Medical Records

Parts of history and physical

• Chief Complaint (CC)

• History of Present Illness (HPI)

• Patient History

• Past Medical History, Past Surgical History, Social history, Family history, etc.

• Review of Systems (ROS)

• Vital Signs

• Physical Examination

• Inspection, palpation, percussion, auscultation (IPPA)

• Laboratory and imaging data

• Diagnosis

• Disposition

• Treatment and plan

Chief Complaint

This is why the patient is seeking medical attention
▪ SUBJECTIVE (Notated in the patient's own words)
▪ Should be written in quotations as a direct quote from the patient
▪ Does not get translated intomedical terminology
For example:
▪ “I have had a bad sore throat for about a week.”

History of present illness - definition and example

• Patient interview with open ended questions

• Chronological narrative of SUBJECTIVE complaint(s)

• Utilizes an “OPQRST” or “OLD CARTS”

• Starts with “This is a *** year old *** who presents with ***”

• Example:

  • CC= “I have had a bad sore throat for about a week.”

  • HPI= This is a 47 year old female who presents with a chief complaint of sore throat. Her symptoms started 1 week prior to presentation. Her sore throat is aching and now constant, worsening over the week. The pain is a 6/10 in severity and it is impacting both sides of her throat however not radiating further. Her pain is worsened when she coughs and minimally relieved by hot beverages and NSAIDs.

    
    

History of present illness - OPRQRST

Onset

provocation/palliation

quality

region&radiation

severity

time

History of Present Illness- Old Carts

Onset

Location

Duration

Character

Aggravating/ Alleviating

Radiation

Time

Severity

HPI Severity

Patient History Categories

Facts of the patient’s history from the following categories:
▪ Medical history: diseases/ diagnoses with date diagnosed
▪ Surgical history: procedure, location, date
▪ Medications: prescription (dose, route, frequency) and over the counter/herbal supplements
▪ Allergies: food, medication, environmental with reported reaction
▪ Vaccinations: childhood, boosters, yearly, etc.
▪ Social history: alcohol, smoking, illicit substances, occupation, living situation
▪ Family history: cancer, heart disease, inheritable conditions, etc.

Review of systems

• Subjective review of each body system

• highlight pertinent pos or neg responses surrounding current chief complaint or HPI

• ros interview cheat sheet in bright space

• Examples

  • general

  • neuro

  • had/ears/eyes/nose/throat

  • respiratory

  • cardio vascular

  • gastrointestinal

  • genito

  • muskuloskeletal

ROS Pertinent questions

Example of pertinent questions:
▪ General: any fevers/ chills? Unexpected weight changes?
▪ Neuro: Any numbness or tingling?
▪ Head/ Ears/ Eyes/ Nose/ Throat: any headache/ runny nose/ watery eyes/ swelling of throat/ difficulty swallowing?
▪ Respiratory: difficulty breathing? Cough?
▪ Cardiovascular: chest pain? Palpitations?
▪ Gastrointestinal:
▪ Genitourinary:
▪ Musculoskeletal: any muscle weakness?

Vital Signs

OBJECTIVE measurements
▪ Important to know your normal vital signs
▪ Just as important to know what abnormal vital signs signify
▪ Vital signs include:
▪ Temperature
▪ Heart rate
▪ Blood pressure
▪ Respiratory Rate
▪ Oxygenation

Vital - Temperature, associated terms

• reported in celsius or Fahrenheit

• measured with thermometer at specific sites such as

  • oral- under tongue

  • axillary

  • tympanic/ear canal

  • rectul

• normal

  • 37 degree c

  • 98.6 degree F

• hypothermia - low temp

• normothormia - normal temp

• hyperthermia - Hugh temp

• thermoreg - maintenance of body temp

vital - heart rate

• Heart Rate:

• Reported in beats per minute

• Measurements:

  • Pulse oximeter on distal finger tips

  • Electrocardiogram (ECG/EKG)

    • ECG/EKG can also assess rhythm

  • Felt & counted by hand x 1 minute at pulse sites if irregular rhythm

  • Auscultated & counted x 1 minute with stethoscope (apical pulse)

  • Normal adult heart rate: 60 - 100 beats per minute

  • Associated Medical Terminology:

    • Tachycardia: condition of fast heart rate,>100 BPM

    • Bradycardia; condition of slow heart rate, <60 BPM

    • Arrhythmia/ Dysrhythmia condition of abnormal heartrhythm
      

pulse sites and measurements

• temporal

• femoral

• popliteal

• posterior tibial

• carotid

• brachial

• radial

• dorsalis pedis

• apical

measure by hand, document rate as well as strength

0= absent

1+= thready/weak

2+=normal

3+=bounding

heart rate related measurements

• ekg

• pulse oximeter

• when documenting, regular or irregular

vital - blood pressure and associated terms

• reported as systolic and diastolic in millimeters of mercury (mmHg)

• measured with sphygmomanometer (BP cuff) most commonly at brachial site

• can be taken manually with bp cuff or electronically

• normal

  • sup = 100-140

  • dip = 60-90

  • map >65

Associated terms

• hypotension = low blood pressure

• hypertension = high bp

• normotensive

blood pressure related measurements

bp = force exerted on atrial walls by blood

sbp = force exerted on atrial walls by blood during systole/ contraction

dbp= force exerted on atrial walls by blood during diastole (relaxation phase of heart beat)

MAP = mean arterial pressure

2(dbp+sbp)/3

vital - respiratory rate, associated terms

Respiratory Rate: 

▪ Reported in breaths per  minute  

Measurement:  

▪ observe chest rise & fall x  1 minute  

▪ auscultation with  stethoscope and count rate x 1 minute  

▪ Can also assess rhythm  (regular/ irregular) and   quality (shallow/ deep)  

▪ Normal adult respiratory  rate:  

▪ 12-20 breaths per minute 

associated terms

• pnea & spir/o = Breathing

• Tachypneic/ tachypnea = condition of rapid breathing (>20 breaths per minute)

• Bradypneic/ bradypnea = condition of slow breathing (<12 breaths per minute)

• Hypoventilation/ hyperventilation = pertaining to amount of ventilation of lungs, too little or too much

• Apnea= Cessation of breathing

vital - oxygenation saturation+ terms

Fraction of oxygen-saturated hemoglobin relative to total hemoglobin
▪ Reported as a percentage (%) out of 100%
▪ Important to outline if they are on oxygen while obtaining measurement
▪ Measured with a pulse oximeter on distal finger tips
▪ Normal adult oxygenation level: >94%, Can tolerate 89-92% in patient’s with chronic lung diseases like COPD

Terms

Ox/o & -oxia = Oxygen
▪ Hypoxia= Low/ deficient oxygen in the tissues
▪ Hypoxemia = Low oxygen in the blood
▪ Anoxia= Without oxygen

physical exam types

inspection

▪ First step in examine a patient or body part
▪ Your observation of the patient
▪ Continuous throughout your entire interview &exam
▪ Preliminary observations:

• General appearance

• Mental status

• Posture

• Skin color/ deformities

• Body language

• Gait

palpation

▪ Utilizing your sense of touch to examine characteristics of body parts
▪ Uses the pads of your fingers
▪ Can be light or deep palpation
▪ Useful to determine characteristics such as...
▪Location of organs/ structures/ masses

• Size

• Texture

• Temperature

• Tenderness

percussion

▪ Utilizing your fingers to tap a portion of the body
▪ Assess underlying tissue/ structure for the presence of fluid or air
▪ Sound differences helps you compare what medium the sound is traveling through
▪ For example, air filled organs will elicit a higher pitched percussion note than fluid filled organs

auscultation

Listening to sounds of specific body areas
▪ Examples of axreas to auscultate: Heart, Blood vessels, Lungs/ airway, Abdomen/ bowels
▪ Done by using a stethoscope (may not be necessary depending on the sound)
▪ Can help determine normal vs abnormal sounds via comparison with other areas of the organ

Nervous - ROS

ROS
▪ Changes in memory?
▪ Mood changes?
▪ Dizziness?
▪ Loss of balance?
▪ Falls?
▪ Tingling?
▪ Numbness?
▪ can ask family/ care taker if appropriate

Nervous - Physical exam

Physical Exam
▪ Level of consciousness:
▪ Alert, lethargic, unconscious
▪ Orientation:
▪ Alert and oriented x3: to person, place, & time
▪ Remote memory/ recent memory
▪ Thought content
▪ Mood
▪ Balance/ coordination
▪ Gait

cardio ros

ROS
▪ Chest pain? If yes -> OPQRST
▪ Palpitations?
▪ Leg swelling
▪ Unhealing sores/ lesions on legs?
▪ Hair loss on legs?
▪ Noticeable veins on legs?

cardio physical exam

Physical Exam
▪ Inspect for limb swelling (edema), color, venous patterns
▪ Palpation of pulses bilaterally
▪ Ex. Carotid, radial, dorsalis pedis
▪ Auscultation of heart sounds

auscultation for heart sounds

Listen for...
▪ S1 & S2
▪ Abnormal rate?
▪ Abnormal rhythm?
▪ Murmurs?
▪ Extra beats?
▪ Distant?

pulmonary ros

Pulmonary System
ROS
▪ Shortness of breath?
▪ At rest vs on exertion
▪ Pain with inspiration?
▪ Cough?
▪ Dry vs wet (productive)
▪ Wheezing?

pulmonary physical exam

Physical Exam
▪ Inspect work of breathing
▪ Posture, flaring nostrils
▪ Able to complete a full sentence?
▪ Cough?
▪ Palpation of air pockets trapped under skin
▪ Auscultate lung sounds

auscultation of lung sounds

Compare bilaterally
▪ Anatomy: R lung has 3 lobes, L lung has 2 lobes
▪ Listen for...
▪ Any decreased breath sounds?
▪ Increased breath sounds?
▪ Unequal breath sounds?
▪ Absent breath sounds?

gastrointestinal ros

▪ Abdominal pain?
▪ Heartburn?
▪ Nausea/ vomiting?
▪ Constipation/ diarrhea?
▪ Changes in stool color?

gastro physical exam

▪ Inspect abdomen size, contour, scars
▪ Auscultate bowel sounds
▪ Percuss to measure size of liver/ spleen
▪ Palpate for masses/ fluid/ tenderness

auscultation for abdominal sounds

Auscultation of abdominal sounds:
▪ Compare 4 quadrants
▪ Listen for...
▪ Any decreased sounds?
▪ Increased sounds?
▪ Unequal sounds?
▪ Absent sounds?

gastrointestinal palpation

Palpation:
▪ Light vs deep
▪ Guarding?
▪ Rebound tenderness?

genitourinary ros

▪ Changes in urine color?
▪ Changes in urine frequency?
▪ Changes in urine amount?
▪ Increased urgency?
▪ Do you get up to pee in the middle of the night?
▪ Pelvic pain? Flank pain? Lower back pain?
▪ Reproductive system assessment if appropriate

Genito urinary physical exam

Physical Exam
▪ Inspect for pelvic distension
▪ Inspect for abnormal changes to genito-urethral area
▪ Palpate flanks and lower back
▪ Percuss on back bilaterally

muskulo skeletal ros

▪ Muscle cramps?
▪ Muscle weakness?
▪ Joint pain/ stiffness?
▪ Limited mobility?
▪ Trouble walking?
▪ Injuries?

musculoskeletal physical exam

Physical Exam
▪ Inspect for swelling, deformities, symmetry, atrophy
▪ Palpate for deformities, temperature, tenderness
▪ Assess range of motion
▪ Active vs passive

integumentary ros

▪ Dry skin?
▪ Itchy skin?
▪ Rashes/ lesions/ sores/ bumps?
▪ Bruises?
▪ Provoked?
▪ Changes in mole size / characteristics?
▪ Changes in hair/ nails?

integumentary physical exam

Inspect skin throughout body for lesions, bruises, abnormalities
▪ Inspect mucous membranes
▪ Inspect nails
▪ Palpate for moisture, temperature, texture, turgor (ability for skin to return to place freely)

special senses ros

Eyes:
▪ Blurry vision/ changes in vision?
▪ Pain ?
▪ Watering/ redness/ itching ?
Ears:
▪ Ringing in your ears? (tinnitus)
▪ Changes in your hearing?
▪ Pain in your ears?

special senses physical exam

Inspect eyes
▪ Eyelids
▪ enophthalmos/ exophthalmos
▪ color of conjunctiva/ sclera
▪ pupils (equality, size, shape, reaction to light)
▪ Visual acuity
▪ Extraocular movements

Inspect ears
▪ Outer ears, middle & inner ear (via otoscope)
▪ Auditory acuity

Palpate external ears, mastoid process, tragus
▪ for tenderness, masses, bruising, swelling

enophthalmos, exophthalmos

eno = recessed or sunken

exo = protrudes

laboratory/ imaging data

Depending on the disease process that you want to work up, you may decide to

obtain labs, for example:
▪ Blood work
▪ Urine studies

Or obtain diagnostic images of certain parts of the body, for example:
▪ X-Ray
▪ Ultrasound
▪ CT scan
▪ MRI
▪ Nuclear medicine scans

laboratory blood tests

Complete Blood Count
▪ CBC
▪ Shows the makeup of your
blood components
▪ Counts the number of

• Red blood cells (erythrocytes)

• White blood cells (leukocytes)

• Platelets (thrombocyte)

Basic/ Complete Metabolic Panel
▪ BMP/ CMP
▪ Indication of your kidney &
liver function
▪ Includes:

• Electrolytes (sodium, potassium, calcium, etc.)

• Kidney enzymes & function

• Liver enzymes & function

laboratory urine tests and urine culture

Urine Analysis: measures...
▪ pH
▪ Specific gravity (ability of the kidneys to concentrate urine)
▪ Biliribuin (liver)
▪ Glucose
▪ Ketones (sugar breakdown)
▪ Protein
▪ Blood
▪ Bacteria
▪ Nitrite (byproduct of bacterial infection)
▪ Leukocytes
▪ Etc.

Urine culture

• If bacteria are present in the urine, then the culture will specify the type of bacteria as well as outline which antibiotics it is sensitive to for most effective treatment.

diagnostic imaging and related terms

Diagnostic Imaging:
▪X-Ray
▪Ultrasound
▪CT scan
▪MRI
▪Nuclear medicine scans
▪Etc.

Associated Medical Terminology:
▪ -gram = Record
▪ -graphy = Process of recording
▪ -Lucent = To shine
▪ -opaque = Obscure
▪ Scan: image of an area, organ, or tissue of body obtained by an imaging study

xray and related terms

X-Ray:
▪ 2-D view of bones & cartilage
▪ Does NOT show ligaments, tendons, etc.
▪ Views are obtained in certain positions described utilizing directional terms
▪ Common x-ray studies: Limbs, chest, abdominal

Associated Medical Terminology:
▪ Radi/o
▪ X-rays
▪ Radiolucent vs Radiopaque

Directional terms:
▪ anteroposterior (AP)
▪ posteroanterior (PA)
▪ lateral
▪ Oblique
▪ Position of body part, for example:
▪. Flexion, extension; abduction, adduction, etc.
▪ Position of body, for example:
▪ Prone, supine, recumbent, etc.

ultrasound/sonography, associated terms

Ultrasound/ Sonography:
▪ Image produced by sound waves/ vibrations as they echo off body parts

Common ultrasounds:
▪ Echocardiogram
▪ Pelvic ultrasound
▪ Transvaginal ultrasound

Associated Medical Terminology:
▪ Son/o = Sound
▪ Echo-= A repeated sound
▪ Ultra-= Beyond

ct scan

CT Scan:
▪ Computed Tomography Scan
▪An X-ray scan that works with a computer to give cross sectional images of a specific area
▪ ie a 3D X-ray that shows depth

Common CT scan sites:

• Head/ brain,

• neck/ cervical spine,

• spinal canal sections,

• chest,

• abdomen/ pelvis (A/P),

• limbs

Can include the use of contrast material in order to better visualize certain structures like vessels
▪ Injection of radiopaque material to show contrast w/ surrounding tissue
▪ Contrast & study examples:
▪ Barium: GI studies
▪ Iodine: angiography

mri, associated term

MRI:
▪ Magnetic Resonance Imaging
▪ Utilizes magnetic field and radio waves to produce views along planes of the body
▪ Detailed image of the soft tissues

Associated Medical Terminology:
▪ Body planes
▪ Sagittal
▪ Coronal
▪ Transverse

nuclear medicine scans

Nuclear Medicine Scans:
▪ Use of radioactive substances in the diagnosis of disease

PET & PET/CT Scan:
▪ Positron Emission Tomography (PET)
▪ Uses small amounts of radioactive isotopes, a special camera, and a computer to evaluate organ/ tissue function
▪ Pictures outline cell metabolic functions ie cells that are metabolizing quicker will be highlighted (like a tumor)

Other NM Studies Examples:
▪ Bone scan
▪ Single-photon emission CT (SPECT)
▪ Thyroid scan
▪ Thallium (TI) scan

diagnosis

Diagnosis:
▪ The identification of an illness/ disease/ problem
▪ Utilizes information from your patient’s history, subjective, and objective data to come to a conclusion
▪ Helps to guide your treatment plan and disposition
▪ Differential Diagnosis: list of possible causes/diseases/ illnesses

plan

Your plan of care for your patient
▪ Will the patient require further imaging? Further lab tests?
▪ If yes, what kind?
▪ Will the patient require treatment/ medication?

disposition

Where will this patient need to go for further medical care?
▪ For example,
▪ Follow up with primary care doctor
▪ Admit to hospital
▪ Admit to intensive care unit
▪ Etc