Medical History and Physical Examination

HISTORY Neuropsychiatric
Identifying Information:      Loss of conciousness, incoordination, tremor, change in
     Patient's name, age, sex, race or descent, marital      sensation, gait disturbance, depression, memory loss,
     status, occupation, residency (other demographic      suicidal thoughts, previous psychiatric care.
     information, if pertinent and not recorded elsewhere). If
     hospitalized, reason for admission. Source(s) and PHYSICAL EXAMINATION
     reliability of information about the patient. Vital Signs
CHIEF COMPLAINT      Temperature, pulse, respiration, blood pressure (if
     Chief or principal symptom(s). Use the patient's own      abnormal, record both arms, supine and standing), height,
     words if possible.      weight. Identify source if you did not obtain measurement.
     Can be multiple (POMR) or single (traditional record)      Appearance, build (habitus), apparent state of health,
     Title of problem or complaint (best definition of problem      pain/discomfort, nutrition, personal hygiene.
     given current info - this is not same as chief complaint) Skin and Lymphatics
     Subjective: chronological history of illness, prior      Skin, hair, nails, clubbing, mucous membranes, tender or
     treatments and response, current status      enlarged lymph nodes.
     Objective: data from previous records, pertinent negs. Eyes
     Medications: those related to this illness      Conjugate gaze, lids, conjunctivae, pupillary response to
     Pertinent negatives.      light (d & c) and accomodation, ocular muscles, fields
PAST MEDICAL HISTORY (PMH)      fundoscopic, visual acuity.
     Active illnesses not listed as separate HPIs: (provide Ears
     enough information to manage illness). Past illnesses,      Hearing, T.M.'s, canals.
     injuries, surgical procedures, health care maintenance Nose and Throat
     (immunizations, skin tests, pap smear, etc).           Turbinates, septum, gingivae, teeth, tongue, posterior
     Hospitalizations. PARA:      pharynx, manual exam of mouth if indicated.
MEDICATIONS      ROM, trachea, nodes, thyroid, swallowing.
     Prescriptions, OTC drugs (ASA etc.), herbal remedies Breasts
FAMILY HISTORY (FH)      Masses, tenderness, discharge.
     Inheritable diseases and predisposing factors for Chest
     parents, siblings, offspring. Diagram pedigree if      Insp:     Symmetry, respiratory movement, use of
     appropriate (male, female, deceased, index case,                    accessory muscles
     penotype expressed).      Palp:     Bony thorax, ribs, excursion of rib cage
SOCIOENVIRONMENTAL HISTORY      Perc:     Resonance, diaphragmatic excursion
     Habits: alcohol, tobacco, drugs, typical day, travel, work      Ausc:   Breath sounds, adventitious sounds
     history, financial or living problems, environmental               (crackles, rhonchi, wheezes)                  
     exposure to toxic substances. Heart
REVIEW OF SYSTEMS (ROS)      Genl:     Rate and rhythm, peripheral circulation,
General                   edema, skin color
     Weight (maximum, minimum, current), appetite, fever,      Insp:     Precordial movements, neck vein height
     exercise level, anemia.                  (CVP), visible apical impulse
Skin and Lymph Nodes      Palp:     P.M.I., location and character, pulse quality
     Itching, rash, change in mole, enlarged or painful nodes.      Ausc:    S1, S2, S3, S4, murmurs, clicks, rubs
HEENT Abdomen
     Headache, vertigo, dizziness, tinnitus, hearing, ear pain,      Appearance, bowel sounds, bruits, organomegaly, masses,
     vision, glasses, eye pain, halos, nosebleed, sinusitis,      tenderness, guarding
     sore throat, teeth, change in voice. Genitalia
Endocrine      Male: penis, testes, hernia exam
     Thyroid disease, temperature regulation, polydipsia.      Female: introitus, b.s.u., vagina, cervix, bimanual, R-V
Breasts Rectal Exam
     Discharge, pain, lumps.      Sphincter, prostate, stool: appearance and heme test
Respiratory Extremities
     Shortness of breath, dyspnea, cough, sputum      Limitation of movement, deformity, pain, pulses, clubbing
     production, wheezing/asthma, hemoptysis. Neurological
Cardiovascular      DTR's, Babinski, cranial nerves, sensation, coordination,
     Chest pain, past heart attack, hypertension, palpitations,      gait and station, muscle strength
     syncope, fatigue, cyanosis, claudication, edema, Mental Status
     rheumatic fever, PND, orthopnea, nocturia.      Affect, mood, thought content, memory
     Dysphagia, nausea, vomiting, regurgitation, pyrosis, Initial Laboratory and X-Ray
     flatulence, ulcer disease, abdominal pain, GI bleeding,  
     melena, change in bowel habits, hernia, hemorrhoids. ASSESSMENT AND PLAN
Genitourinary, Gynecologic and Sexual History (Impression / Differential Diagnosis)
     Dysuria, frequency, incontinence, urethral disease, VD, List of Problems
     impotence, libido, dyspareunia, menstrual history, vaginal      Differential diagnosis and plan for each active problem.
     bleeding, contraception.      A&P may be combined or two separate sections.
     Muscle pain, weakness, arthritis, arthralgia.                   M-2 Physical Diagnosis Robert Wigton, MD September 2000