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Subjective Data: What the patient tells you

Objective Data: What you detect during the examination. All physical examination
ndings.
Identifying data: age, gender, occupation, marital status
Source of the historythe patient, but can be a family member or friend, letter of
referral, or the medical record
Reliability: The one or more symptoms or concerns causing the patient to seek care
Present Illness
Amplies the Chief Complaint; Includes patient's thoughts and feelings about
the illness
May include medications, allergies, habits of smoking and alcohol, which are
frequently pertinent to the present illness describes how each symptom
developed
Past History
- Childhood Illness Measles, rubella, mumps, whooping cough, chicken pox
Chronic childhood illnesses: asthma, diabetes
Lists adult illnesses with dates for at least four categories: medical; surgical;
obstetric/gynecologic; and psychiatric
Includes health maintenance practices such as immunizations, screening tests,
lifestyle issues, and home safety
Family History
Outlines or diagrams age and health, or age and cause of death, of siblings,
parents, and grandparents
Documents presence or absence of specific illnesses in family, such as
hypertension, coronary artery disease, HTN,CAD, Hypercholesterolemia,
Stroke, DM, Thyroid disease, Renal disease, CA, Arthritis, TB, Asthma,
HA, Seizure, Psych, Drug/ETOH addiction
Personal and Social History
Describes educational level, family of origin, current household, personal
interests, and lifestyle. Living situation, Significant other sources of stress,
Important life experiences, Present job, Religious affiliation, ADL
Review of Systems
Documents presence or absence of common symptoms related to each major
body system

Chief Complaint
Make every attempt to quote the patient's own words Ex: I have had chest pain
for the past 3 hours and I feel like I can't breathe
Sometimes the patient may not have a complaint and will instead state their goals
Ex: I have come for my regular checkup
HPI
This section is a complete, clear, and chronological account of the present illness.
It should include the onset of the problem, the setting in which it has developed, its
manifestations and any treatments.
The principal symptoms should be well described using LMNOPQRST. Include
pertinent negatives and positives form the ROS
Also include current medications, allergies, tobacco, alcohol and drug use
HPI (history of present illness)
L- Location
M-Management of Disease
N- New or Old
O-Onset
P-Precipitating Factors
Q- Quality
R- Relieving Factors
S- Severity
T- Treatment/Timing
Alcohol and Drug History
CAGE Questions
C- Cut down?
A- Annoyed/Angry
G- Guilty?
E- Eye-opener
The Vital Signs
Include: blood pressure, heart rate, respiratory rate, and temperature. Check
either the BP or pulse first. Continue either one and count the respiratory rate
without alerting the patient.
Heart Rate
The radial pulse is the most common place used to assess the heart rate with the
pads of your index and middle fingers, compress the radial artery until a
maximal pulsation is detected
If the rate seems normal and the rhythm regular then count the pulse for 15
seconds and multiply by 4.
If the rate is unusually slow or fast, count it for 60 seconds Rhythm

Rhythm
Feel the radial pulse
Is the rhythm regular or irregular?
If irregular identify the pattern: Do early beats appear in a basically regular
rhythm? Does the irregularity vary consistently with respiration
Is the rhythm totally irregular?
Temperature
Average Oral temperature: 37C (98.6F)
fluctuates throughout the day and is lowest in the early morning (96.4F) and
highest in the late afternoon (99.1F)
Rectal Temperature: are higher than oral temperatures by an average of 0.4-0.5C
(0.7-0.9F)
Blood Pressure
Read the diastolic and systolic pressures to the nearest 2mmHg.
It is good practice to measure the blood pressure in both arms.
A difference of more than 10-15mm Hg suggests arterial compression or
obstruction on the side with the lower pressure.
A fall in systolic pressure of more than 20mm Hg indicates orthostatic
hypotension
Right lung
divided into upper, middle, and lower lobes
Left lung
is divided into upper and lower lobes
Trachea
bifurcates into its main stem bronchi at the levels of the sternal angle anteriorly
and the T4 spinous process posteriorly
Pleurae
are serous membranes that cover the outer surface of each lung(visceral pleura),
and also the inner rib cage and upper surface of the diaphragm (parietal pleura)
Dyspnea
Dyspnea is a non-painful but uncomfortable awareness of breathing that is
inappropriate to the level of exertion
Hemoptysis
Hemoptysis is the coughing up of blood from the lungs; it may vary from bloodstreaked phlegm to frank blood

Percussion
Percussion helps establish whether the underlying tissues (5 to 7 cm deep) are
air-filled, fluid-filled, or solid
Examination: Posterior Chest Auscultation
Auscultation of the lungs is the most important examining technique for
assessing air flow through the tracheobronchial tree.
Together with percussion, it also helps to assess the condition of the surrounding
lungs and pleural space
Normal Breath Sounds:
Vesicular: soft and low pitched; usually heard over most of both lungs
Bronchial: louder and higher in pitch; usually heard over the manubrium
Broncho vesicular: intermediate intensity and pitch; usually heard over the 1st
and 2nd interspaces
Adventitious (Added) sounds
Crackles, Wheezes, and Rhonchi
Visual acuity: Snellen eye chart or near vision card
Visual fields: peripheral vision
Extraocular movements: Six cardinal directions of gaze; Tests cranial nerves III, IV, VI
Pupils: direct and consensual reaction to light
Ophthalmoscope: examination of fundus-Stand directly in front of the patient, 15 inches
away and start at an angle of 15 degrees lateral to the patient's line of vision
Shine the beam of light onto the pupil and look for an orange glow - this is the red reflex
Ears
Inspection:
Auricle for lesions,
Ear canal for lesions
Tympanic membrane for landmarks, fluid
Auditory Acuity
Whisper test
Weber: Lateralization of sound; if present, then suspect conduction loss

Rinne
Compare time of air vs. bone conduction
If bone conduction is equal or greater than air conduction, then suspect
conduction loss
If air conduction is more than twice as long as bone conduction, then suspect
sensory neural loss
Neck Inspection
symmetry, masses, scars, enlarged glands or lymph nodes, Trachea - position,
alignment
Thyroid gland - symmetry
Neck- Palpation
Lymph Nodes (size, shape, delimitation, mobility, consistency, tenderness)
Preauricular, posterior auricular, occipital, tonsillar, submandibular, submental,
superficial cervical, posterior cervical, deep cervical chain, supraclavicular
Thyroid gland: consistency, masses, tenderness