HPI

 Location (radiate)

 Intensity (scale, how affects life)

 Quality (pain type)

 Onset + precipitating factors (frequency, length)

 fever, chills, nausea, vomiting, headache, weight changes, SOB, dizziness, travel, cough

 Alleviating factors

 Aggravating factors

Past Medical Hx

 Recent/chronic illness (DM, HTN, CAD, Chol, Asthma, Arthritis, Gout)

 Hospitalizations/surgeries

 Medications

 OB/Gyn (LMP, GPA)

Family Hx

 Family member with similar problem

 Any health problems in the family?

Social Hx

 Occupation

 Who do you live with?

 Spiritual/religious

 What do you do for fun?

 Smoking/alcohol/drugs

 Sexually active
HEENT
 Inspect: normocephalic/atraumatic | conjunctiva redness/exudates EOMI | Pupils PERRLA | Visual Fields
o Nose: clear | congested | inflamed turbinates
o Mouth/throat: moist membranes | lesions | tonsils++ | dentition
 Fundoscopic exam:
 Palpate: External ear pain | mastoid pain | TMJ
 Otoscopic exam of ear canal/tympanic membrane:
 Weber: quiet side= conductive loss
 Rinne: confirm conductive loss w/ bone conduction better than air

Cardiovascular
 Inspect: Scars | JVD | Cyanosis
 Palpate: PMI non-displaced | retrosternal heave | thrills
 Auscultation x4 areas: Aortic | Pulmonic | Tricuspid | Mitral
 Carotid/thyroid bruits:
 Pedal edema, peripheral pulses:

Respiratory
 Inspect: normal rate/rhythm | scars | accessory muscle use
 Palpate: equal expansion | delayed expansion | asymmetry
o Tactile Fremitus: “toy boat” increased (consolid/fluid) | decreased (COPD)
 Percuss: resonant | dull | tympanic
 Auscultate: clear | wheezes | ronchi | egophany | diminished

Abdomen
 Inspect: scars | asymmetry | distention
 Auscultate: bowel sounds + | bruits
 Percuss: bowel gas | splenomegaly | hepatomegaly
 Palpate: NTND | Pain | Tenderness | Masses | Abd Aorta
 Psoas: flex hip against knee pressure= retroperitoneal
 Obturator: bent knee/hip, knee medial/ankle lateral= appendix or pelvic
 Murphy’s: pain R costal margin w/inspiration= gallbladder/liver
 CVA tenderness: none | left | right

Neurologic
 Oriented: x4 | Person | Place | Time | Event
 CN: Grossly Intact | II= vision | III, IV, VI= EOM | V= facial sensation VII= Smile, raise brows, close eyes against fingers
| IX, X= symmetrical palate raise | XI= shrug shoulders | XII= Stick out tongue
 Motor: Strength 5/5 in all groups
 DTR: Intact and symmetric
 Babinski sign:
 Sensation:
 Cerebellum: Romberg + Finger to nose fail
 Gait
 Neck Stiffness: none | present
 Tremor: none | Resting | Action

Mental Status
 Oriented: x4 | Person | Place | Time | Event
 Immediate Memory (3 objects): One | Two | Three objects
 Recent Memory: Lunch Yesterday
 Distant Memory: Name high school
 Short Term Memory: One | Two | Three objects
 Concentration: serial 7s
Joint:
 Inspect: Swelling Redness Asymmetry Contusions
 Palpate: Tenderness Crepitus Warmth Swelling Effusion
 ROM:
 Reflexes (4), Strength (5), Pulses (4)