North Versailles Medical Associates West Penn Allegheny Health

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					North Versailles Medical Associates                                       West Penn Allegheny Health System             1744 Greensburg Avenue North Versailles, PA 15137 Phone: 412-823-2371 Fax: 412-824-9307


NAME:                                        DOB:               DATE:                                                                                                                                      VITALS
CHIEF COMPLAINT:____________________________________________ O SDA    O Follow up                                                                                                                          W
___________________________________________________________________________________________________________H
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___________________________________________________________________________________________________________BP
___________________________________________________________________________________________________________PR
___________________________________________________________________________________________________________RR
___________________________________________________________________________________________________________Pain
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Review of Systems: ( + = Positive   O = Negative)____________________________________________________________________________________
ROS ____Fever _____Chill _____Rigors _____Wt. Gain/loss _____________________________________________________________________________
Eyes: _____Vision Loss _____ Pain _____Drainage _____Itch ____________________________________________________________________________
ENT: _____Sore throat _____Drainage _____Pain _____Bleeding _____Dental_______________________________________________________________
Cardiovascular: _____Chest Pain _____Orthopnea _____PND _____Palpitations_____________________________________________________________
Respiratory: _____SOB _____Cough _____Wheezing___________________________________________________________________________________
Gastrointestinal: _____N _____V _____D _____C _____Heartburn _____Appetite____________________________________________________________
Genitourinary: _____Dysuria _____Freg _____Blood _____Incontinence___________________________________________________________________
Gyne: _____ Discharge _____Itch _____Odor _____Lesions _____Bleeding__________________________________________________________________
Musculoskeletal: _____Joint Pain _____ Back Pain _____ Pain____________________________________________________________________________
Skin: _____ Rash _____Lesion _____ Itch_____________________________________________________________________________________________
Neurologic: _____Weakness _____ Syncope _____Unsteadiness___________________________________________________________________________
Psychiatric: _____ Depression _____Anxiety ___________________________________________________________________
Endocrine: _____ Thirst _____ Hot/Cold Intolerance____________________________________________________________________________________
Heme/Lymph: _____ Bleeding _____ Nodes___________________________________________________________________________________________
Allergic/Immunologic: _____Urticaria _____ Allergies__________________________________________________________________________________
History Form _______ Reviewed _____ Updated ______________________________________________________________________________________
                                                    ABNORMAL DETAILS                                          ELEMENT OF EXAM
        ELEMENT OF EXAM
AREA                                                                                                  AREA                                               ABNORMAL DETAILS
                                                                                                                 NABS                   Mass
        3 Vitals                 stable
Cont                                                                                                  GI/AB   _                   Tenderness
                                                                Obese           Calm        Anxious                           Hepatomegaly
        General
                                                                                                              _______________Splenomegaly
                                                      Pale          red                                                   Costovertebral angle
        Conjunctiva             pink
Eye                                                                                                   GU      _              tenderness
        Pupil size             mm                                                                             Vagina        Lesion
        equal
                                                                                                              Urethra              Tenderness
        Ophth Optic disc
                                                                                                              Bladder              Tenderness
        External ear/nose           Deformity
ENT
                                                                                                              Cervix                         Lesion
        Oto:Ext audit canal/TM         b/l intact
                                                                                                              _                          Tenderness
                                                                                                              Uterus            Size         Mass
        Hearing                         normal
        Nasal mucosa       pink                              pale         red                                 Adnexa/parametria
        ______________________lesion                                                                          _                          Tenderness
                                                                                                              Gait                         Limping
        Lip/teeth/gums                  lesion
                                                                                                      Musc
        Oropharyngx(tongue/ tonsils)                                                                          Digit/Nails
        _                           lesion
                                                                                                              Range of Motion
             Mass                   symmetry
Neck
                                                                                                              Muscle strength
                                Thyromegaly
        Breast                           Mass                                                                                                 Lesion
Chest   _                    Nipple Discharge                                                         Skin
                                                                                                              Subcutaneous                       Mass
        Respiratory effort             dyspneic
Resp
        Auscultation               Rhonchi                                                                    CN 11-XII
        _ Wheeze             Rales     Rubs                                                           Neuro
                                                                                                              Deep Tendon Reflex
        Percussion           Dullness/Flatness
                                                                                                              Sensation                        Deficit
        Palpation             Tactile fremitus
                                                                                                              Orientation:          Oriented
Cardio Palpation                          Thrill
                                                                                                      Psych
        Auscultation                   Murmur                                                                 Memory
        _         Rate                 Rhythm
        Carotid                                                                                               Mood/Affect
        Bruit
                                                                                                              Lymphadenopathy                    Neck
        Abd Aorta                         Bruit
                                                                                                      Lymph _          Axilla                   Groin
        Femoral Artery                     Bruit
        Pulse
        Pulses                          Radial
        _                               Pedal

				
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