Memory Joggers: QFP/Blessing History and Physical Exam
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS Chrolonological order of time/place of symptom(s) onset, duration, frequency, location, quality, quantity/severity, aggravating/alleviating factors, associated symptoms, self treatment, relevant laboratory values, pertinent negatives
PAST MEDICAL HISTORY
GENERAL HEALTH
date, type, outcome, complications of CHILDHOOD ILLNESSES (measles, mumps, rubella, whooping cough, chicken pox, rheumatic fever, scarlet fever, polio); ADULT ILLNESSES; ACCIDENTS/INJURIES; hospitalizations not already listed; IMMUNIZATIONS (DPT, MMR, polio, hepatitis B, H. influenza, S. pneumoniae, varicella); SCREENING TESTS(hematocrit, urinalysis, tuberculin skin test, pap smear, mammogram, occult stool blood, cholesterol)
PAST SURGICAL HISTORY
Operation date, type, reason, outcome, blood transfusions, complications
GYNE HISTORY
FAMILY HISTORY
Age, health/death of parents, siblings, spouse, children; CHECK diabetes, heart disease, hypertension, stroke, cancer, bleeding disorders, asthma, arthritis, tuberculosis, epilepsy, mental illness, symptoms of presenting illness
SOCIAL HISTORY
Birthplace, education, employment, religion, marriage/divorce, living accommodations, persons at home, hobbies, diet, exercise
MEDICATIONS
Name, dose, frequency, duration, reason for taking, compliance, availability
ALLERGIES
Medications causing reactions (rash, swelling, etc)
TOBACCO, ALCOHOL, DRUGS
Type, amount, frequency, duration, reactions, treatment
REVIEW OF SYSTEMS
- GENERAL: weight change, fatigue, weakness, fever, chills, night sweats
- SKIN: skin, hair, nail changes; itching; rashes; sores; lumps; moles
- HEAD: trauma; headache location, frequency, nausea, vomiting, visual changes
- EYES: glasses, contact lenses, bluriness, tearing, itching, acute visual loss
- EARS: hearing loss, tinnitus, vertigo, discharge, earache
- NOSE, SINUSES: rhinorrhea, stuffiness, sneezing, itching, allergy epistaxis
- MOUTH,THROAT,NECK: bleeding gums, hoarseness, sore throat, swollen neck
- BREASTS: skin changes, masses/ lumps, pain discharge, self-exam
- RESPIRATORY: shortness of breath, wheeze, cough, sputum, hemoptysis, pneumonia, asthma, bronchitis, emphysema, tuberculosis, last chest xray
- CARDIAC: hypertension, murmurs, angina, palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, edema, last EKG
- GI: appetite, nausea, vomiting, indigestion, dysphagia, bowel movement frequency/change, stool color, diarrhea, constipation, bleeding (hemetemesis, hemorrhoids, melena, or hematechezia), abdominal pain, jaundice, hepatitis
- URINARY: frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, incontinence, stones, infections
- GENITAL: Male: penile discharge or sores, testicular pain or masses, hernias; Female: menarche, period irregularity, frequency, duration, dysmenorrhea, last period, itching, discharge, sores, pregnancies and complications, miscarriages/abortions, birth control, menopause, hot flashes/ sweats; General: STD history/treatment; sex interest, function, problems, contraception methods
- VASCULAR: leg edema, claudication, vericose veins, throboses/emboli
- MUSCULOSKELETON: muscle weakness, pain; joint stiffness, range of motion, instability, redness, swelling, arthritis, gout
- NEUROLOGIC: loss of sensation/ numbness, tingling, tremors, weakness/paralysis, fainting/blackouts, seizures
- HEMATOLOGIC: anemia, easy bruising/bleeding, petechiae, purpura, transfusions
- ENDOCRINE: heat/cold intolerance, excessive sweating, polyuria, polydipsia, polyphagia, thyroid problems, diabetes
- PSYCHIATRIC: mood, anxiety, depression, tension, memory
PHYSICAL EXAM:
- GENERAL:sex, race, state of health, stature, development, dress, hygiene, affect
- VITALS: blood pressure, pulse, respirations, temperature, height, weight
- SKIN: skin scars, rashes, bruises, tattoos; hair consistency; nail pitting, stippling
- HEAD: size, shape, trauma
- EYES: pupil size, shape, reactivity; conjunctival injection; scleral icterus; fundal papilledema, hemorrhage; lids; extraocular movements; visual fields and acuity
- EARS: shape/symmentry,tenderness, discharge, external canal/tympanic membrane inflammation, gross auditory acuity
- NOSE: symmetry, tenderness, discharge, mucosa/turbinate inflammation, frontal/maxillary sinus tenderness
- MOUTH,THROAT: hygiene, dentures, erythema, exudate, tonsillar enlargement
- NECK: masses, range of motion, spine/trachea deviation, thyroid size
- BREASTS: skin changes, symmetry, tenderness, masses, dimpling, discharge
- HEART: rate, rhythm, murmurs, rubs, gallops, clicks, precordial movements
- LUNGS: chest symmetry with respirations, wheezes, crackles, vocal fremitus, whispered pectoriloquy, percussion, diaphragmatic excursion
- ABDOMEN: shape, scars, bowel sounds, consistency(soft/firm), tenderness, rebound, masses, guarding, spleen size, liver span, percussion(typany, shifting dullness), costovertebral angle(CVA) tenderness
- GENITOURINARY: Male: rashes, ulcers, scars, nodules, induration, discharge, scrotal masses, hernias; Female: external genitalia, vaginal mucosa, and cervix: inflammation, discharge, bleeding, ulcers, nodules, masses; internal vaginal support; bimanual and rectovaginal palpation of cervix, uterus, ovaries
- RECTAL: sphincter tone, prostate consistency, masses, occult blood
- MUSCULOSKELETAL: muscle atrophy, weakness; joint range of motion, instability, redness, swelling, tenderness; spine deviation; gait
- VASCULAR: carotid, radial, femoral, popliteal, posterior tibial, dorsalis pedis pulses; carotid bruits, jugular venous distension, edema, vericose veins
- LYMPHATIC: cervical, infraclavicular, axillary, trochlear, inguinal adenopathy
- NEUROLOGIC: cranial nerves, sensation, strength, reflexes, cerebellum, gait
LABS
Hematology, chemistry, urinalysis, cultures, EKG, Xrays, CT/MRI scan, etc.
ASSESSMENT/PLAN
Differential diagnosis, supporting history and exam; medication changes, lab tests, procedures, consults, etc.
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