intact, Alert and oriented to person and place. Cranial Nerves Intact I: able to discriminate odors II: 20/20 in left eye III, IV, VI: Normal extraocular movements. V: Facial sensation intact with dull, sharp and soft sensation. VII: Symmetrical, no drooping. VIII: Lateralization normal, hearing intact bilaterally. IX, X: Gag intact XI: Strength of sternomastoid and trapezius muscles normal against resistance. XII: Tongue midline, no wasting or fasciculations. Motor Intact: Gait normal with no impairment Sensory Intact: Stereognosis and graphesthesia ability intact. Reflexs Intact: Active bilaterally to triceps, biceps, brachioradialis, ankles and knees.

Cardiovascular

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Musculoskeletal

Complains of stiffness and pain on the sides and back of her neck, which worsens with movement

No general muscle weakness, difficulties with a range of motion, pain, swelling or joint instability. no back pain or gait.

Gastrointestinal

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Genitourinary

Psychiatric

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Maintains good contact while answering all the questions. She is very alert, calm, and responsive through all the physical examination. Does not seem stressed or anxious. No depression, anxiety, mood instability or sleeping problems. Speech clear and appropriate.

Gynecological

Problem List

6 Decreased sensation in the right foot

11

2 Neck stiffness

7 Migraines

12

3 Acute pain

8 tension headache

13

4 Spinal cord injury

9 whiplash

14

5 Cervical sprain

10

15