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HISTORY OF PRESENT ILLNESS (HPI): Chronological narrative of the circumstances leading up to the chief complaint(s). Discussion of associated complaints and the signs and symptoms of the chief complaint, but no diagnostic label.

PAST MEDICAL HISTORY (PMH):

1. Major Illnesses
2. Injuries
3. Operations
4. Immunization history
5. Allergies to medication, food, contact, asthma
6. Dates of last chest X-ray and PAP smear; results?
7. Use of medications? Non-prescription, prescription, birth-control pills, caffeine, recreational, smoking

FAMILY HISTORY (FH): Father, mother: Age or age of death, cause of death, illnesses they have had; cancer, heart-disease, diabetes, stroke, alcoholism; history of illness of all primary relatives.

PERSONAL / SOCIAL HISTORY (SH): Place of birth, residence, occupation, marital status, number / age / sex of all children, brief description of lifestyle and eating and sleeping habits, travel, religion.

1. Tobacco (pk-yrs), EtOH, recreational drugs consumption.
2. Sexual History: Sexual trauma (rape, incest), sexually active, male homosexuality, multiple partners, risk-factors for STD's and AIDS, contraception, satisfaction with sex life.

REVIEW OF SYSTEMS (ROS): Interview patient about somatic systems

1. General: Height, weight, appetite, fatigue, weakness, chills, night sweats, anorexia, syncope, insomnia
2. Skin: Color change, itching, rashes, dryness, moles, infections, tumors
3. Head: Headaches, trauma
4. Eyes: Itching, redness, vision, glasses, blindness or blind spots, glaucoma, burning, dryness.
5. Ears: Hearing, vertigo, earaches, discharge, tinnitus
6. Nose / Sinuses: Bleeding, dryness, discharge, obstruction, pain, sinusitis
7. Mouth: Dental caries, bleeding gum, sore tongue, post-nasal drip.
8. Throat: Hoarseness, painful swallowing, tonsillitis.
9. Neck: Stiffness, pain, decreased motion, lumps, swollen glands, goiter.

1. Breasts: Pain, tenderness, lumps, nipple discharge
2. Respiratory: Exertional dyspnea, cough, sputum, hemoptysis, wheezing, TB Test, recurrent respiratory infections
3. Cardiac: Angina, orthopnea, paroxysmal nocturnal dyspnea, murmur, palpitations, syncope
4. Vascular: Varicosities, Raynaud's (cold-exposed pallor, cyanosis, redness).
5. Gastrointestinal: Nausea, vomiting, dysphagia, heartburn, hematemesis, hemorrhoids, blood in stool, constipation, food intolerances
6. Urinary Tract: Hematuria, dysuria, burning, incontinence, history of infections, polyuria, nocturia
7. Female Reproductive: Age at menarche, menorrhagia, postcoital bleeding, vaginal discharge, obstetrical history (miscarriages, gravida, para), libido, contraceptive use, menstrual regularity, dysmenorrhea
8. Male Reproductive: Penile discharge, pain, history of venereal disease, libido, infertility, impotence, testicular pain or masses.
9. Hematologic: anemia, easy bruising, easy bleeding, bleeding gums, lymphadenopathy
10. Musculoskeletal: Muscle pain, weakness, joints, abnormal curvature (kyphosis, lordosis)
11. Endocrine: Heat / Cold intolerance, breath change, voice change, Diabetes (polydipsia, polyuria, polyphagia)
12. Central Nervous System: Headache, syncope, seizures, vertigo, blindness, diplopia (double-vision), tremor, ataxia, memory, numbness, paresthesias.
13. Psychiatric: Nervousness, depression, hyperventilation, insomnia, phobias, emotional instability, delusions

PHYSICAL EXAM (PE)

1. Vital Signs
1. Temperature
2. Respiratory Rate
3. Pulse
4. Blood Pressure
5. Height
6. Weight
2. General Appearance: Nutrition, body habitus, apparent age, color, general behavior
3. Skin: Dry, coarse, smooth, rashes and scars (indicate position), temperature, baldness, hair, abnormal pigmentations, needle tracks, bruises, hirsutism
4. Lymph Nodes: Enlargement, tenderness; anterior + posterior cervical, axillary, inguinal, femoral. Record size in cm if enlarged.
5. Head: Size, shape, symmetry, contour, tenderness, bruits; anterior fontanelle (ped)
6. Eyes: Conjunctiva, sclerae, pupil size and reaction, ptosis, protrusion, gross visual acuity, extraocular movements, visual fields, pupillary light and accommodation reflexes; Funduscopic: optic disc, fovea, papilledema.
7. Ears: Tympanic membrane, discharge, cerumen, hearing, Weber test, Rinne test.
8. Nose: Septum, mucosa, airway obstruction, discharge, polyps
9. Mouth and Throat: Odor of breath, color of lips, tongue, and gums, caries, tonsils, uvula, larynx, epiglottis, anterior cervical and submaxillary nodes, carotid and jugular pulses.
10. Breasts: Tenderness, lumps, gynecomastia, symmetry.
11. Back: Mobility, curvature, tenderness on palpation or percussion.
12. Thorax: General symmetry, movement with respiration.
13. Respiratory:
1. Inspection: Labored or shallow breathing, use of accessory respiratory muscles.
2. Palpation: Palpate costochondral junction for areas of tenderness
3. Percussion: Dullness, hyperresonance, diaphragm excursion.
4. Auscultation: Crackles, wheezes, rubs
14. Heart:
1. Inspection: Heaving, bulging, point of maximal impulse.
2. Palpation: Costochondral junctions for tenderness.
3. Percussion: Heart size
4. Auscultation: Rate and rhythm of normal sounds at each of the valve locations, S3, S4, murmurs; draw diagrams indicating time and location of extra sounds.
15. Abdomen:
1. Inspection: Obese, flat, distended, dilated veins, scars, hair distribution
2. Palpation: Tenderness, rigidity, hernia, liver span, spleen palpable?
3. Percussion: Organ size, dullness, tympany
4. Auscultation: Bowel sounds, rubs, bruits
16. Extremities: Joint swelling, tenderness, edema, rashes; muscle weakness, hair distribution.
17. Vascular: Pulses (carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial). Use three point scale to indicate magnitude of pulse.
18. Male Genitalia: Size / tenderness of testis, urethral discharge, epididymis
19. Female Genitalia:
1. External: Hair distribution, labia, clitoris, introitus, urethra
2. Internal: Cervix, Cervical pain with motion, adnexa including ovaries, cul-de-sac, PAP smear, rectovaginal
20. Rectal: Prostate, feces analysis, polyps or masses.
21. Neurological
1. Mental Status
2. Cranial Nerves Tests
3. Somatic Reflexes
4. Motor: Muscular Strength, flaccidity / spasticity, tremor, dystonia
5. Cerebellar: Gait, finger-to-nose, finger-to-finger, Romberg Test
6. Sensory: Dermatome distribution, two-point discrimination

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