New Inpatient Evaluation (History and Physical)

New Inpatient Evaluation Patient Name DOB MRN
Review of Systems Chief complaint/Reason for consult Start Time Stop Time Date
Review of Systems Yes No
Constitution
Fatigue or Malaise
Fever or chills
History of Present Illness Patient is Nonverbal. History obtained from Family Medical records
Appetite changes
Eyes
Conjunctivitis

New eye pain
Blurred vision
ENT/mouth
Sore throat
Swollen uvula
Jaw pain
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Respiratory
Dyspnea
Cough
Phlegm www.e-medtools.com
Hemoptysis
Wheeze

Pleuritic Symptoms
Cardiovascular

Chest pain
Diaphoresis Ambulatory Bedridden
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Pain present Level (1-10 Scale) 1 2 3 4 5 6 7 8 9 10
Ankle edema
Syncope Allergies and Medications
Palpitations
Gastrointestinal
Allergy List reviewed No drug allergies No food allergies
Nausea or vomiting
Weight changes Medications reviewed Medications reconciled with Nursing Home data
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Diarrhea
Abdominal pain Past Medical, Family Social History (PFSH)
Genitourinary Past Medical History
Hematuria Asthma Diabetes Obstructive Sleep Apnea Other
Dysuria COPD Hepatic Dysfunction Seizure Disorder
Urethral discharge Congestive Heart Failure(CHF) HIV/AIDS
www.e-medtools.com Thyroid disease Hyper Hypo
Musculoskeletal Coronary Artery Disease Hypertension Tuberculosis
Myalgias
Arthralgias Malignancy Yes No
Joint swelling Adrenal Breast Colon Leuk/Lymph Lung Melanoma Renal cell Skin Pituitary Prostate Testicular Thyroid
Recent trauma Treatment Surgical Resection Radioablation Chemotherapy Radiation
Skin/Breasts
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Masses ADLs This patient is able to perform the following independently Eating Bathing Dressing Toileting Transfers
New skin lesions Vaccines This patient is current on the following Seasonal Influenza H1N1 Influenza Pertussis Pneumococcal Varicella Tetanus
Rash
Neurologic Surgeries
Headaches Appendectomy Cholecystectomy Pacemaker Organ transplant
Seizures Arterial bypass Colon resection Defibrillator
Numbness Coronary Artery Bypass Hysterectomy Other
Paresthesias Cardiac valve repair or replace Nephrectomy Hip replacement
Carotid Endarterectomy Splenectomy Knee replacement
Endocrinologic
Hair loss Social History Risk factors
Polydipsia Denies Yes Tobacco use Number Pack-Years ______
Tremors Denies Yes Quit tobacco use Quit date _________
Neck pain Willingness to Quit Unwilling Considering Quit but resumed Within 1 month
Heme/Lymph Patient has tried smoking cessation aids Nicotine Replacement Receptor blockade Buproprion or nortriptyline
Bleeding gums
Unusual bruising
Denies Yes Recreational drug use Route Inhalation Injection Ingestion
Denies Yes Drug dependence Type Narcotics Benzodiazepines
Swollen lymph nodes
Allergy/Immunology Denies Yes Alcohol use ___ Drinks per Day Week
Nasal congestion
Rhinorrhea Family History
Psychologic Asthma Coronary Artery Disease Renal Dysfunction Malignancy
Agitation CHF Pancreatitis Thrombotic disorder Other
Hallucinations COPD Peripheral Artery Disease Thyroid Disease
©MB and RR 2006-2010 e-medtools.com Revised 12Jan2010 Health Care Provider Signature
Exam
Ventilator Constitutional WNL = Within Normal Limits
Mode ACSIMVPCPRVC Height _______ in cm Weight _______ lb kg Temperature _____

AND Rhythm Regular Irregular
Date of Intubation ________________
Respiratory Rate _______ Pulse Rate _______
Endotracheal Tube Size _____
Blood Pressure Sitting __________ OR Standing __________ OR Lying __________
Tracheostomy Tube Size _____
Rate ____ Tidal Vol ____ FiO2 ____ Optional Sats _____ % Cardiac Output _____ SVR _____
PEEP ____ PS ______ Plateau _____ Body habitus WNL Cachectic Obese
ARDS ALI WNL Unkempt
Groomingwww.e-medtools.com
PO2/FiO2 <200 201-300 >300 ENT
WNL Edema or erythema present
Nasal mucosa, septum, and turbinates
Dentition and gums WNL Dental caries
Gingivitis
NonInvasive Ventilator
CPAP BiPAP Ins ____ Exp ____
WNL Edema or erythema present Oral ulcers Oral Petechiae
Oropharynxwww.e-medtools.com
IV Medications Mallampati I II III IV
Antiarrhythmics Narcotics Neck
Antihypertensives Pressors Neck WNL Erythema or scarring consistent with recent or old radiation dermatitis
Diuretics Sedation Thyroid WNL Thyromegaly Nodules palpable Neck mass
Drotrecogin alfa Steroids WNL JVD present a, v or cannon a waves present
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Jugular Veins
Heparin Thrombolytic Respiratory
Insulin TPN Chest Free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis
Antibiotics Scarring consistent withOld, healed radiation dermatitis Prior surgery Trauma Other
Respiratory effort WNL Accessory muscle use Intercostal retractions Paradoxic movements
WNL Dullness to percussion Lt Rt Hyperresonance Lt Rt
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Chest percussion
Lines & Monitors Tactile fremitus WNL Increased Decreased
Telemetry Auscultation WNL Bronchial breath sounds Egophony Rales Rhonchi Wheezes Rub present
Chest tube Cardiovascular
Left Air leak Present Absent Heart sounds Clear S1 S2 No murmur, rub or gallop Gallop audible Rub audible
Right Air leak Present Absent Murmur present Systolic Diastolic Grade I II III IV V VI
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NG/ND tube Peripheral pulses Palpable and symmetric Absent Weak
PEG/PEJ tube Peripheral edema Absent Present
Foley catheter Gastrointestinal
Ostomy WNL Mass present LUQ RUQ LLQ RLQ Pulsatile
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Abdomen
Central line/PICC Liver and spleen Palpable and WNL Unable to palpate LiverSpleen Organomegaly Liver Spleen
No sign of infection
Site Lymphatics (2 areas must be examined)
Lymph node exam WNL Areas examined Neck Axilla Groin Other
Peripheral venous access Lymphadenopathy noted Neck Submental Axillary Epitrochlear Inguinal Other
Site Musculoskeletal
Muscle tone WNL, and no atrophy noted Increased Decreased Atrophy present
Port access Gait and station WNL Ataxia Wide based gait Shuffle Patient leans Rt Lt Front Back
Extremities
Labs Exam WNL Clubbing Cyanosis Petechiae Synovitis Rt Lt
Skin
\____/ ____ / ____ / ____ / Exam WNL Rash Ecchymosis Nodules Ulcer
/ \ \ \ \ Neurologic
Orientation Oriented NOT oriented to Person Time Place
Affect WNL Agitated Anxious Depressed
Radiology Additional Findings
CXR CT/Chest Other
Impression and Plan
Data Reviewed I have personally discussed Code Status with this patient, and believe that this patient (or their surrogate
ER Notes decision maker) understands their medical condition, their prognosis and the consequences of their Code
Old medical records Status decision.
Labs Code Status Patient is a FULL CODE
Radiology data DO NOT ATTEMPT Cardiac Resuscitation
Pathology DO NOT Intubate
ECHO
This patient has advanced health care directives. Their HCPOA is
EKG
Stress Test
Pulmonary Function Test www.e-medtools.com
Care Coordinated with
Patient
HCPOA / Surrogate
Other physician or Consultant www.e-medtools.com
Case Management or Social Worker
Pharmacy
Nursing
Recommended Actions
Aggressive pulmonary toilet www.e-medtools.com
DVT prophylaxis
Stress ulcer prophylaxis
Daily sedation vacation and
neurologic assessment
Head of bed elevated > 30 Degrees www.e-medtools.com
Insulin infusion Goal: 100-150
Central line change/removal culture tip
Physical therapy
Enteral/Parenteral feeds
Smoking cessation aids www.e-medtools.com
Pneumonia vaccine prior to discharge
Influenza vaccine prior to discharge
Antibiotics
Recommended Diagnostics www.e-medtools.com
Cultures
Sputum Blood Urine CSF

Influenza swab, wash or aspirate
PPD
Quantiferon
Serum Mycoplasma
Urine for Histoplasma and Legionella
CBC with differential
PT, PTT, INR
Metabolic Panel
BNP
Cardiac Enzymes
HIV C-FNP or PA-C Signature
DIC Panel
Thyroid function studies I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the NP or PA above
and I agree with the assessment and plan as outlined.
EKG
ECHO Physician Signature
Other cc

New Inpatient Evaluation (History and Physical)

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New Inpatient Evaluation (History and Physical)

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New Inpatient Evaluation Patient Name DOB MRN

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