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History and Examination at a Glance 1st Ed
History and Examination at a Glance 1st Ed
From deniz demir
Current Clinical Strate- gies
History and Physical Ex-amination
Tenth Edition
Paul D. Chan, M.D.Peter J. Winkle, M.D.
Current Clinical Strategies Publishing
www.ccspublishing.com/ccs
Digital Book and Updates
Purchasers of this book may download the digital bookand updates for Palm, Pocket PC, Windows andMacintosh. The digital books can be downloaded at theCurrent Clinical Strategies Publishing Internet site:
www.ccspublishing.com/ccs
Copyright
©
2005 Current Clinical Strategies Publishing.All rights reserved. This book, or any parts thereof, maynot be reproduced or stored in an information retrievalnetwork without the permission of the publisher. Nowarranty exists, expressed or implied, for errors or omissions in this text.Current Clinical Strategies Publishing
27071 Cabot Road
Laguna Hills, California 92653-7012
Phone: 800-331-8227
Fax: 800-965-9420
E-mail: info@ccspublishing.com
Internet: www.ccspublishing.com/ccs
Printed in USA ISBN 1-929622-28-7
Medical Documentation
History and Physical Examination
Identifying Data:
Patient's name; age, race, sex. List thepatient’s significant medical problems. Name of informant (patient, relative).
Chief Compliant:
Reason given by patient for seekingmedical care and the duration of the symptom. List allof the patients medical problems.
History of Present Illness (HPI):
Describe the course of the patient's illness, including when it began, character of the symptoms, location where the symptoms began;aggravating or alleviating factors; pertinent positivesand negatives. Describe past illnesses or surgeries, andpast diagnostic testing.
Past Medical History (PMH):
Past diseases, surgeries,hospitalizations; medical problems; history of diabetes,hypertension, peptic ulcer disease, asthma, myocardialinfarction, cancer. In children include birth history,prenatal history, immunizations, and type of feedings.
Medications:
Allergies:
Penicillin, codeine?
Family History:
Medical problems in family, including the
patient's disorder. Asthma, coronary artery disease,heart failure, cancer, tuberculosis.
Social History:
Alcohol, smoking, drug usage. Maritalstatus, employment situation. Level of education.
Review of Systems (ROS):General
: Weight gain or loss, loss of appetite, fever,chills, fatigue, night sweats.
Skin:
Rashes, skin discolorations.
Head:
Headaches, dizziness, masses, seizures.
Eyes:
Visual changes, eye pain.
Ears:
Tinnitus, vertigo, hearing loss.
Nose:
Nose bleeds, discharge, sinus diseases.
Mouth and Throat:
Dental disease, hoarseness,throat pain.
Respiratory:
Cough, shortness of breath, sputum(color).
Cardiovascular:
Chest pain, orthopnea, paroxysmalnocturnal dyspnea; dyspnea on exertion, claudication,edema, valvular disease.
Gastrointestinal:
Dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation,melena (black tarry stools), hematochezia (bright redblood per rectum).
Genitourinary:
Dysuria, frequency, hesitancy,hematuria, discharge.
Gynecological:
Gravida/para, abortions, last menstrual period (frequency, duration), age of menarche,menopause; dysmenorrhea, contraception, vaginalbleeding, breast masses.
Endocrine:
Polyuria, polydipsia, skin or hair changes,heat intolerance.
Musculoskeletal:
Joint pain or swelling, arthritis,myalgias.
Skin and Lymphatics:
Easy bruising,lymphadenopathy.
Neuropsychiatric:
Weakness, seizures, memorychanges, depression.
Physical ExaminationGeneral appearance:
Note whether the patient appearsill, well, or malnourished.
Vital Signs:
Temperature, heart rate, respirations, bloodpressure.
Skin:
Rashes, scars, moles, capillary refill (in seconds).
Lymph Nodes:
Cervical, supraclavicular, axillary, inguinalnodes; size, tenderness.
Head:
Bruising, masses. Check fontanels in pediatricpatients.
Eyes:
Pupils equal round and react to light and accommo-
of 00
History and Physical Exam
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| Upload Date: | 07/15/2009 |
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