Fever HISTORY_LIST ***** HISTORY OF PRESENT ILLNESS onset of fever degree of fever duration of fever shaking chills cough sore throat rhinorrhea stiff neck dysuria increased urination frequency night sweats vaginal discharge back pain myalgia nausea vomiting diarrhea weight loss malaise anorexia calf pain exposure to TB exposure to hepatitis exposure to foreign travel recent or new medication ***** HISTORY CHRONIC DISEASE SYSTEMIC DISORDERS cirrhosis of the liver diabetes valvular disease HIV or AIDS SURGERY PREVIOUS HOSPITALIZATIONS any previous surgeries recent dental procedures recent GI procedures IV or foley catheters fever of unknown origin undiagnosed after a week of evaluation or extensive studies PREVIOUS TESTS tuberculin tests recent WBC count recent differential blood count allergy testing SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine high risk AIDS activities transfusions,IV drugs unsafe sex ALLERGY medications foods seasonal MEDS_LAB_TESTS ***** MEDS recent antibiotics penicillin aspirin barbiturates H2 blocker hydralazine isoniazid methyldopa nitrofurantoin phenytoin procainamide quinidine sulfonamides ***** LAB Electrolytes BUN Creatnine CBC blood C&S LFT's sputum sputum gram stain sputum C&S tuberculin test HIV test UA urine C&S ***** TESTS lumbar puncture CXR abdominal X-rays gallium scan indium scan REVIEW_OF_SYSTEMS_1 GENERAL weight changes appetite changes anorexia difficulty sleeping fever chills polyphagia hypophagia changes in thirst sleeping habit change bowel habit change fatigue hypertension previous physical exams SKIN pigmentation changes texture changes lesions eruptions pruritis easy bruising easy bleeding unusual hair loss changes in hair distribution skin masses finger/toe nail change rashes hives striae skin atrophy uremic frost hirsutism plethora neurofibromatosis lesion HEENT head trauma skull fractures head masses hearing loss vertigo chronic ear infection ear discharge ear pain hearing aid use loss of vision recent change in vision photophobia diplopia (double vision) glaucoma exudates dry eyes eye pain cataracts eye surgery itchy eyes excessive tearing corrective lenses nose bleeds chronic sinusitis nasal fractures nasal drainage polyps changes in sense of smell edentulous (without teeth) partial plate full plate recent dental work oral lesions tonsillitis strep throat tongue problems voice changes chronic hoarseness chronic halitosis NECK neck masses enlarged thyroid gland brachial cleft cysts neck injury REVIEW_OF_SYSTEMS_2 CHEST chronic coughing sputum production hemoptysis wheezing pneumonia bronchitis TB TB exposure SOB (altered by position?) edema chest pains pacemaker HEART MI coronary artery disease heart murmur heart valve disease left ventricular hypertrophy mitral valve stenosis pericarditis palpitations DOE paroxysmal nocturnal dyspnea orthopnea edema hypertension rheumatic fever cardiomyopathy ectopic heart beats arrhythmia exercise intolerance claudication heart medications ABDOMEN abdominal pain nausea vomiting diarrhea constipation hematochezia hematemesis hemorrhoids GI x-rays GI scopings rectal bleeding ulcers bowel polyps bowel incontinence gall bladder disease gall stones hepatitis cirrhosis hepatomegaly splenomegaly GU renal insufficiency renal failure dialysis kidney stones kidney disease kidney cyst flank pain hematuria pyuria dysuria chronic cystitis nocturia anuria hesitancy enuresis change in urine color prostatitis epididymitis scrotal problems TURP pain on intercourse genital lesions genital discharge REVIEW_OF_SYSTEMS_3 OB/GYN metorrhagia menorrhagia irregular menses problems in pregnancy use of contraception breast masses nipple discharge breast skin changes changes in axillary nodes monthly breast exam breast feeding children EXTREMITIES difficulty with gait weakness joint swelling joint stiffness muscle pain muscle swelling muscle injuries sagittal plan scoliosis coronal plane scoliosis fractured bones SLE osteoarthritis rheumatoid arthritis fibromyalgia NEURO seizures head injury LOC loss of coordination difficulty in balance sciatica difficulty in fine motor skills difficulty speaking CVA (stroke) weakness in arms weakness in legs tingling in legs and feet tingling in arms PSYCHIATRIC depression bipolar disorder suicide attempts hospitalization,for psychiatric problems personality disorders ENDOCRINE goiter exophthalmos dry skin dry hair intolerance to heat intolerance to cold changes in growth sterility impotence decreased libido LYMPHATIC AND HEMATOLOGICAL lymphadenopathy transfusion anemia PHYSICAL_EVAL_1 VITALS BP Pulse Temp (rectal) Heart rate GENERAL lethargy toxic appearance SKIN color temperature capillary refill rash purpura petechia desquamation ecthyma gangrenosum pustules cellulitis furuncles abscesses cysts malar/discoid rash HEENT papilledema Roth's spots dental carries tooth tenderness tempanic membrane sinus infection pharyngeal erythema pharyngeal exudate NECK rigid neck lymphadenopathy PHYSICAL_EVAL_2 CHEST rhonchi crackles dullness to percussion HEART murmur ABDOMEN abdominal masses liver tenderness hepatomegaly splenomegaly Murphy's sign,(rt upper quad tenderness,& arrest of respirations,secondary to pain) shifting dullness ascites costrovertebral,angle tenderness supra pubic tenderness GU prostate tenderness occult blood rectal flocculence fissures ulcers foley catheter OB/GYN recent pelvic exam cervical discharge cervical motion tenderness adnexal or uterine tenderness, or masses genital herpes lesions EXTREMITIES cellulitis infected decubitus ulcers, or wounds IV catheter tenderness calf tenderness Homan's sign joint tenderness joint swelling petechia bone pain insect bites Osler's node Janeway's lesions DIFF_DIAGNOSIS INFECTIOUS CAUSE abscess TB infection cystitis pyelonephritis oseteomyolytis IV phlebitis sinusitis otis media upper respiratory infection pharyngitis pelvic infection cellulitis infected decubitus ulcer furuncle peritonitis abdominal abscess urosepsis AIDS endocarditis wound infection diverticulitis cholangitis mastitis viral infection rickettsial infection chlamydia infection parasite infection MALIGNANCY CAUSE lymphoma leukemia solid tumors or carcinomas CONNECTIVE TISSUE DISEASE SLE rheumatic fever rheumatoid arthritis temporal arteritis sarcoidosis OTHER CAUSES OF FEVER Atelectasis PE pericarditis pancreatitis alcohol withdrawal DVT MI IBD gout porphyria thyroid storm Addsion's crisis drug fever factitious fever MEDS ASSOCIATED WITH FEVER aspirin barbiturates H2 blocker hydralazine isoniazid methyldopa nitrofurantoin pencillins phenytoin procainamide quinidine sulfonamides