1. JI Heinrich A. Bawalan January 13, 2010

2. Identifying Data Reliability Chief Complaint(s) Present Illness Past History Family History Personal and Social History Review of Systems

3. age, gender,occupation, marital status patient,family member, friend, letter of referral, or the medical record

4. Varies according to the patient’s memory, trust, and mood

5. one or more symptoms or concerns causing the patient to seek care

6. Chronologically describes how each symptom developed principal symptoms : (1) location, (2) quality, (3) quantity or severity, (4) timing (onset, duration, & frequency) (5) the setting in which they occur, (6) factors that have aggravated or relieved the symptoms, and (7) associated manifestations

7. Includes pertinent positives & pertinent negatives reveal the patient’s responses to his or her symptoms and what effect the illness has had on the patient’s life Medications should be noted, including name, dose, route, and frequency of use

8. Childhood illnesses (measles, rubella, mumps, whooping cough, chicken pox, rheumatic fever, scarlet fever, and polio) Adult illnesses: 1. medical: diabetes, hypertension, hepatitis, asthma, HIV disease 2. surgical: dates,indications, and types of operations

9. 3. obstetric/gynecologic: obstetric history, menstrual history, birth control, and sexual function 4. psychiatric: dates, diagnoses, hospitalizations, and treatments Includes health maintenance practices: immunizations, screening tests

10. Outlines or diagrams of age and health, or age and cause of death of siblings, parents, and grandparents Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, etc.

11. Describes educational level, family of origin, current household, personal interests, & lifestyle

12. Documents presence or absence of common symptoms related to each major body system General: Usual weight, recent weight change, weakness, fatigue, fever Skin: Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails Head, Eyes, Ears, Nose, Throat (HEENT): Head: Headache, head injury, dizziness, lightheadedness

13. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble

14. Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums, dentures, sore tongue, dry mouth, frequent sore throats, hoarseness Neck: Lumps, goiter, pain, or stiffness in the neck

15. Breasts: Lumps, pain or discomfort, nipple discharge, self-examination practices Respiratory: Cough, sputum (color, quantity), hemoptysis, dyspnea Cardiovascular: chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema

16. GI: Trouble swallowing, heartburn, appetite, nausea, bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching, jaundice

17. GUT: Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy,dribbling Genital: Male: discharge from or sores on the penis, testicular pain or masses

18. -Female: bleeding between periods or after intercourse, last menstrual period; dysmenorrhea, premenstrual tension; age at menopause, menopausal symptoms, postmenopausal bleeding

19. Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, and backache, presence of any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity Neurologic: Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or tremors or other involuntary movements

20. Hematologic: Anemia, easy bruising or bleeding, past transfusions and/or transfusion reactions Endocrine: heat or cold intolerance, excessive sweating, polydipsia, polyphagia, polyuria, change in glove or shoe size

21. Psychiatric. Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant.

22. General Survey: patient’s general state of health, height, build, and sexual development, posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath Vital Signs Skin: lesions; Inspect and palpate the hair and nails

23. Head, Eyes, Ears, Nose, Throat (HEENT) Neck: Inspect and palpate the cervical lymph nodes. Note any masses or unusual pulsations in the neck. Feel for any deviation of the trachea. Inspect and palpate the thyroid gland.

24. Chest and Lungs: Inspect, palpate, and percuss the chest; Listen to the breath sounds, & any adventitious sounds

25. Cardiovascular System: Observe & measure the JVP Inspect and palpate the carotid pulsations Inspect and palpate the precordium. Note the location, diameter, amplitude, and duration of the apical impulse Listen for the first and second heart sounds, and for physiologic splitting of the second heart sound, & for any abnormal heart sounds or murmurs

26. Abdomen: Inspection: color. Lesions, scars, striae, superficial blood vessels, contour, shape & symmetry, visible mass, visible peristalsis & pulsation, umbilicus Auscultation: describe the bowel sounds, listen for possible bruit Palpation: describe the consistency of the abdomen as to soft, firm, rigid

27. Special maneuvers To test for localized peritonitis 1. Rebound tenderness 2. Jar tenderness (Markle’s sign) 3. Psoas sign 4. Obturator sign Murphy’s sign Ballotment maneuver

28. Percussion: measure the liver span, estimate the size of the spleen, detect the presence of ascites by eliciting fluid wave and dullness Lower Extremities: Palpate the femoral pulses Palpate the inguinal lymph nodes Inspect for lower extremity edema, discoloration, or ulcers

29. Nervous System Mental Status: orientation, mood, thought process, thought content, abnormal perceptions, insight and judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and constructional

30. Cranial Nerves Motor System Sensory System Additional Examinations Rectal Examination in Men Genital and Rectal Examination in Women