Physical Examination

Vital Signs: temperature; pulse; respiratory rate; blood pressure: sitting and standing (orthostatic
hypotension); weight; height; BMI
General Appearance: apparent health; developmental status; apparent physiologic age; habitus;
hygiene; nutrition; gross deformities; mental state and behavior; facies; posture
Skin: color; texture; moisture; turgor; eruptions; abnormalities of hair and nails (pallor,
pigmentation, cyanosis, clubbing, edema, spider nevi, petechiae)
Head: symmetry; deformities of cranium, face, or scalp (tenderness, bruits)
Eyes: visual acuity; visual fields; extraocular movements; conjunctive; sclera; cornea; pupils
including size, shape, equality and reaction; ophthalmoscopic exam including lens, media, disks,
retinal vessels and macula; tonometry (pallor, jaundice, proptosis, ptosis)
Ears: hearing acuity; auricles; canals; tympanic membranes (mastoid tenderness, discharge)
Nose: nasal mucosa and passages; septum; turbinates; transillumination of sinuses (tenderness
over sinuses)
Mouth and Throat: breath; lips; buccal mucosa; salivary glands; gingival; teeth; tongue
Neck: range of motion; thyroid; trachea; lymph nodes; carotid pulses (venous distension,
abnormal arterial and venous pulsations, bruits, tracheal deviation)
Lymph Nodes: cervical, supraclavicular, axillary, epitrochlear and inguinal nodes (enlargement,
consistency, tenderness, and mobility)
Breasts: symmetry; (nodules including size, consistency, tenderness, mobility, dimpling; nipple
discharge and lymph nodes)
Thorax and Lungs: configuration; symmetry; expansion; type of respiration; excursion of
diaphragms; fremitus; resonance; breath sounds (retraction, labored breathing, prolonged
expiration, cough, sputum, adventitious sounds including crackles, wheezes, rhonchi, and rubs)
Cardiovascular system: precordial activity; apical impulse; size; rate and rhythm of heart sounds;
abdominal aorta; peripheral arterial pulses including carotid, radial, femoral, posterior tibial, and
dorsalis pedis pulses; (thrills; murmurs; friction rubs; bruits; central venous distension; abnormal
venous pulsations)
Abdomen: contour; bowel sounds; abdominal wall tone; palpable organs including liver, spleen,
kidney, bladder, and uterus; liver span; (scars; dilated veins; tenderness; rigidity; masses;
distension; ascites; pulsations; bruits)
Musculoskeletal: symmetry; range of motion of joints; peripheral arterial pulses; color;
temperature; (curvatures of spine; costovertebral angle tenderness; joint deformities; muscle
tenderness; edema; ulcers; varicosities)
Neurologic exam: cranial nerves; station; gait; coordination; sensory and motor systems; muscle
stretch reflexes; (paresthesias, weakness, muscle atrophy, fasciculations, spasticity, abnormal
reflexes, tremors)
Genitourinary: female- external genitalia; vagina; cervix; cytology smear; fundus; adnexae;
rectovaginal exam (vaginal discharge, tenderness)
male- penis; scrotal contents; urethral discharge; hernias; prostate
Rectum: sphincter tone; test for occult blood; (hemorrhoids, fissures; masses)
Mental state exam: appearance; attitude; motor behavior; mood and affect; intellectual
functions; thought content and processes; insight into mental functioning; judgment
*Selected abnormalities in parentheses
SUMMARY AND INTERPRETATION
1. Summary of important data
2. Initial problem list
3. Initial management plans (for each problem)
4. Signature and date of completion

History and Physical Examination Outline

(See Pediatric Supplement for Patients Under Age 18)

The Patient Centered Medical History

Revised 2011

IDENTIFYING DATA (obtain for the patient write up only):

Date, time and patient record number
Source and reliability of history

SETTING THE STAGE FOR THE INTERVIEW:

Introduce self and identify role; asks the patients name; use the patients name; asks patients age
Ensure the patient readiness, comfort, privacy; remove barriers to communication
Elicit or comment on some personal quality or observation about the patient to establish rapport

OBTAINING THE AGENDA AND CHIEF CONCERN:

Indicate time available; indicate own needs

Elicited full list of patient concerns starting with presenting concern
Summarize and finalize the agenda (negotiate specifics if too many items are on the agenda
HISTORY OF PRESENT ILLNESS: (Listen; use nonfocusing open-ended skills: silence, neutral
utterances, nonverbal encouragement. Observe nonverbal cues, physical characteristics, autonomic
changes, accoutrements and environment. Consider attribution: what patient thinks is wrong;
Consider motivation: why seeking treatment now; who is concerned/affected patient, family,
employer, etc.)
C Characteristics (quality, severity)
L Location and radiation
O Onset and duration (gradual, sudden, continuous, progressive, intermittent)
S Symptoms associated with the concern
E Exacerbating factors
R Relieving factors (include what the patient has tried as therapeutic maneuvers)

PAST MEDICAL HISTORY:

Allergies: verify allergies and drug reactions: allergic diseases (e.g., asthma, hay fever) drugs, foods,
environmental
Medications: current/recent prescribed, over the counter, alternative therapies and health care
Medical history: screen for major diseases: diabetes mellitus, cancer, heart attack, stroke; screen for
major treatments in the past (cortisone, blood transfusions, insulin, digitalis, anticoagulants); toxins
and/or industrial exposures; visits to the doctor in the last year
Surgical history: surgical procedures both inpatient and outpatient and date
Hospitalizations: surgical, nonsurgical, psychiatric, obstetric, rehabilitation, other and date
Gynecological/Obstetric (female):
Menstrual history (onset of menses, cycle length, number of pads daily); pregnancy/childbearing
(births, spontaneous or induced abortions); complications of pregnancy; menopause (onset);
contraception (birth control pills and/or other means; hormonal preparations); sexually transmitted
diseases; mammogram; last pap smear
Immunizations: tetanus-diphtheria in all patients; Measles-Mumps-Rubella in children; influenza and
pneumococcal in patients with certain chronic illnesses (cardiovascular, pulmonary, metabolic, renal,
hematologic, immunosuppression) and in patients over the age of 65
Diet: What did the patient eat the day before including meals and snacks; salt intake, fiber intake,
caffeine intake, sugar intake in patients who have diabetes
Trauma history: prior history of injury and how injury was treated
Growth and development/childhood diseases/birth history: younger age groups

FAMILY MEDICAL HISTORY:

Summary of ages and states of physical and mental health of immediate family members (including
depression or substance abuse, whether parents and siblings are alive, and causes of death)
Family members with similar symptoms and signs
Presence of chronic and/or infectious diseases in family members
Family relationships (note family interaction patterns-happy, successful, competitive, distant,
dysfunctional, love, anger)

PERSONAL/SOCIAL HISTORY:

Marriage/other relationships and outcome: (spouse, partner, children, number of living children)
Household composition/living situation: alone or with others; relationships; care giving
Ethnicity
Sources of social support: friends, community, organizations, pets, spiritual beliefs or community
Personal background: education, occupation, military, travel, religion, dwelling, financial, stress
Directives for care: living will, health care Power of Attorney, CPR, transfusions, known health risks

PREVENTION/RISK FACTORS:

Prevention: recreation, exercise, firearms, seat belts, smoke detectors, current stressors, sleep,
periodic health examinations
Tobacco, alcohol, recreational drugs: current use/ past use
Sexual History: sexually active, partners (male/female/both), practice safe sex; Male: History of
sexually transmitted disease (female ask in past medical history)
Occupational hazards/environmental exposures
Violence risk (Ex: Do you feel safe? Are you afraid of anyone? Has anyone hurt you?)
REVIEW OF SYSTEMS (Within the last year have you experienced..):
General: change in weight; change in appetite; overall weakness; fatigue; fever, chills or sweats;
anhedonia
Skin: sores; itching or rashes; color or texture changes; hair or nail changes; change in mole(s)
Endocrine: thyroid enlargement; heat or cold intolerance; loss of libido; salt cravings; excessive thirst;
enlarging hat or glove size
Hematopoietic: lymphadenopathy; enlarging glands; bleeding or bruising tendencies; frequent or
unusual infections
Musculoskeletal: frequent fractures; joint pain, stiffness, or swelling; muscle pain or weakness; low
back pain; difficulty moving or walking; claudication
Head and Neck: headaches; trauma; neck stiffness
Eyes: bright flashes of light; changes in vision; scintillating scotomata; floaters; diplopia; pain
Ears, Nose, Sinuses, Mouth and Throat: sore throat; painful tooth; decrease or change in sense of
taste; difficult speech; hoarseness; epistaxis; change or loss of hearing; tinnitus
Breasts: pain; masses; discharge
Respiratory: cough; dyspnea; wheezing; hemoptysis; pleurisy
Cardiovascular: chest pain; orthopnea; paroxysmal nocturnal dyspnea; edema; palpitations; syncope
Gastrointestinal: dysphagia; reflux; nausea; vomiting; hematemesis; eructation; flatulence;
constipation; diarrhea; melena; abdominal pain; jaundice; pruritis ani
Urinary: frequency; urgency; dysuria; hematuria; nocturia; incontinence; renal stones; hesitancy
Female reproductive: vaginal pain; discharge; sore or lesions on vagina; menometarrhagia; irregular
periods; amenorrhea; hot flashes
Male reproductive: scrotal mass; hernia; scrotal pain; urethral discharge; penile sores; retrograde,
bloody or premature ejaculation; erectile dysfunction
Neurologic: weakness; numbness; seizures; headaches; incoordination; alternating consciousness;
sleep disorders; memory disorders; tremor; dizziness
Psychiatric: anxiety; depression; mania; intrusive thoughts; loss of good judgment and/or insight;
hallucinations