History And Physical Essay

5873 words - 23 pages

CC HPI When symptoms started? How? Severity, intensity, duration? Has it moved? Radiation? Positioning, does it get better or worse in certain body positions? Modality or Tx- ie: Pharm Ever feel like this before? PMH Only that which has been medically dx and tx. Immunizations Substance abuse CAGE, HALT, BUMP, FATAL DT Diet Sleep patterns Allergies Medications Compliance? EH Where pt works and activities at work and home? Exposure to Haz Mat, where pt lives, hobbies? FH Genetic Hx of dz Where did pt grow up? (urban, rural) Hx of family illnesses Psychosocial Hx Pt education, life experiences, religious beliefs (in assoc w/ healthcare beliefs)? Where do they liveOthers living w/ pt SH Smoking Pack Yrs- # packs/day x # yrs smoking Drinking Drugs Excersize Sexual, Reproductive, and Gyn Hx Is pt sexually active? Type of sexual practices? Has pt ever been emotionally, physically, or sexually abused? If female, Menarche Regularity, duration, # of tampons used each day at heaviest flow? Pregnancies, deliveries, abortions (spontaneous or induced) If male Ability to procreate? ROS General Usual state of health Fever Chills Usual wt Change in weight Weakness Fatigue Sweats Heat or cold intolerance Hs of anemia Bleeding tendencies Blood transfusions and possible rxn Exposure to radiation Skin Rashes Itching Hives Easy bruisability Hx of eczema Dryness Changes in skin color Changes in hair texture Changes in nail texture, appearance Hx of previous skin disorders Lumps Use of hair dyes Head Dizziness Headaches Pain Fainting Hx of head injury Stroke Eyes Use of eyeglasses Current vision Change in vision Double vision Excessive tearing Pain Recent eye exams Pain when looking at light Unusual sensations Redness Discharge Infections Hx of glaucoma Cataracts, Injuries Ears Hearing impairment Use of hearing aid Discharge Dizziness Pain Ringing in ears Infections Nose Nosebleeds Infections Discharge Frequency of colds Nasal obstruction Hx of injury Sinus infections Hay fever Mouth and Throat Condition of teeth Last dental appointment Condition of gums Bleeding gums Frequent sore throats Burning of tongue Hoarseness Voice changes Postnasal drip Neck Lumps Goiter Pain on movement Tenderness Hx of swollen glands Thyroid trouble Chest Cough Pain Shortness of breath Sputum prod (quan and appearance) Tuberculosis Asthma Pleurisy Bronchitis Coughing up bld Wheezing Last x-ray Last test for tb Hx of bacilli Calmette- Guérin vaccine Cardiac Chest pain High bld pressure Palpitations Shortness of breath w/exertion Shortness of breath while sleeping (sudden) Hx of heart attack Rheumatic fever Heart murmur Last ECG Other tests for heart fxn Vascular Pain in legs, calves, thighs, or hips...

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