Concept Map

Initials: BF

Age: 58

Gender: MALE

Height

Weight

BP

HR

RR

Temp

SPO2

Pain

Allergies

5/10

Medication: Codeine (nausea, vomiting )

Food: NKA

Environment: NKA

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.

Patient stated current and up to date with immunizations including annual flu shot and tetanus (10/2014). All childhood immunizations were received. Patient denies past surgical history or hospitalizations.

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 denies smoking and tobacco use. Denies illicit drug use. Patient states drinking approximately 2-3 beers per week, mostly weekends.

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.

Father: deceased at 75 (colon cancer); PMH: hypertension, hyperlipidemia, obesity Mother: alive (80 y/o); PMH: DM type 2, hypertension Brother: deceased at 24- MVC Sister: alive (52 y/o); PMH: DM type 2, hypertension Maternal grandmother: deceased age 65- breast cancer Maternal grandfather: deceased age 54- MI Paternal grandmother: deceased age 78- pneumonia Paternal grandfather: deceased age 85- natural causes Son: alive, age 26; no PMH Daughter: alive, age 19; PMH: asthma

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 20lbs in last year

☐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:

Click or tap here to enter text.

☐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 Click or tap here to enter text.

☐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:

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

☐Headache Click or tap here to enter text.

☐Numbness

☐Tingling

☐Sensation Changes

Choose an item.

☐Speech Deficits Click or tap here to enter text.

☐Other: PT

☒Chest pain Uncomfortable chest tightness

☐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 Click or tap here to enter text.

☐Stiffness Click or tap here to enter text.

☐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 Due to chest pain

☐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

Skin

HEENT

Respiratory

Neuro

Cardiovascular

Ausculatation points (aortic, pulmonic, Erb’s point, Tricuspid, mitral): revealed S3 heart sounds, ventricular gallop Carotid Auscultation: Right side positive for bruit Palpation: Right carotid artery positive for thrill (3+) Popliteal, Tibial, and Dorsalis Pedis artery palpation: no thrill, amplitude 1+ bilaterally

Inspection: No JVD noted (3 cm at sternal angle), chest symmetrical with no abnormalities Auscultation: left carotid- no bruit noted; no bruit noted in right renal artery, left renal arter, right iliac artery, left iliac artery, right femoral artery, left femoral artery Capillary refill less than 3 seconds (both hands and feet) No edema noted on bilateral lower extremities Palpation: Left carotid artery negative for thrill (2+); PMI: displaced laterally, 3 cm; brisk and tapping Brachial, Radial, and Femoral artery palpation: no thrill, amplitude 2+ bilaterally EKG: regular sinus rhythm with no ST elevation Skin tugor WNL

Musculoskeletal

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

Gastrointestinal

Genitourinary

Psychiatric

Anxiety due to chest pain

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 Unhealthy diet

11 Lack of exercise

2 Abnormal heart sound S1, S2, S3

7 Bilateral popliteal artery +1

12

3 Right carotid artery bruit

8 Bilateral tibialartery +1

13 Weight gain

4 Fine crackles bilateral lower lobes

9 Bilateral dorsalis pedis artery +1

14

5 Right carotid artey thrill (+3)

10 Hyperlipidemia

15