 Chief Concern (CC)  History of Present Illness (HPI)  Past Medical History (PMH)  Family History (FamHx)  Social History (SocHx)  Review of Systems (ROS)  Vitals

 In the patient’s own words  Duration of symptoms

 OPQQRST › O nset & duration › P osition › Q uality of CC › Q uantity /severity (e.g. pain—scale of 1 to 10) › R elated symptoms › S etting/context of symptoms › T ransforming factors (alleviating or exacerbating factors)  Pertinent review of system

 Chronic Conditions › year of diagnosis, complications  Medications & Allergies › dosage and frequency, route, formulation › allergies: type of reaction to allergen  Surgeries › date of surgery, complications during or after  Immunizations & Health Screenings  Accidents (e.g. car accident, house fires, etc…)  Hospitalizations › dates, events, diagnoses

 First-degree relatives – all medical conditions  Extended family – conditions/cancers that run in the family and conditions/cancers related to CC

 Occupation and education › years worked, highest level of education  Single/married/divorced  Sexual history, orientation, partners, STI’s  Living accommodations, people at home, safety, pets  Lifestyle › diet, activity level, stress level  Tobacco/alcohol/drugs › pack years, drinks per week, last recreational drug use  Travel › especially concerned with exposure to areas with Ebola and Zika

 Occupation and education › years worked, highest level of education  Single/married/divorced  Sexual history, orientation, partners, STI’s  Living accommodations, people at home, safety  Lifestyle › diet, activity level, stress level  Tobacco/alcohol/drugs › pack years, drinks per week, last recreational drug use  Travel › especially concerned with exposure to areas with Ebola and Zika

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 General › fevers, chills, night sweats › fatigue, weakness › weight change

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 HEENT (Head, Eyes, Ears, Nose, Throat) › H: headache, trauma › E: vision changes, tearing, itching › E: hearing loss, tinnitus, vertigo, earache › N: congestion, nosebleeds, sneezing, itching › T: soreness, hoarseness, difficulty swallowing

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Cardiac › chest pain › palpitations › shortness of breath (SOB) on exertion › SOB while sleeping

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Respiratory › Shortness of breath › cough, wheezing, sputum › blood in sputum

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Gastrointestinal (GI) › change in appetite › nausea, vomiting › change in bowel habits (diarrhea or constipation) › abnormal stool color, blood in stool › abdominal pain › jaundice

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Genitourinary (GU) › change in frequency, urgency › pain upon urination, blood in urine › incontinence › penile/vaginal discharge or sores

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Musculoskeletal › muscle weakness, pain › joint stiffness, decreased range of motion › redness, swelling, arthritis

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Skin › changes in hair or nails › itching, rashes, sores, lumps › changes in moles or new moles

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Vascular › leg edema › pain with exertion in extremities › varicose veins

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Hematologic › easy bruising/unexplained bruising › increased bleeding

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Endocrine › heat/cold intolerance › excessive sweating › increased urination, thirst, and/or hunger

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

 Neurologic › numbness or tingling › weakness or paralysis › fainting/blackouts › seizures

Multiple organ systems  General  HEENT (Head, Eyes, Ears, Nose, Throat)  Cardiac  Respiratory  Gastrointestinal (GI)  Genitourinary (GU)  Musculoskeletal  Skin  Vascular  Hematologic  Endocrine  Neurologic  Psychiatric

› change in mood or anxiety › hallucinations › change in memory › suicidal ideation

 Blood Pressure  Pulse  Respiratory Rate  Temperature  Height & Weight

“Selecting the Correct Blood Pressure Cuff  Width of the inflatable bladder of the cuff should be about 40% of upper arm circumference (about 12–14 cm in the average adult).  Length of the inflatable bladder should be about 80% of upper arm circumference (almost long enough to encircle the arm).  The standard cuff is 12 × 23 cm, appropriate for arm circumferences up to 28 cm.”  Too small (narrow) = read high  Too large (wide) = read low on small arm and high on large arm

 Steps to Ensure Accurate Blood Pressure Measurement › Ideally, 30 mins without smoking or caffeine before measuring › Quiet, comfortably warm room › Keep patient in chair for ~5 minutes, not examining table › Arm free of clothing › Palpate brachial artery to confirm viable pulse › Arm at heart level – supported on table or held by healthcare professional  Artery is below heart = BP will be higher  Artery is above heart = BP will be lower

 If the rhythm is regular and the rate seems normal, count the rate for 30 seconds and multiply by 2. If the rate is unusually fast or slow count for 60 seconds. The range of normal is 50–90 beats per minute.  Note the rhythm as well

 Count the number of respirations in 1 minute either by visual inspection or by subtly listening over the patient’s trachea with your stethoscope during your examination of the head and neck or chest.

 For oral temperatures, if using an electronic thermometer, carefully place the disposable cover over the probe and insert the thermometer under the tongue. Ask the patient to close both lips, and then watch closely for the digital readout. An accurate temperature recording usually takes about 10 seconds.

 Need height and weight to calculate BMI, which is used to determine if the patient’s weight is underweight, normal, overweight, or obese.  Weigh and measure the height of the patient with shoes off.

 Bickley, Lynn S., and Peter G. Szilagyi. "Chapter 4: Beginning the Physical Examination: General Survey, Vital Signs, and Pain." Bates' Guide to Physical Examination and History Taking. 11th ed. Philadelphia: Wolters Kluwer Health, 2013.