~ History ~

IDENTIFYING DATA:  Name, address, age, place of birth, marital status, race, occupation, and religion

REFERRAL SOURCE, if any

SOURCE OF HISTORY

CHIEF COMPLAINT(S)

PRESENT ILLNESS:  A chronalogic account of the symptoms and their attributes.  The meaning of the illness to the patient and his or her responses to it.

PAST HISTORY AND PAST SURGICAL HISTORY

.....General health, as the patient perceives it

.....Childhood illnesses

.....Adult illnesses

.....Psychiatric illnesses

.....Injuries

.....Operations

.....Hospitalizations

CURRENT HEALTH STATUS

.....Medications

.....Allergies

.....Tobacco use

.....Alcohol, drug use

.....Screening tests

...........TB, Paps, Mammogram, cholesterol, stools

.....Immunizations

.....Sleep patterns

.....Exercise patterns

.....Environmental hazards

FAMILY HISTORY:  Age and medical condition of at least parents, siblings, spouse and child, and the age at death, with its cause, of any who have died.  Familial and hereditary diseases, presence of disease similar to patient's in any family member.

PSYCHOSOCIAL HISTORY: Home situation, significant others, and daily life.  Important past experiences such as school, work, marriage(s).  Outlook on present and future.  Relevant religious beliefs.

General (or Constitutional):  Usual weight, recent weight change, fatigue, fever, chills, night sweats

Skin:  Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails

Head: Headaches, head injury

Eyes:  Vision, glasses or contact lenses, last eye exam, pain, redness, excessive tearing, double vision, spots, specks, flashing lights, glaucoma, cataracts

Ears:  Hearing, tinnitus, vertigo, earaches, infection, discharge

Nose and sinuses:  Frequent colds; nasal stuffiness, discharge, itching; hay fever, nosebleeds, sinus trouble

Mouth and throat:  Condition of teeth and gums, bleeding gums, last dental exam, sore tongue, frequent sore throats, hoarseness

Neck:  Lumps in the neck, "swollen glands," goiter, pain or stiffness in the neck

Breasts:  Lumps, pain or discomfort, nipple discharge, self-examination

Respiratory: Cough, sputum (color, quantity), hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy; last chest x-ray

Cardiac:  Heart trouble, high blood pressure, rheumatic fever, heart murmurs; chest pain or discomfort, palpitations; dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema; past ECG or other heart tests

Gastrointestinal:  Trouble swallowing, heartburn, appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion. Frequency of bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black tarry stools, hemorrhoids, constipation, diarrhea.  Abdominal pain, food intolerance, excessive belching or passing of gas.  Jaundice, liver or gallbladder trouble, hepatitis

Urinary:  Frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of the urinary stream, hesitancy, incontinence; urinary infections, stones

Genital, Male:  Hernias, penile discharge or sores, testicular pain or masses, any sexually transmitted diseases and their treatments, exposure to AIDS, precautions taken against it and other STDs.  Sexual interest, orientation, function, satisfaction, and problems; contraceptive methods.

Genital, Female:  Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding between periods or after intercourse, last menstrual period; dysmenorrhea; premenstrual tension; age at menopause, menopausal symptoms, postmenopausal bleeding.  Discharge, itching, sores, lumps, any sexually transmitted diseases and their treatments, exposure to AIDS, precautions taken against it and other STDs.  Number of pregnancies, number of deliveries, number of abortions (spontaneous and induced); complications of pregnancy; contraceptive methods.  Sexual interest, orientation, function, satisfaction; any problems, including dyspareunia

Peripheral vascular:  Intermittent claudication, leg cramps, varicose veins, clots in the veins

Musculoskeletal:  Muscle or joint pains, stiffness, arthritis, gout, backache.  If present, describe the location and associated symptoms (swelling, redness, pain, tenderness, stiffness, weakness, limitation of motion or activity)

Neurologic:  Fainting, blackouts, seizures, weakness, paralysis, numbness, tingling, tremors or other involuntary movement

Hematologic:  Anemia, easy bruising or bleeding, past transfusions and possible reactions

Endocrine:  Thyroid trouble, heat or cold intolerance, excessive sweating; diabetes, excessive thirst or hunger, polyuria

Psychiatric:  Nervousness, tension, mood including depression; any suicidal ideation; memory

~Physical examination~

General survey, described in a succinct paragraph

Vital signs:  Pulse rate, respiratory rate, blood pressure, and possibly temperature

Height and weight

Skin:  Color,texture, lesions; hair and nails

HEENT:  (as one paragraph with or without the following subheadings, or as individual major headings per your client's requirements)

.....Head:  Hair, scalp, skull, face

.....Eyes:  Vision, visual fields; conjunctiva, sclera; cornea, iris, lens; pupils (size,shape, reactions to light), extraocular movements; ophthalmoscopic exam

.....Ears:  Auricles, canals, drums, auditory acuity, and, if indicated, Weber and Rinne tests

.....Nose:  Mucosa, septum, sinus tenderness

.....Mouth:  Lips, oral mucosa, gums, teeth, tongue, pharynx

Neck: Thyroid gland, trachea

Lymph nodes:  Cervical, axillary, epitrochlear, inguinal

Thorax/lungs:  Breathing (pattern, effort, sound), shape of chest, fremitus, percussion note, breath sounds, adventitious (added) sounds

Cardiovascular:  Carotid pulses, jugular venous pressure, apical pulse, heart sounds, extra sounds, heart murmurs

Breasts:  Size, symmetry, tenderness, masses

Abdomen:   Shape, scars.  Bowel sounds.  Percussion note and pattern. Tenderness, including costovertebral angle tenderness; masses.  Liver, spleen, kidneys, aorta

Genitalia, male:  Penis, scrotum and contents, including testes; hernias.

Genitalia, female:  Vulva, vagina, cervix, uterus (size, shape, position), adnexa.  Rectovaginal examination included.

Rectum:  Anus,rectum and (in men) prostate.  Stool for occult blood

Peripheral vascular:  Skin color, peripheral pulses, edema, varicose veins

Musculoskeletal:  Deformities, swollen or tender joints.  Back (curvature or tenderness).  Ease and range of motion, signs of inflammation in or around joints, condition of surrounding tissue, deformities including abnormal curvature of spine.  Includes straight leg raise, Phalen and Tinel tests for carpal tunnel

.....Motor system:  body position, involuntary movements.  Muscle bulk, muscle tone,strength: elbow extension and flexion, wrist extension, grip, finger abduction, thumb opposition, trunk flexion, hip flexion, adduction, extension; knee extension, flexion; ankle dorsiflexion, plantar (grading 0 to 5).  Coordination (is part of motor exam but often will be dictated as a separate heading):  Rapid alternating movements, point-to-point movements including gait, heel-to-toe, heel walk, toe walk, Romberg, pronator drift

.....Sensory system:  pain, temperature, light touch, vibration, position sense, sensation in legs and arms (glove and stocking loss), two-point discrimination, point localization.

.....Reflexes:  Biceps, triceps, DTRs, supinator (brachioradialis), abdominals, upper/lower spine, knee, ankle jerks, plantar (Babinski, clonus), asterixis (grade 0 to 4+)

Mental status:

.....Appearance and behavior:  Level of consciousness, posture, motor behavior, dress, grooming, facial expressions, manner, affect, relation to persons and things

.....Speech and language

.....Mood

.....Thought and perceptions: Thought processes, thought content, perceptions(hallucinations), insight/judgment

.....Cognitive functions:  Digit span, serial 7s, spelling W-O-R-L-D backwards, remote memory, recent memory, new learning ability