H&P Notes

Patient Name: Sam (default to respectful address)

DOB, medical record #
Chief complaint ear pain
History of present illness (COLDERAS, especially effective for pain)
o Character
o Onset (3 days ago)
o Location (right ear)
o Duration (constant over 2 days)
o Exacerbation (hurts worse when laying down on right side and
yawning)
o Relief (Tylenol, temporary)
o Associated symptoms (felt hot, subjective fever, runny nose, clearyellow, some sneezing, no hearing loss, no dizziness, bilateral fullness,
congestion, but no ear drainage, non-productive cough, no shortness of
breath, no facial tenderness, no chapped lips or dry eyes, decreased
appetite, no nausea, vomiting, or diarrhea, denise weight change,
fatigue, weakness, chills, night sweats)
o Severity (8/10 at the worst, 5/10 on Tylenol)
o Ill contacts: some classmates are sick with runny nose and cough
Past medical history
o Seasonal allergies
o Right forearm fracture at 4 years old
o No other problems (that would be asked about in a good question
battery)
Past surgical history
o Appendectomy at 8
Social history
o College student, single
o No smoking, alcohol, or drug use
o No recent travel
o Not sexually active
Family history
o Mother 55 alive and well
o Father 57 high blood pressure and cholesterol
o Sister 18 healthy
Medications
o Zyrtec 10mg tablet by mouth once daily (Zyrtec 10 mg po qd)
o Tylenol for pain prn
Allergies
o Sulfa rash
o No pet/insect/latex/food allergies
ROS
o HEENT: denies head trauma, headaches, tinnitus, dizziness, epistaxis
mild sore throat, with drainage, no difficulty swallowing no eye
drainage, redness, itching, vision changes

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Hematology: denies easy bruising, bleeding, petechiae, purpura,

transfusions, no lumps, enlarged nodes or nodules
Musculoskeletal: denies thrombosis, muscle weakness, myalgias,
swelling, arthritis, gout
Cardiovascular: denies palpitations, edema, chest pain
Gastroenterology: denies change in bowel movements, abdominal
pain, jaundice
Respiratory: denies dyspnea, hemoptysis, sputum production
Skin: denies diaphoresis, rashes, sores, lumps, moles
Genitourinary: denies urinary frequency, hesitancy, urgency, dysuria,
hematuria, STDs

Vitals
o 120/78 mmHg
o 78 bpm
o 18 breaths/min, unlabored
o 100.5 degrees
o 511, 178 lbs
o 97% pulseox
General survey
o Alert and appropriate, well-nourished, appears mildly ill
o Skin feels warm, no rash, normal turgor
o HEENT normocephalic, atraumatic, pupils equal, round, and reactive
to light and accommodation (PERRLA), extraocular movement intact
(EOMI), no scleral icterus or injection, no discharge, external ear canals
patent, with small amount of cerumen bilaterally, right tympanic
membrane erythematous and bulging, landmarks not visible, left
tympanic membrane a little dull with no erythema, loss of landmarks,
or bulging, nasal mucosa pink, yellow drainage seen in the nasal
passages bilaterally, septum mid-line, oral mucosa pink without
enlarged tonsils or exudates, neck supple with shotty anterior cervical
adenopathy, no thyromegaly, trachea mid-line, normal ROM of neck
o Pulmonary thorax symmetric with good expansion, clear to
ausculatation bilaterally
o Cardiovascular normal S1 S2, no S3 S4, no murmurs, rubs or clicks,
regular rate and rhythm
Labs/diagnostic studies
o If any. If not, put in Assessment.
Assessment
o Differential diagnosis (at least 3)
o Other pertinent diagnoses
Plan
Sign with name and current title

Submit to ICM1511 box in lobby of clinical education office, 3rd floor of

Glendale Hall, by 4PM Monday September 21st
sali52@midwestern.edu

tpathiyil12@midwestern.edu