Physical Exam

 • Characteristics of symptoms: Onset Provocations (associated signs) and Past experience, Quality Radiation Severity Time (duration/frequency) Modifying factors • How has this impacted your life? • What are you most worried abt?

• Medical/Surgical/Psyciatric • Medications/Allergies • Women’s Health: Menstrual history: (onset of menses, cycle length, and/or # pads daily) Pregnancy/Complications Mammogram/Pap smear • Health maintenance Immunizations Injury prevention (seat belt, texting) • Family History Members, Ages, Deaths Diseases (HTN, DM, Cancer) • Sexual history (Contraceptive use, orientation, partners, sexual abuse)

Substance abuse (Smoking, alcohol, drugs) Living arrangement Support/Significant Other Occupation Exercise Diet Mood

weight, weakness, fatigue, apatite, fever, chills, sweats, anhedonia

sores, itching, rashes, color/texture change, hair/nail change, mole change

enlarged thyroid, hot/cold intolerance, sexual drive, salt craving, thirst, change in hat/glove size

swelling, lumps, bumps, bleeding, bruising, frequent/unusual infections

fractures, joint pain, stiffness, swelling, mm pain/weakness, back pain, difficulty moving/walking, aching/cramping w/ calves while walking?

headaches, head injury, neck stiffness

sore throat, painful tooth, taste, speech hoarseness, nasal drainage/bleeds, hearing loss, ringing ears

pain, masses, discharge

cough, SOB, wheezing, tightness, hemoptysis, chest pain when coughing or breathing 

chest pain, orthopnea, paroxysmal nocturnal dyspnea, edema, palpitations

difficulty swallowing, heartburn, N/V/D, hematemesis, excessive belching, flatulence, constipation, melena, abd pain, jaundice, rectal pain/discharge/itching

frequency, urgency, urinary incontinence, hesitancy, stones, dysuria, hematuria, nocturia

vaginal pain/discharge/sores/lesions, heavy/irregular/amenorrhea, hot flashes

lumps, swelling, scrotal pain, sores, difficulty with erection, changes in ejaculate

syncope, seizures, paralysis, tremors, anesthesia, parasthesia, dizziness, incoordination, alteration in consciousness, sleep, memory, migraine

anxiety, depression, mania, intrusive thoughts, judgement/insight, hallucinations

General, Skin, Endocrine, Hematologic, Musculoskeletal, Head/Neck, Eyes, Ears, Nose, Throat, Sinuses, Breast, Respiratory, Cardiac, GI, Urinary, Female/Male reproductive, Neurologic, Psychiatric

• Are there any questions/concerns?
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• Physical Exam