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Dilated Cardiomyopathy-Specific H&P

iH&P "custom H&Ps, Charts and Notes"

Complete format
Date: 5/6/2012 22h:18min

The History ID name, age, sex, race, marital status, CC This xx-year-old-race-gender complaining of..., HPI Onset (date/mode), Symptoms, Precipitating Events, current status, character, Dx,
progressive dyspnea, orthopnea, PND, pillows needed when supine, exercise tolerance, weight gain, peripheral edema, fatigue and weakness. Hx of myocarditis, endocrinopathies, genetic disease, postpartum, drugs, etc., Meds, see ROS,

PRINT

PMH Illnesses, Surgeries, Trauma Hx, Blood transf., Im & Vacc., HM Cardiac Risk Factors (Male >45y, smoking, obesity, +FH, +DM, cholesterol, HTN, etc.), Allergies MEDS SH Smoking , packs per year, ETOH, type, quantity, duration, IVDA, type, quantity, duration,
Diet, exercise, Work,

FH ob-gyn LMP, Pregnancies, contraception, pap, sex life, ROS

GS weight, Wt change, appetite, temp, fatigue, strength, weakness, overall status, HEENT headache, Visual acuity, Lens/type, Hearing, Sinuses (paranasal), sore throat, CV chest pain,

palpitations, dyspnea, orthopnea, exe SOB, PND, edema, symmetry, pitting, postural, localization, Resp wheezing, cough, sputum, GI reflux, heartburn, nausea, vomiting, Bleeding, Abdominal symptoms, constipation, Diarrhea, Stool, Liver, cholecystokinetics, GU dysuria, flank pain, urine, nocturia, stones, urination, stream, Prostatic symptoms, Penis, Testes, sexual fx, intercourse, orgasm, menses, dysmenorrhea, menopause, Breasts, masses, lesions, Nipple, MS strength/weakness, Joints, arthralgias, ROM, back/neck pain, Derma lesions, Neuro h/a, LOC, transitory deficit, memory, motor, Psych affect, depression, anxiety, suicide idea, drug abuse, Endo weight, polys, heat/cold int, obesity, Hemo-Onc pallor, bruising, bleeding, nodes,

The Physical Examination GA age , race, sex, conscious, alert, Ox3, NAD, cooperation, facies, VS Temp RR HR tachycardia, BP BP (right/left, upright/decubitus), PP,
pulse ox BW IBW, BMI,

Skin Nodes HEENT Head AT/NC, exo/endostoses, scalp, Facies, movs, CN V, CN VII, Sinuses, TMJ,
Eyes xanthelasma, Conjunctivae, Sclerae, Cornea, Visual acuity (CN II), EOMI, CN III, IV, VI, PERRLA, OF Ears Timpanic membrane, Hearing, Nose nares, septum, Throat mucosa, mmm, tongue , tonsils, gag reflex,

Neck ROM, Spine, CN XI trapezius, Trachea, Parotids, Nodes, Carotids, bruits, hums, JVP, JVD, Thyroid Chest respiration, Lungs CTA+P, pleural effusion (decreased PAL & AUS , dull PER, shifts away), diaphragmatic excursion, BS, A/E, crackles (fine, coarse, rales), wheezes, Heart cardiomegaly, PMI, (sustained, wide, displaced PMI), lifts, rubs, RRR, S1, S2, gallops, S3, S4, murmurs, (intensity, pitch, quality, location, configuration, radiation, modification), Breasts skin, masses, lumps, Nipples, Nodes, Back ROM, Abdomen shape/volume/symmetry, NT/ND, Pulses, hernias, Ascites (shifting dullness, wave sign), hepato-jugular reflux, Masses, BS, Liver tenderness, Hepatomegaly, Spleen Other
organs

Dilated Cardiomyopathy

Ext CCE, edema (pretibial, dependent, symmetrical, pitting), skin, pulses, joints, Hands,
DTRs,

Genitalia escutcheon, inguinal canal, hernia, Rectal sphincter, walls, masses, Prostate, Hemoccult , Neuro
Cerebral Fx MMSE CN Motor Reflexes Sensory Cerebellar

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2012/05/06