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A template for documenting the history and physical examination of a patient with chest pain. Includes chief complaint, history of present illness, review of systems, vital signs, and organ system examinations.
Learn how to document a thorough history and physical examination for adult patients using a standard format and template. Includes examples, tips and a review of systems checklist.
Browse actual history and physical examination (H&P) reports written by UNC students during their inpatient clerkship rotations. See how to structure, format and document H&Ps for different cases and diagnoses.
It includes patient demographics, medical, family, and social history, a review of systems, and findings from a physical examination. Explore the essential guide to the history and physical forms, streamlining patient assessments for accurate diagnosis and effective care management.
Comprehensive Adult History and Physical (Sample Summative H&P by M2 Student) Chief Complaint: “I got lightheadedness and felt too weak to walk” Source and Setting: Patient reported in an in-patient setting on Day 2 of his hospitalization. History of Present Illness: Patient is a 48 year-old well-nourished Hispanic male with a 2-month
8 Δεκ 2022 · History of 2-3 generations for similar disease or related disease, hypertension or diabetes mellitus. 7. Drug and Allergy history: Prescribed drugs and other medications; Compliance; Allergies and reaction; Neonatal history taking. Physical Examination. General examination: G/C – Note relevant findings and abnormalities in – Mnemonic ...
History of Present Illness: Ms J. K. is an 83 year old retired nurse with a long history of hypertension that was previously well controlled on diuretic therapy. She was first admitted to CPMC in 1995 when she presented with a complaint of intermittent midsternal chest pain.
