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HPI
• 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?
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Medical History
• 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)
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Psychosocial
Substance abuse (Smoking, alcohol, drugs) Living arrangement Support/Significant Other Occupation Exercise Diet Mood
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ROS: General
weight, weakness, fatigue, apatite, fever, chills, sweats, anhedonia
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ROS: Skin
sores, itching, rashes, color/texture change, hair/nail change, mole change
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ROS: Endocrine
enlarged thyroid, hot/cold intolerance, sexual drive, salt craving, thirst, change in hat/glove size
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ROS: hematopoetic
swelling, lumps, bumps, bleeding, bruising, frequent/unusual infections
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ROS: Musculoskeletal
fractures, joint pain, stiffness, swelling, mm pain/weakness, back pain, difficulty moving/walking, aching/cramping w/ calves while walking?
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ROS: Head and Neck
headaches, head injury, neck stiffness
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ROS: Ears, Nose, Sinus, Mouth, Throat
sore throat, painful tooth, taste, speech hoarseness, nasal drainage/bleeds, hearing loss, ringing ears
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ROS: Breast
pain, masses, discharge
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ROS: Respiratory
cough, SOB, wheezing, tightness, hemoptysis, chest pain when coughing or breathing
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ROS: CV
chest pain, orthopnea, paroxysmal nocturnal dyspnea, edema, palpitations
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ROS: GI
difficulty swallowing, heartburn, N/V/D, hematemesis, excessive belching, flatulence, constipation, melena, abd pain, jaundice, rectal pain/discharge/itching
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ROS: Urinary
frequency, urgency, urinary incontinence, hesitancy, stones, dysuria, hematuria, nocturia
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ROS: Female Reproductive
vaginal pain/discharge/sores/lesions, heavy/irregular/amenorrhea, hot flashes
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ROS: Male Reproductive
lumps, swelling, scrotal pain, sores, difficulty with erection, changes in ejaculate
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ROS: Neurologic
syncope, seizures, paralysis, tremors, anesthesia, parasthesia, dizziness, incoordination, alteration in consciousness, sleep, memory, migraine
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ROS: Psychiatric
anxiety, depression, mania, intrusive thoughts, judgement/insight, hallucinations
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ROS order of general topics
General, Skin, Endocrine, Hematologic, Musculoskeletal, Head/Neck, Eyes, Ears, Nose, Throat, Sinuses, Breast, Respiratory, Cardiac, GI, Urinary, Female/Male reproductive, Neurologic, Psychiatric
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At the end of ROS:
- Are there any questions/concerns?
- WASH HANDS
- Vitals
- Physical Exam
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