Should include major risk factors, e.g. hypertension, coronary artery disease in a stroke patient. History of present illness - to include all pertinent positives and negatives, including pertinent past medical history and family history. Do not include week by week details of evaluation and treatment, only information that contributes in an important way to diagnosis and management. Past medical history - to include prior hospitalizations and operations, current medications, allergies, and significant current adult illnesses. Review of systems.
List positives only.
List systems reviewed. Physical examination - include vital signs, a general description of the patient, and specific evaluation of each organ system. Motor testing - including strength, bulk, tone, drift in the upper extremities and fine motor movement in the hands, and adventitious movements such as tremor, chorea or fasciculations. Sensory - including pin, touch, vibration, position, and where indicated, hot and cold testing. Always have a hypothesis to guide your sensory exam.