General HISTORY_LIST onset character of symptom location aggravating factors relieving factors radiation related factors INFECTIOUS DISEASES strep throat rheumatic fever scarlet fever tonsillitis tuberculosis pneumonia pleurisy meningitis HIV hepatitis STD's CHRONIC DISEASES OR DISORDERS diabetes heart dz. MI thyroid dz. hypertension asthma emphysema COPD ulcers cirrhosis chlolelithiasis pancreatitis kidney dz. arthritis gout anemia coagulopathy neoplasms SURGERY/PREVIOUS HOSPITALIZATIONS eye surgery tonsillectomy appendectomy coronary bypass breast biopsy mastectomy cholecystectomy hysterectomy IMMUNIZATIONS MMR tetanus Hepatitis B (number of 3) pneumonia influenza polio PREVIOUS TESTS TB (PPD) HIV CXR brochoscopy allergy testing GI x-rays GI scopings TRAUMA OR INJURIES head trauma chest trauma abdominal trauma broken bones MVA's DISABILITIES congenital acquired SOCIAL HISTORY married children smoking occupation alcohol caffeine cocaine heroine LSD marijuana ALLERGY medications foods seasonal FAMILY HISTORY heart dz. hypertension stroke diabetes cancer gout asthma bronchitis TB ulcer dz. jaundice blood disorder migraine headache obesity MEDS_LAB_TESTS **** MEDS aspirin NSAIDS opiates muscle relaxers birth control pills hormone replacement therapy sleeping pills antacids laxatives cold medication diuretics blood pressure medication heart medication **** LAB Electrolytes BUN creatnine CBC WBC count platelets differential H & H LFT cholesterol triglycerides uric acid UA **** TESTS ECG CXR Ultrasound MRI CT 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 purpura ecchymosis 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 visual acuity photophobia diplopia (double vision) glaucoma exudates dry eyes eye pain cataracts 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 gingival bleeding recent dental work oral lesions tonsillitis strep throat sore throat hoarseness throat pain 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 SOB SOB altered by position chest pain sputum production character of sputum hemoptysis wheezing pneumonia bronchitis TB TB exposure edema chest pains pacemaker HEART angina MI coronary artery disease heart murmur heart valve disease left ventricular hypertrophy mistral valve stenosis pericarditis palpitations DOE paroxysmal nocturnal dyspnea orthopnea hypertension rheumatic fever cardiomyopathy ectopic heart beats arrhythmia exercise intolerance claudication ABDOMEN abdominal pain nausea vomiting diarrhea constipation hematochezia hematemesis hemorrhoids 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 priapism REVIEW_OF_SYSTEMS_3 OB/GYN Gravida Para abortions living children LMP age of menarche menopause metorrhagia menorrhagia irregular menses abnormal uterine bleeding last pap smear last pelvic exam results of last pelvic exam results of last pap smear problems in pregnancy use of contraception breast masses last mammogram results of last mammogram nipple discharge breast skin changes changes in axillary nodes monthly breast exam breast feeding children EXTREMITIES difficulty with gait weakness joint swelling joint stiffness joint pain 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 memory changes depression bipolar disorder suicide attempts hospitalized for psych. problems personality changes personality disorders difficulty falling asleep waking unrefreshed ENDOCRINE polyuria polydipsia polyphagia goiter exophthalmos dry skin skin changes dry hair hair changes intolerance to heat intolerance to cold changes in growth sterility impotence decreased libido LYMPHATIC AND HEMATOLOGICAL lymphadenopathy rapid onset of node enlargement transfusion anemia hemorrhage tendency PHYSICAL_EVAL_1 VITALS BP Postural BP Pulse Temp Heart rate GENERAL alert lethargic cooperative combative NAD in mild distress in moderate distress in severe distress SKIN rashes scars pigmentation on palm creases pigmentation on nipples pigmentation on genitalia pigmentation on scars moles capillary refill HEENT normocephalic atraumatic bruising tenderness PERRLA EOMI visual fields acuity fundi papilledema arteriovenous nicking retinal hemorrhages retinal exudates conjunctival redness scleral icterus ptosis ear discharge tympanic membrane dull tympanic membrane shiny tympanic membrane intact tympanic membrane injected tympanic membrane bulging lateralization on Weber Test Rinne Test nasal discharge nasal exudate nasal polyps deviated nasal septum oral mucus membranes moist oral mucus membranes pink oral lesions good dentition and oral hygiene poor dentition and oral hygiene edentulous (without teeth) partial plate full plate gingival bleeding tonsils NECK JVD thyromegaly lymphadenopathy full range of motion restricted range of motion masses carotid bruits hepatojugular reflex PHYSICAL_EVAL_2 CHEST equal expansion tactile fremitus percussion auscultation rhonchi crackles wheezes breath sounds rubs egophony whisper pectorilloquy HEART regular rate & rhythm PMI thrills S1 S2 S3 S4 murmur Grade I/VI murmur Grade II/VI murmur Grade III/VI murmur Grade IV/VI murmur Grade V/VI murmur Grade VI/VI BREAST normal symmetry masses retractions tenderness dimpling nipple discharge gynecomastia ABDOMEN obese flat distended scaphoid scars (+) bowel sounds x 4 decreased bowel sounds increased bowel sounds abdominal tenderness organomegaly normal liver span increased liver span splenomegaly guarding rebound tenderness abdominal bruits costrovertebral angle tenderness abdominal hernia percussion MALE GU penis circumcised inguinal masses inguinal hernia external lesions scrotum enlarged testicle mass testicular tenderness varicocele urethral discharge PELVIC EXAM vulva masses vulvar lesions vaginal dryness urethral discharge vaginal discharge vaginal mucosal erythema cervical discharge uterus normal size uterus enlarged uterus anteverted uterus retroverted uterus anteflexed uterus retroflexed uterus midposition cervical erythema cervical erosion cervical tenderness pelvic masses adnexal masses adnexal tenderness cul-de-sac masses cul-de-sac tenderness ovaries palpated ovary tenderness suprapubic tenderness cyctocele rectocele RECTAL sphincter tone rectal masses hemorrhoids rectal fissures guaiac (occult blood) stool in rectal vault prostate tender prostate enlarged prostate nodules palpated EXTREMITIES warm cold capillary refill joint swelling range of motion edema cyanosis clubbing all pulses 2+/4 bilaterally radial pulse ulnar pulse femoral pulse popliteal pulse posterior tibial pulse dorsalis pedis pulse Homan's sign varicosities NEURO gait normal gait abnormal cranial nerves 2-12 grossly in tact CN I intact CN II intact CN III intact CN IV intact CN V intact CN VI intact CN VII intact CN VIII intact CN IX intact CN X intact CN XI intact CN XII intact upper extrem strength bilat. equal upper extremity DTR's 2+ bilat. lower extrem strength bilat. equal lower extremity DTR's 2+ bilat. Babinski's sign superficial touch sensation deep pressure superficial pain positional sense vibration sense temperature Romberg Test rapid rhythmic alternating movements finger-to-finger test finger-to-nose test heel-to-shin test stereognosis two-point discrimination extinction phenomenon graphesthesia point location nuchal rigidity Brudinski's sign Kernig's sign PSYCH/MINI METAL EXAM unkept appearance poor hygiene well groomed cooperative hostile irritable affect congruent affect incongruent affect blunted affect flat flight of ideas circumstantially thoughts preservation thoughts verbigeration thoughts loosening of associations normal speech slow speech rapid speech pressured speech appropriate content of thought obsessional content of thought delusional content of thought alert retarded psychomotor activity agitated depressed excited hypothetical insight & judgment disorganized insight & judgment organized insight & judgment convulsions seizures confusion lethargic delirium stupor coma restless paranoid ideation neurotic ideation suicidal ideation homicidal ideation auditory hallucination visual hallucination MINI MENTAL EXAM Orientation = (one point each) - year? - season? - day of the week? - date? - time? - month? - state? - city? - hospital - floor? Registration = (repeat 3 objects, one point each) - apple - hospital - coat Attention/Calculation (one point for each letter) - spell "WORLD" backward Memory (recall 3 objects, one point each) - dog - tree - orange Language (Name 2 objects, one point each) - watch - pillow Repeat "No if's, and's or but's" (1 point) Follow commands (3 points) Take this paper in your right hand fold it in half, and put it on the floor Written command (1 point) "Close your eyes" Write a sentence See the lazy fox run. Visual Spatial (1 point) Copy 2 overlapping pentagons Total Score = 30 point Normal: 25-30 Mild intellect impaired = 20-25 Mod intellect impaired = 10-20 Severe intellect impaired = 0-10 DIFF_DIAGNOSIS