Name

CC
Where? When did it start? why did it happen?
Quality? Quantity? (pain 0-10; SOB/cough NYHA I-IV) Radiation?
when is it worse? duration, frequency(laying down, day time, night time, standing
up; exercising/ambulating)
What makes it better?
what makes it worse?
Have u taken anything for it? (aspirin, tylenol, nyquil, Ben gay)

PMH: Recent hospitalizations/illnesses, Immunizations, Psych;

DM/HTN/CA/Asthma/Thyroid
Meds:
Allergies:
PSH:
Blood Transfusions: blood type
Social: EtOH (how much/hz/kind), nicotine, drugs. Sex, living accomodations, diet,
exercise

ROS
General: Fever, chills, wt loss/gain, night sweats, fatigue weakness
Skin: Nail changes, itching, hair loss, rashes, bumps
Head: Trauma, HA, nausea, dizziness
Eyes, Visual changes/blurry vision, tearing itching
Ears: Hearingloss, tinnitus, ringing, vertigo, aches, discharge
Nose/Sinuses: Rhinorrhea, stuffiness, sneezing, itching, allergies, bleeding
Mouth: Bleeding gums, hoarseness, voice changes, sore throat,
Neck: Swollen neck, tenderness,
Breast: skin changes (color/txtr), lumps, pain, discharge, self exams
Cardiac: CP, palpitations, dyspnea on exertion, orthopnea, PND, edema
Pulm: SOB, wheezing, cough, phlegm, hemoptysis, asthma, TB
GI: N/V/D/Constipation, hematemesis, dysphagia, BM changes, hematochezia, melena,
color, hemorrhoids, abdominal pain, hepatitis
GU: Hz, hesitancy, urgency, polyuria, polydypsia, nocturia, incontinence, stones,
infx
Genitals: General: STDs, hetero/homo, problems, function, contraception
M:discharge, sores, pain, masses, hernias; F:Menarche, regularity, last period,
itching, discharge, sores, gestations/complx/abortions, birth control, menopause
Vascular: Leg edema, claudication, varicose vv, DVTs
MS: weakness, pain, stiffness, ROM, instability, redness, swelling, arthritis,
gout
Neuro: numbness, paraesthesias, twitching, fainting, LOC, seizures
Hem: anemia, bruising, bleeding, petechia, purpura
Endo: heat/cold intolerance, excessive sweating, DM, thyoid probs
Psych: depression, bipolar, concentration/memory anxiety

Physical Exam:
VS: BP, P, R, T, Ht, Wt
General: state of health, hygeine, affect

Skin: scars, rashes, bruises, tattoos, nail stippling

Head: size, shape, trauma, hair distribution, bumps, bleeding

NCAT, good hair distribution,no scars or bleeding
Eyes: pupils, symmetry, conjunctival injection, scleral icterus, fundal
papilledema, hemorrhage, lid edema, extraocular movements, visual field acuity,
discharge, whisp test
PERRLA, no redness or cataracts, ...
Ears: symmetry, tenderness, discharge, external canal, TM patency/inflammation
Nose: symmetry, tenderness, discharge, bleeding, dryness, turbinate inflammation,
sinus tenderness
Mouth: hygeine, dentures, erythema, exudate, tonsilar enlargement
Neck: masses, ROM, spine, trachea, thyroid
Breasts: skin color, symmetry, dimpling, tenderness, discharge,
Heart: rate, rhthm, murmurs, rubs, gallops, clicks, bruits
Pulm: symmetry w/ respirations, fremitus, tympany/dullness to percussion,
auscultation (wheezing, crackles, rales, stridor, egophony; bronchial vs
vesicular), diaphragmatic excursion
Abd: scars, striae, shape (scaphoid, flat, protruberent, pannus), bowel sounds
(none, active), renal bruits, percuss for liver and spleen span, stroke for
peritonitis, palpate for masses/hernias, palpate for hepatosplenomegaly/kidneys,
rebound tenderness; murphy's sign
GU: M: inspect for edema, rashes, ulcers, bumps, discharge, induration, palpate
for tenderness, hernias; F: inspect for ulcers, warts, bumps, dryness, redness,
inflammation, patency of urethra/vagina; Speculum-cervix color, bleeding,
friability; digital exam-palpate for cervical motion tenderness, ovarian/uterine
masses, vaginal support, rectovaginal fistulas
Rectal: tone, prostate (consistency, lumps), colon texture (smooth, ridges,
polyps), feces (amount, consistency)
MS: atrophy, weakness, ROM, stability, redness, swelling, tenderness, spine
deviation (midline, scoliosis), strength (5/5)
Vasc: pulses (carotid, radial, femoral, popliteal, posterior tibial, dorsalis
pedis), JVD (waves-a,x,c,y,v)
Lymph: cervical, supra/infra clavicular, axillary, inguinal
Neuro: twitching, CN 2-12 (I smell; II visual acuity, fields, fundoscopic exam;
III/IV/VI eyelid opening extraocular movements, direct/consensual light reflexes,
wisp test(VI); V sensation forehead, cheek, jaw, masseter muscle; VII eyebrow
raise, eyelid close, smile, frown, pucker, taste; VIII auditory, Rinne (air vs
bone [mastoid] conduction), Weber [tuning fork on head-->air], Oculocephalic
reflex [dolls eye maneuver], oculovestibular reflex [ear canal distribution], IX,
X palate elevation, swallowing, posterior taste, phonation, gag reflex; XI lateral
head rotation, neck rotation, neck flexion, shoulder shrug; XII tongue protrusion
and lateral movement), DTR (1+ - 5+; achilles tendon, babinski, patellar, biceps,
tendon, trapezius), cerebellar (heel to shin, rapid alternating movements, finger
to nose), clonus, rigidity; GCS (3-15)
Psych: MMSE (Time-year, season, month, day/date/president, Place-state, county,
city, hospital, country; Retistration-remember 3 things; Concentration-Serial 7's;
Recall-repeat 3 objects; Language-Repeat "no ifs ands or buts"; Name 2 objects;
follow 3 step command; Read and obey CLOSE YOUR EYES; Write a sentence; Copy a
design) mood, SIGECAPS, DIGFAST, S/H I, A/V H

** PMH-Past Medical History; GI-Gastrointestinal; GU-Genitourinary; MS-

Musculoskeletal; Hem-Hematology; Endo-Endocrine; VS-Vital signs, BP-blood
pressure, P-pulse, R-respiratory rate, T-temperature; NCAT-normocephalic
atramatic; PERRLA-pupils equal round reactive to light and accomidation; JVD-
jugular venous distension; MMSE-Folstein Mini Mental Status Exam