Physical Examination
Terms
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- Informant
- source of information
- Chief Complaint (CC)
- reason for the visit
- History of Present Illness (HPI)
- onset, course, treatment for CC
- Medications
- list with doses/time of day, reason for medications, include OTC
- Allergies
- list and ask what happens
- Past Medical History (PMH)
- all hospitalizations; medical illness; trauma; OB/GYN hx; surgeries
- Family History
- blood relatives - review illnesses (i.e. HTM; DM; CA); age; ?deceased
- Social History
- place of birth; education; occupation; diet; exercise; caffiene intake; drug/ETOH use; tobacco use
- Review of Systems (ROS)
- list by symptoms; expand on postive symptoms
- Physical Exam (PE)
- complete from head to toe; includes neuro and mental status
- General Appearance
- describe patient’s appearance
- Vital Signs
- TPR; BP; weight; height
- Skin
- inspect color, lesions, moisture, edema
- Head
- includes face, scalp, neck
- Head - inspect
- general size & contour; facial expression; symmetry of neck; involuntary movements?; edema?; lesions?; active ROM;