Patient History and Physical

Identifying data

• DOS

• Legal/preferred name

• DOB

• Sex at birth/gender

• language used to gather basic demographic information about a patient

Chief Complaint

Pt stated problems with

HPI (OPQRST)

Onset

Progression, palliates/provokes

Quality/character, location

Radiation

Severity, 0-10

Time, duration/frequency

Other; effect on life, associated sx’s, exposures, treatments

What to document for PMH

1. Allergies/sensitivities

2. Medications

3. Medical Hx

4. Surgical Hx

5. Hospitalizations

6. Childhood disease

7. Immunizations

8. Injuries

9. Pregnancy

10. Screenings

Allergy/Sensitivity Documentation

• meds

• food

• environmental

Reaction and severity for each

Medication Documentation

• Prescription

• Over the counter

• Complementary and Alternative Medicine

Include name, strength, frequency, route

Common Medical Hx to Note

• CAD/MI, Htn, CVA, vascular, VTE, HLD, dysrhythmias.

• asthma/COPD, OSA

• GI/GERD/PUD, liver/bowel dz, renal dz

• RA/OA/gout

• DM/thyroid

• psych/self/harm/suicide

  • cancers, seizures, anemia, infections/TB/STI, skin dz.

Surgical Hx

Include diagnosis, procedure, and date

Hospitalization Hx

medical/surgical hx

Childhood disease hx

• measles

• rubella

• mumps

• chickenpox

• pertussis

• rheumatic fever

• polio

Immunization documentation

• Childhood

• Flu

• Hep A&B

• Pneumonia

• TDAP

• Shingles

• Covid

• HPV

Injury Documentation

• Type

• Treatment

• Disability

Pregnancy Documentation

• Gravid

• Parity

• Abortion (spontaneous/surgical)

• Ectopic

• Complications

• Lactation

Screening Documentation

• Cancer

• Infections

• Disease

• Safety

• Dental/Eye

Family Hx Documentation

For parent/sibling/child:

• Heart disease, vascular/heme, htn, hld, stroke

• asthma/COPD, cystic fibrosis, DM

• thyroid, renal, RA, gout

• cancer (type)

• allergies

• seizures

• migraine, psych illness, dementia

• blood disease/anemia/sickle cell

• visual/hearing, glaucoma

• infections

• other

Social History Includes (PHMSS)

• Personal

• Habits

• Military

• Spiritual

• Sexual

Personal Social History

• occupation

• education

• hobbies

• family/household

• pets

• support

• stress

• violence/trauma

• race/ethnicity

• social determinants of health

• culture/ancestry

• travel

• legal

• advanced directives

Social History: Habits

• exercise

• diet

• caffeine

• ETOH

• nicotine

• vape

• substance use and route

Social History: Military

• branch

• date

• job

• location

Social History: Spiritual (FICA)

• Faith

• Importance

• Community

• Action

Social History: Sexual

• partner

• practices/sites

• protection

• past STI

• prevent pregnancy

• PrEP

Review of Systems includes:

• General

• Skin

• Eyes

• Ears

• Nose

• Throat/Mouth/Neck

• Pulmonary

• Cardiovascular

• Chest/Breast

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Neuro

• Psychiatric

• Endocrine

• Hematologic

RoS: General

• wt change

• energy

• fever/chills

• appetite

• sleep

• malaise

• fatigue

RoS: Skin

• rash

• lumps

• pigment

• redness/red streaks

• sores

• nails

• hair

• hyperhidrosis

RoS: Eyes

• vision changes/diplopia

• discharge

• pain

• correction type

• photophobia

RoS: Ears

• pain

• discharge

• hearing

• tinnitus

• vertigo

RoS: Nose

• pain

• obstruction

• discharge

• smell

• sinus pain

• epistaxis

RoS: Throat, Mouth, Neck

• dentition

• taste

• gums/bleeding

• swallowing

• throat soreness

• ulceration

• lump

• voice quality

• tongue

Ros: Pulmonary

• cough

• mucous

• hemoptysis

• wheeze

• DOE

• pain with respiration

• dyspnea

RoS: Cardiovascular

• chest pain

• SOB

• palpitations

• murmur

• edema

• orthopnea

• nocturia

• PND

• claudication

• varicosities

• DVT

• phlebitis

• ulcerations

• HTN

• exercise tolerance

RoS: Chest/Breast

• pain

• discharge

• mass

• color change

• nodes

RoS: Gastrointestinal

• ABD pain

• radiation

• N/V/D/C

• hematemesis

• bowel changes

• melena/hematochezia

• heartburn

• appetite

• dysphagia

• food intolerance

RoS: Genitourinary

General:

• dysuria

• urgency

• stream

• frequency

• hematuria

• CVA pain

• dribbling

• hesitancy

• nocturia

• incontinence

• sex health

Penis/Teste/Prostate

• discharge

• lesion

• pain

• swelling

• mass

• erectile function

• circumcision

Vagina/cs/uterus

• discharge

• odor

• lesions

• dyspareunia

• LMP/cycle

RoS: Musculoskeletal

• pain

• ROM

• stiffness

• swelling

• redness

• warmth

• neck/back

RoS: Neurological

• HA

• dizzy

• LOC

• head injury

• seizures

• tremor

• weakness

• paralysis

• sensation

• coordination

• balance

• syncope

• vision change

• memory/mentation

RoS: Psychiatric

• depression

• anxiety

• stress

• hallucinations

• personality change

• mania

• concentration

• suicidal/homicidal

• self-harm

• thought/intent

• mood

• sleep

RoS: Endocrine

• temperature intolerance

• sweating

• hirsutism

• polydipsia

• polyphagia

• polyuria

RoS: Hematologic

• anemia

• bruising

• bleeding

Components of a Physical Exam: Vital Signs

• temp

• BP

• HR

• RR

• O2 Sat

• Ht

• Wt

• BMI

• Visual acuity

Components of a Physical Exam: General

• posture

• appearance

• distress

Components of a Physical Exam: Skin

• color

• temperature

• moisture

• nails

• rash

• redness/red streaks

• mass

• lesion

• scar

Components of a Physical Exam: Head

• symmetry

• tenderness

• lesion

• mass

Components of a Physical Exam: Eyes

• visual acuity

• pupils

• lids

• conjunctiva

• sclera

• cornea

• lens

• fundus

Components of a Physical Exam: Ears

• hearing

• auricle

• EAC’s

• TM’s

Components of a Physical Exam: Nose

• external

• internal

• mucosa

• septum

• sinuses

Components of a Physical Exam: Throat/Mouth

• lips

• mucosa

• tongue

• gums

• teeth

• pharynx

• palate

• tonsils

• voice

Components of a Physical Exam: Neck

• ROM

• Strength

• thyroid

• nodes

• trachea

• swallow

Components of a Physical Exam: Chest/Lung

• symmetry

• distress

• sounds

• percussion

• excursion

• tenderness

Components of a Physical Exam: Cardiovascular

• PMI

• sounds

• murmur

• JVD

• HJR

• edema

• peripheral/central pulses

• bruits

• capillary refill

• skin/hair changes legs

• varicosities

Components of a Physical Exam: Chest/Breasts

• nipple change/discharge

• mass

• nodes

• color changes

• tenderness

• symmetry

Components of a Physical Exam: Abdomen

• appearance

• sounds

• tenderness

• organomegaly

• masses

• CVA tenderness

Components of a Physical Exam: Rectal

• tenderness

• hemorrhoid

• mass

• prostate

• sphincter tone

• lesion

Components of a Physical Exam: Genitourinary

Penis:

• foreskin

• meatus

• lesion

• discharge

Scrotum:

• testes

• epididymis

• vas deferens

• tenderness/swelling

• hernia

• mass

Vulva:

• swelling

• lesions

• tender

Vagina/Cervix:

• introitus

• discharge

• odor

• lesions

• os mobility/color

Uterus/adnexa:

• size

• symmetry

• tenderness

• mass

• position

Components of a Physical Exam: MSK/Spine

• ROM

• Tenderness

• muscle tone/atrophy

• deformity

• swelling

• redness

• warmth

• neck/back

• CNS

Components of a Physical Exam: Neurologic

• Alert & oriented x4 (spell world backwards, count back rom 100 by 3’s)

• Test cranial nerves

• Sensory

• Motor

• Reflexes

• Balance and Cerebellar

Components of a Physical Exam: Psych

• appearance (neglect, facial expressions, affect)

• attention

• memory

• reasoning

• behavior

• speech

• cognition

• insight

• mood

• eye contact

• perception

• thought (form/content)

• agitation

CN1

Olfactory

Test: Smell

CN2

Optic

Test: Vision

CN3

Oculomotor

Test: Pupil/EOM

CN4

Trochlear

Test: EOM

CN5

Trigeminal

Test: sensation, strength

CN6

Abducens

Test: EOM

CN7

Facial

Test: Facial movementCN

CN8

Acoustic

Test: Hearing

CN9

Glossopharyngeal

Test: Say Ah, Swallow

CN10

Vagus

Test: Say Ah, swallow

CN11

Spinal Accessory

Test: Shoulder shrug

CN12

Hypoglossal

Test: Tongue out

How to test sensory function:

• sharp/dull

• hot/cold

• vibration

• proprioception

How to test motor function:

• strength

• tone

• atrophy

• involuntary movement

• tremor

How to test reflexes:

• DTR’s

• Babinski

• clonus

How to test balance and cerebellar:

• gait

• heel to toe

• finger to nose

• rapid hand

• heel on shin

• Romberg