ADULT complete history IDENTIFICATION SHEET Full Name Age Sex • marital status r eligion home hospital birth

date: service. Bed record date and time of direct ex amination or indirectly responsible person (specify name and relationship: frien d, neighbor, brother, father, mother, uncle, etc..) Name who develops • • • • • • • • • • • • • FAMILY BACKGROUND INHERITS (Edited) • • • • • • • mother's age, health status, if living or deceased and cause of the latter or co ndition being treated. father: same as above. Brothers: number, live, healthy, s ick, dead, because of this last direct guys age, health status, maternal and pat ernal, maternal grandparents deceased their cause, age, health status, if they a re alive or deceased and cause of the latter . paternal grandparents, age, healt h status, if they are alive or deceased and cause of the latter as well: childre n, grandparents, uncles with hereditary diseases. The following conditions were told that they should ask each family. And at the end of the interrogation record which were denied. Were divided into three group s for the recall being the most common. Hereditary 1. 2. 3. 4. 5. 6. Hypertension. Diabetes Mellitus. Cerebrovascular Disease Hypercholesterolemia Ob esity Thyroid disease. Collagen diseases (rheumatoid arthritis, lupus erythemato sus) Cancer Asthma and allergies mental illness. (Suicide, Family Addiction 1. Alcoholism 2. Drug 3. smoking Infectious 12. 13. 14. AIDS Hepatitis Tuberculosis. 7. 8. 9. 10. 11. schizophrenia, etc.). convulsions. NO PERSONAL BACKGROUND PATHOLOGICAL (Edited) • • • • • • • Origin, residence (place and time) and recent travel. Education, occupation (tim e labor, occupational hazards, type of employment), religion. Room: type, materi al, location area (urban, suburban, rural), number of rooms, natural lighting an d ventilation, or number of windows per room, kitchen inside or outside the room , bathroom (toilet, septic tank or black) latter distance of the house, garbage collection, flora and fauna within and outside the home, pests. hygiene, bathing , changing underwear, tooth brushing. Food: usual daily food intake (number of m eals per day, daily rations) and supplements or dietary restrictions and consump tion of coffee, tea or other caffeinated beverages (servings per day, number of

meals per day). Junk food). Recreation and exercise (frequency and type) safety measures (use of seat belts, bike helmets, sunscreen, smoke detectors and other instruments associated with specific risks); practical alternatives to health ca re and family dynamics. Childhood immunizations, adult, elderly, pregnant. Delineate the patient's personality and interests, sources of support, how to de al with problems, strengths and weaknesses. Causes of stress (recent and old) re levant experience in your life (military service, employment history, financial status, and retirement. Medical history. (Edited) They were divided into two gro ups and those in subgroups: (ask if any presented, age at presentation, complica tions, warrants or hospitalization.) Childhood exanthematous: Varicella Measles Rubella exanthema subitum. obesity, malnutrition, asthma and allergies thyroid d isease, juvenile rheumatoid arthritis Juvenile diabetes headaches cancer / leuke mia / lymphoma. Congenital Heart Malformations. Head (conjunctivitis, IRAS (comm on cold, otitis, sinusitis, nasopharyngitis, tonsillitis (presentations per year ) Neck (laryngitis, mumps) Chest (whooping cough, pneumonia and tuberculosis (TN T) Abdomen (diarrhea, hepatitis) Genitourinary. AIDS. fractures, head injuries, surgeries motivation, treatment used, hospitalization, complications appeared, a ge of each. - plasma, whole blood, red cell, albumin, (reason, number of transfu sions received, complications) General: Infectious Surgical and / or traumatic Transfusion General Adult Infectious Diseases: exanthematous and infectious per se General: Systemic hypertension, diabetes mellitus, hypercholesterolemia, cerebro vascular disease, thyroid disease, obesity, collagen diseases (rheumatoid arthri tis, lupus erythematosus), cancer, asthma and allergies, seizures. Psychiatrist: suicide, schizophrenia, etc. Surgical or traumatic. Addiction transfusions. (Attached interrogation necessary ) early detection methods Gynecoobstetric Number and gender sexual partners, unsafe sex. (Only if male patient) fractures, €brain injuries, multiple trauma, surgery motivation, treatment used, hospitaliz ation, complications appeared, age of each. When, why? that transfused (plasma, whole blood, red cell, platelets), complications, allergic reactions, requiring hospitalization for transfusion. Alcohol addiction smoking Pap, mammogram (after 40 years). chest x-ray (> 35 yea rs or sooner, according to risk factors), EKG HIV, VDRL, hepatitis, cholesterol, blood sugar levels. Trig. Prostate exam after 40 years. Menarche, Telarc, pubar ca active sexual initiation rate and duration amount contraception deeds, for, a bortions, cesarean section (this last occasion) during pregnancy pathologies dat e of last menstrual period date of last delivery date of the last C-section no. Sexual partners and type of sex. Menstrual or sexual disorders. Menopause -

Addiction. a) b) c) Alcohol consumption questionnaire: ever felt the need to stop drinking have ever felt annoyed by criticism of your drinking ever felt guilty about your drinking ever had to drink in the morning to calm Rip or cut the nerves few times a week , comes up more drunk? You eat? From what age? Questionnaire drug consumption: h ow much marijuana consumption, cocaine, heroin, amphetamines, prescription drugs or sleeping pills to lose weight, it feels pain when making negative reactions have ever had family or work problems ever tried to leave each quantum. from tha t age. With adolescents mentioned. Many young people use drugs at this time, tha t happens in your school, or friends. snuff consumption questionnaire. since age Currently suffer how many packs a day using that type of cigar, pipe, cigar. I. II. signs and symptoms (reason for visit). Example: cough, fever, vomiting. Semiolog y of each of the signs and symptoms in chronological order. Example: ments: time evolution, expectorant or dry, sputum characteristics, prevalence of scheduling, access, dyspnea, or cianozante emetic. Fever ... ... .... Full expl anation, clear and chronological disorder; Home (time evolution prior to hospita l admission and consultation) b) circumstances in which development c) events se miology For each of the signs or symptoms can be based on the semiology pain: th e more features it has and change according to each one: SEVEN ATTRIBUTES a) loc ation (where your located, to where it radiates) b) quality (as is) c) the quant ity or intensity (how strong is it? (pain 1-10) d) including start times, durati on and frequency (when it begins (began) how long, how often is) e) situation pr esented (including environmental, personal, emotional reactions or other conditi ons make to disease), f) factors that aggravate or alleviate the symptoms (there is something better or worse than) g) accompanying manifestations (have you not iced anything else to accompany him) III. Treatments: used before admission to h ospital did not have him in the hospital. Medications should be recorded, noncom mercial generic name, dosage, administration route and frequency of use. Home re medies, nonprescription drugs, vitamin supplements, minerals, herbs, pills and m edicines given by family and friends. Register allergies, reactions to each spec ific rash or nausea, food allergy, insect or environmental factors. EXAMINATION FOR EQUIPMENT AND SYSTEMS. Questioning signs and symptoms present, they are not as important for the patient but yet can help give diagnoses or diagnostic compl ement added. Must be presented at that time and no history of having or having s ubmitted. Describe the semiology of each sign or symptom to present in each sect ion. a) • • • General symptoms. Weight loss, fatigue, weakness, anorexia and fever or hyperoxi a. Skin. Rashes, lumps, sores, itching, dryness, color change, changes in hair o r a head, eyes, ears, nose and throat. a) Head, headache, head injuries, dizzine

ss, vertigo. b) c) d) e) • • • • • • Eyes, vision, pain, redness, tears excessive, double vision, blurred vision, spo ts, dust, glare, haze. Ears, hearing, tinnitus, vertigo, pain, infection, discha rge. Decreased hearing. Nose and paranasal sinuses, nasal congestion, discharge, pruritus, epistaxis, pain in malar region or front). Throat (mouth and pharynx) conditions teeth, gums, bleeding gums, tongue ulceration, dry mouth,€sore throa t, hoarseness. Cuello. Mass, swollen glands, enlargement of anterior neck pain, stiffness Mamas . Mass, pain or discomfort, nipple discharge, etc.. Respiratory factors. Cough, sputum (color and quantity), hemoptysis, dyspnea, wheezing, chest pain cardiovas cular factors. Heart disease, chest pain or discomfort, palpitations, dyspnea, o rthopnea, edema. digestive factors. Swallowing disorders, heartburn, appetite, n ausea, bowel movements, color and size of stool, change in bowel habits, rectal bleeding or black stools (melena), tarry stools, hemorrhoids, constipation, diar rhea. Abdominal pain, food intolerance, belching, or excessive flatulence, jaund ice. Urinary factors. Frequency of urination, polyuria, nocturia, urgency, burni ng or pain during urination, hematuria, incontinence, in men decrease in the siz e or force of urine stream, hesitancy, dribbling. genitals. MALE. Hernias, disch arge or sores on the penis, pain, or testicular masses, FEMALE. Amount of bleedi ng, or intermenstrual bleeding after intercourse, dysmenorrhea. Discharge, itchi ng, ulcers, masses, sexual interest, sexual function and satisfaction. periphera l vascular factors. Claudication, cramps, varicose veins, pain in the pelvic lim bs. • • • • • • • skeletal muscle factors. Muscle or joint pain, stiffness, back pain. Describe th is location, swelling, redness, pain, tenderness, stiffness, weakness or limitat ion of movement. neurological factors. Loss of consciousness, lagoons, involunta ry movements, weakness, paralysis, numbness, loss of sensation, tingling, or pin prick sensation, tremors. haematological factors. Pallor, facial bruising or ble eding. Endocrine factors. Heat or cold intolerance, excessive sweating, thirst o r hunger disproportionate. Polyuria, weight gain. Psychiatric factors. Nervousne ss, tension, mood, including depression, memory changes. COMPLETE PHYSICAL EXAMINATION. 1. General inspection. a) general health-apparent chronological age c) complexion d) creation e) sexual development f) position g ) h motor activity) march i) clothing j) personal grooming and hygiene k) body o dor or breath. l) Facial expressions m) Behaviour n) Affection o) reactions to p eople and things in the environment p) Listen to his speech q) Level of consciou sness vital signs) TA b) Pulse c) Respiratory rate d) anthropometric body temper ature. (Anthropometry). 1. weight 2. Size 3. MUAC 4. skinfold 5. body mass index in June. square meter of body surface. skin. a) injury and record location, dis tribution, distribution, type and color b) feel for hair, nails, c) explore hand s d) according to rest continue exploring other head, eyes, nose, throat) head. Hair, scalp, skull and face b) eyes, check visual acuity and visual fields, posi tion and alignment of eyes, eyelids and inspect sclera and conjunctiva, oblique illumination both corneas, iris, lens, pupil and compare reactions to light, mov ement extraocular fundus. c) Hearing. Ear, ear canals and eardrums, hearing acui ty, air and bone conduction. b)

2. 3. 4. 5. d) Nose and sinuses. Outside. , Nasal mucosa, septum and turbinates. Palpate fronta l and maxillary sinus tenderness 6. 7. Pharynx. lips, buccal mucosa, gums, teeth, tongue, palate, tonsils and pharynx f ) cranial nerves. Cuello. a) cervical lymph nodes b) mass c) Unusual clicks d) t racheal deviation palpate and) noise and respiratory effort of the subject. f) P alpate thyroid gland. posterior chest and lungs (inspection, palpation, percussi on and auscultation) a) spine and upper back muscles b) percusses palpate chest c) diaphragmatic dullness level d) breath sounds and) noise added f) vocal noise s transmitted. anterior chest and lungs (inspection, palpation, percussion and a uscultation) g) observe, feel and percussion h) breath sounds i) noise added j) vocal noises transmitted breast, underarm, lymph epitrocleales. (Inspection and palpation) women with relaxed, one arm raised and one hand on the hip b) axillar y lymph search, axillary or epitrochlear. cardiovascular system. (Inspection, pa lpation, percussion and auscultation) a) jugular venous pulsations b) jugular ve nous pressure in relation to the sternal angle c) carotid pulse, carotid bruit s earch. Precordial area. Location, size, scope and duration of peak shock Hear ti p and lower sternal separation of the second heart sound physiological or other abnormal sound or murmur.€(Four outbreaks aortic, pulmonary, tricuspid and mitra l) abdomen. (Inspection, auscultation, palpation and percussion) a) values, and percussion auscultate abdomen b) palpate superficial, deep, c) recognize liver, spleen by percussion and palpation d) and kidney) and aorta palpable pulse f) on percussion posterior costovertebral angles . (Inspection, palpation) peripheral vascular system. Femoral pulses, popliteal lymph nodes, edema, color change or ulcers, godet. b) musculoskeletal system. Deformity or enlargement of joints, pa lpate joints, limiting movement. c) nervous system. Rate leg muscle mass, tone, strength, sensation and reflexes. Abnormal movements. 7. Exploration on foot. a) peripheral vascular system. Varicose veins b) musculoskeletal system. Spinal al ignment and range of motion and alignment legs and feet c) back, inspect and pal pate spine and back muscles) e) 8. a) 9. 10. 11. pelvic limbs, thorax, spine. 12. nervous system.

i. ii. mental status, mood, thought processes, thought content, abnormal perceptions, i nsight, and trial, memory, attention, information and vocabulary, calculation ab ility, abstract thinking and capacity building. Cranial nerves. Sense of smell, temporal and masseter muscles, facial movements, gag reflex, strength and sterno mastoid trapezius muscle. iii. 13. motor system. i. ii. 14. sensory system. Nervous system. March, ability to walk from heel to toes on toes and heels, jump and perform squats, Romberg test, pronator deviation. volume. Tone, muscle stre ngth. Cerebellar function. Rapid alternating movements, point to point (toe and heel to shin nariz_), March 15. i. pain, temperature, light touch, vibration and discrimination ii. compare righ t with left iii. areas proximal to distal limb reflexes. Biceps, triceps, braqui orradia, patellar, Achilles tendon reflex deep. Plantar reflex or Babinski Further exploration. a) b) c) I. male examination. Sacrococcigeas and perineal a reas palpate the anal canal, rectum and genitals before rectal prostate explore if you can not walk II. examining women. a) genital examination and rectal examination in women. ii. iii. iv. v. examining external genitalia, vagina, cervix Pap smear palpate uterus and annexe s straight vaginal and rectal examination. PHYSICAL EXAMINATION. SUMMARY OF SEQUENCE POINT 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1 1. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 1. 2. 3. 4. 5. 6. general skin ex amination vital signs, upper torso and back head and neck. Includes optional thy roid and lymph nodes. nervous system, state of mind, cranial nerves, upper extre mity motor strength, mass and muscle tone, cerebellar function. Musculoskeletal chest and lungs as indicated Breast: upper limb cardiovascular pressure, jugular vein, carotid pulse and breath, shock-art cardiovascular, search for S3 and car diovascular mitral stenosis murmur of aortic insufficiency murmur search option. Chest and lungs, breasts and armpits before peripheral vascular abdomen: option al bottom skin of the torso and limbs of the nervous system: lower extremity mot or strength, mass and tone, sensitivity, musculoskeletal Babinski reflex, as ind icated optional. Optional front and rear skin. Nervous system, including optiona l motion. Musculoskeletal, complete. female pelvic exam and rectal exam male pro state and rectal sitting supine with head elevated 30 degrees as well, with money left hemiparesi s sat leaning forward or sitting supine standing 7. 8. supine with hips flexed in abduction and external rotation and knee flexion (lit hotomy) left lateral decubitus.