Paul D. Chan, MD
Christopher R. Winkle, MD
Peter J. Winkle, MD
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the patient's illness, including when it began, character of the symptoms, location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives. Describe past illnesses or surgeries, and past diagnostic testing.
hospitalizations; medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction, cancer. In children include birth history, prenatal history, immunizations, and type of feedings.
Family History:Medical problems in family, including the
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.
nausea, vomiting, hematemesis, diarrhea, constipa- tion, melena (black tarry stools), hematochezia (bright red blood per rectum).
strual period (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding, breast masses.
modation (PERRLA); extra ocular movements intact (EOMI), and visual fields. Funduscopy (papilledema, arteriovenous nicking, hemorrhages, exudates); scleral icterus, ptosis.
turbulence); regular rate and rhythm (RRR), first and second heart sounds (S1, S2); gallops (S3, S4), murmurs (grade 1-6), pulses (graded 0-2+).
scars, bowel sounds, bruits, tenderness, masses, liver span by percussion; hepatomegaly, splenomegaly; guarding, rebound, percussion note (tympanic), costovertebral angle tenderness (CVAT), suprapubic tenderness.
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