Fever

HISTORY_LIST
***** HISTORY OF PRESENT ILLNESS
onset of fever
degree of fever
duration of fever
shaking chills
cough
sore throat
rhinorrhea
stiff neck
dysuria
increased urination frequency
night sweats
vaginal discharge
back pain
myalgia
nausea
vomiting
diarrhea
weight loss
malaise
anorexia
calf pain
exposure to TB
exposure to hepatitis
exposure to foreign travel
recent or new medication
***** HISTORY
CHRONIC DISEASE
SYSTEMIC DISORDERS
cirrhosis of the liver
diabetes
valvular disease
HIV or AIDS
SURGERY
PREVIOUS HOSPITALIZATIONS
any previous surgeries
recent dental procedures
recent GI procedures
IV or foley catheters
fever of unknown origin undiagnosed
  after a week of evaluation or 
  extensive studies
PREVIOUS TESTS
tuberculin tests
recent WBC count
recent differential blood count
allergy testing
SOCIAL HISTORY
smoking
alcohol
caffeine
illicit drugs - cocaine
high risk AIDS activities
  transfusions,IV drugs
  unsafe sex
ALLERGY
medications
foods
seasonal

MEDS_LAB_TESTS
***** MEDS
recent antibiotics
penicillin
aspirin
barbiturates
H2 blocker
hydralazine
isoniazid
methyldopa
nitrofurantoin
phenytoin
procainamide
quinidine
sulfonamides
***** LAB
Electrolytes
BUN
Creatnine
CBC
blood C&S
LFT's
sputum
sputum gram stain
sputum C&S
tuberculin test
HIV test
UA
urine C&S
***** TESTS
lumbar puncture
CXR
abdominal X-rays
gallium scan
indium scan

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
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
photophobia
diplopia (double vision)
glaucoma
exudates
dry eyes
eye pain
cataracts
eye surgery
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
recent dental work
oral lesions
tonsillitis
strep throat
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
sputum production
hemoptysis
wheezing
pneumonia
bronchitis
TB
TB exposure
SOB (altered by position?)
edema
chest pains
pacemaker
HEART
MI
coronary artery disease
heart murmur
heart valve disease
left ventricular hypertrophy
mitral valve stenosis
pericarditis
palpitations
DOE
paroxysmal nocturnal dyspnea
orthopnea
edema
hypertension
rheumatic fever
cardiomyopathy
ectopic heart beats
arrhythmia
exercise intolerance
claudication
heart medications
ABDOMEN
abdominal pain
nausea
vomiting
diarrhea
constipation
hematochezia
hematemesis
hemorrhoids
GI x-rays
GI scopings
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

REVIEW_OF_SYSTEMS_3
OB/GYN
metorrhagia
menorrhagia
irregular menses
problems in pregnancy
use of contraception
breast masses
nipple discharge
breast skin changes
changes in axillary nodes
monthly breast exam
breast feeding children
EXTREMITIES
difficulty with gait
weakness
joint swelling
joint stiffness
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
depression
bipolar disorder
suicide attempts
hospitalization,for
  psychiatric problems
personality disorders
ENDOCRINE
goiter
exophthalmos
dry skin
dry hair
intolerance to heat
intolerance to cold
changes in growth
sterility
impotence
decreased libido
LYMPHATIC AND HEMATOLOGICAL
lymphadenopathy
transfusion
anemia

PHYSICAL_EVAL_1
VITALS
BP
Pulse
Temp (rectal)
Heart rate
GENERAL
lethargy
toxic appearance
SKIN
color
temperature
capillary refill
rash
purpura
petechia
desquamation
ecthyma gangrenosum
pustules
cellulitis
furuncles
abscesses
cysts
malar/discoid rash
HEENT
papilledema
Roth's spots
dental carries
tooth tenderness
tempanic membrane
sinus infection
pharyngeal erythema
pharyngeal exudate
NECK
rigid neck
lymphadenopathy

PHYSICAL_EVAL_2
CHEST
rhonchi
crackles
dullness to percussion
HEART
murmur
ABDOMEN
abdominal masses
liver tenderness
hepatomegaly
splenomegaly
Murphy's sign,(rt upper quad
  tenderness,& arrest of 
  respirations,secondary 
  to pain)
shifting dullness
ascites
costrovertebral,angle tenderness
supra pubic tenderness
GU
prostate tenderness
occult blood
rectal flocculence
fissures
ulcers
foley catheter
OB/GYN
recent pelvic exam
cervical discharge
cervical motion tenderness
adnexal or uterine tenderness,
  or masses
genital herpes lesions
EXTREMITIES
cellulitis
infected decubitus ulcers,
 or wounds
IV catheter tenderness
calf tenderness
Homan's sign
joint tenderness
joint swelling
petechia
bone pain
insect bites
Osler's node
Janeway's lesions

DIFF_DIAGNOSIS
INFECTIOUS CAUSE
abscess
TB infection
cystitis
pyelonephritis
oseteomyolytis
IV phlebitis
sinusitis
otis media
upper respiratory infection
pharyngitis
pelvic infection
cellulitis
infected decubitus ulcer
furuncle
peritonitis
abdominal abscess
urosepsis
AIDS
endocarditis
wound infection
diverticulitis
cholangitis
mastitis
viral infection
rickettsial infection
chlamydia infection
parasite infection
MALIGNANCY CAUSE
lymphoma
leukemia
solid tumors or carcinomas
CONNECTIVE TISSUE DISEASE
SLE
rheumatic fever
rheumatoid arthritis
temporal arteritis
sarcoidosis
OTHER CAUSES OF FEVER
Atelectasis
PE
pericarditis
pancreatitis
alcohol withdrawal
DVT
MI
IBD
gout
porphyria
thyroid storm
Addsion's crisis
drug fever
factitious fever
MEDS ASSOCIATED WITH FEVER
aspirin
barbiturates
H2 blocker
hydralazine
isoniazid
methyldopa
nitrofurantoin
pencillins
phenytoin
procainamide
quinidine
sulfonamides

