Physical Exam

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Author:
770aky
ID:
199724
Filename:
Physical Exam
Updated:
2013-02-11 13:25:21
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Physical Exam
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Description:
Physical exam
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  1. 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?
  2. 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)
  3. Psychosocial
    Substance abuse (Smoking, alcohol, drugs) Living arrangement Support/Significant Other Occupation Exercise Diet Mood
  4. ROS: General
    weight, weakness, fatigue, apatite, fever, chills, sweats, anhedonia
  5. ROS: Skin
    sores, itching, rashes, color/texture change, hair/nail change, mole change
  6. ROS: Endocrine
    enlarged thyroid, hot/cold intolerance, sexual drive, salt craving, thirst, change in hat/glove size
  7. ROS: hematopoetic
    swelling, lumps, bumps, bleeding, bruising, frequent/unusual infections
  8. ROS: Musculoskeletal
    fractures, joint pain, stiffness, swelling, mm pain/weakness, back pain, difficulty moving/walking, aching/cramping w/ calves while walking?
  9. ROS: Head and Neck
    headaches, head injury, neck stiffness
  10. ROS: Ears, Nose, Sinus, Mouth, Throat
    sore throat, painful tooth, taste, speech hoarseness, nasal drainage/bleeds, hearing loss, ringing ears
  11. ROS: Breast
    pain, masses, discharge
  12. ROS: Respiratory
    cough, SOB, wheezing, tightness, hemoptysis, chest pain when coughing or breathing 
  13. ROS: CV
    chest pain, orthopnea, paroxysmal nocturnal dyspnea, edema, palpitations
  14. ROS: GI
    difficulty swallowing, heartburn, N/V/D, hematemesis, excessive belching, flatulence, constipation, melena, abd pain, jaundice, rectal pain/discharge/itching
  15. ROS: Urinary
    frequency, urgency, urinary incontinence, hesitancy, stones, dysuria, hematuria, nocturia
  16. ROS: Female Reproductive
    vaginal pain/discharge/sores/lesions, heavy/irregular/amenorrhea, hot flashes
  17. ROS: Male Reproductive
    lumps, swelling, scrotal pain, sores, difficulty with erection, changes in ejaculate
  18. ROS: Neurologic
    syncope, seizures, paralysis, tremors, anesthesia, parasthesia, dizziness, incoordination, alteration in consciousness, sleep, memory, migraine
  19. ROS: Psychiatric
    anxiety, depression, mania, intrusive thoughts, judgement/insight, hallucinations
  20. 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
  21. At the end of ROS:
    • Are there any questions/concerns?
    • WASH HANDS
    • Vitals
    • Physical Exam

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