General

HISTORY_LIST
onset
character of symptom
location
aggravating factors
relieving factors
radiation
related factors
INFECTIOUS DISEASES
strep throat
rheumatic fever
scarlet fever
tonsillitis
tuberculosis
pneumonia
pleurisy
meningitis
HIV
hepatitis
STD's
CHRONIC DISEASES OR DISORDERS
diabetes
heart dz.
MI
thyroid dz.
hypertension
asthma
emphysema
COPD
ulcers
cirrhosis
chlolelithiasis
pancreatitis
kidney dz.
arthritis
gout
anemia
coagulopathy
neoplasms
SURGERY/PREVIOUS HOSPITALIZATIONS
eye surgery
tonsillectomy
appendectomy
coronary bypass
breast biopsy
mastectomy
cholecystectomy
hysterectomy
IMMUNIZATIONS
MMR
tetanus
Hepatitis B (number of 3)
pneumonia
influenza
polio
PREVIOUS TESTS
TB (PPD)
HIV
CXR
brochoscopy
allergy testing
GI x-rays
GI scopings
TRAUMA OR INJURIES
head trauma
chest trauma
abdominal trauma
broken bones
MVA's
DISABILITIES
congenital
acquired
SOCIAL HISTORY
married
children
smoking
occupation
alcohol
caffeine
cocaine
heroine
LSD
marijuana
ALLERGY
medications
foods
seasonal
FAMILY HISTORY
heart dz.
hypertension
stroke
diabetes
cancer
gout
asthma
bronchitis
TB
ulcer dz.
jaundice
blood disorder
migraine headache
obesity

MEDS_LAB_TESTS
**** MEDS
aspirin
NSAIDS
opiates
muscle relaxers
birth control pills
hormone replacement therapy
sleeping pills
antacids
laxatives
cold medication
diuretics
blood pressure medication
heart medication
**** LAB
Electrolytes
BUN
creatnine
CBC
WBC count
platelets
differential
H & H
LFT
cholesterol
triglycerides
uric acid
UA
**** TESTS
ECG
CXR
Ultrasound
MRI
CT


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
purpura
ecchymosis
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
visual acuity
photophobia
diplopia (double vision)
glaucoma
exudates
dry eyes
eye pain
cataracts
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
gingival bleeding
recent dental work
oral lesions
tonsillitis
strep throat
sore throat
hoarseness
throat pain
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
SOB
SOB altered by position
chest pain
sputum production
character of sputum
hemoptysis
wheezing
pneumonia
bronchitis
TB
TB exposure
edema
chest pains
pacemaker
HEART
angina
MI
coronary artery disease
heart murmur
heart valve disease
left ventricular hypertrophy
mistral valve stenosis
pericarditis
palpitations
DOE
paroxysmal nocturnal dyspnea
orthopnea
hypertension
rheumatic fever
cardiomyopathy
ectopic heart beats
arrhythmia
exercise intolerance
claudication
ABDOMEN
abdominal pain
nausea
vomiting
diarrhea
constipation
hematochezia
hematemesis
hemorrhoids
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
priapism

REVIEW_OF_SYSTEMS_3
OB/GYN
Gravida
Para
abortions
living children
LMP
age of menarche
menopause
metorrhagia
menorrhagia
irregular menses
abnormal uterine bleeding
last pap smear
last pelvic exam
results of last pelvic exam
results of last pap smear
problems in pregnancy
use of contraception
breast masses
last mammogram
results of last mammogram
nipple discharge
breast skin changes
changes in axillary nodes
monthly breast exam
breast feeding children
EXTREMITIES
difficulty with gait
weakness
joint swelling
joint stiffness
joint pain
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
memory changes
depression
bipolar disorder
suicide attempts
hospitalized for psych. problems
personality changes
personality disorders
difficulty falling asleep
waking unrefreshed
ENDOCRINE
polyuria
polydipsia
polyphagia
goiter
exophthalmos
dry skin
skin changes
dry hair
hair changes
intolerance to heat
intolerance to cold
changes in growth
sterility
impotence
decreased libido
LYMPHATIC AND HEMATOLOGICAL
lymphadenopathy
rapid onset of node enlargement
transfusion
anemia
hemorrhage tendency




PHYSICAL_EVAL_1
VITALS
BP
Postural BP
Pulse
Temp
Heart rate
GENERAL
alert
lethargic
cooperative
combative
NAD
in mild distress
in moderate distress
in severe distress
SKIN
rashes
scars
pigmentation on palm creases
pigmentation on nipples
pigmentation on genitalia
pigmentation on scars
moles
capillary refill
HEENT
normocephalic
atraumatic
bruising
tenderness
PERRLA
EOMI
visual fields
acuity
fundi
papilledema
arteriovenous nicking
retinal hemorrhages
retinal exudates
conjunctival redness
scleral icterus
ptosis
ear discharge
tympanic membrane dull
tympanic membrane shiny
tympanic membrane intact
tympanic membrane injected
tympanic membrane bulging
lateralization on Weber Test
Rinne Test
nasal discharge
nasal exudate
nasal polyps
deviated nasal septum
oral mucus membranes moist
oral mucus membranes pink
oral lesions
good dentition and oral hygiene
poor dentition and oral hygiene
edentulous (without teeth)
partial plate
full plate
gingival bleeding
tonsils
NECK
JVD
thyromegaly
lymphadenopathy
full range of motion
restricted range of motion
masses
carotid bruits
hepatojugular reflex

PHYSICAL_EVAL_2
CHEST
equal expansion
tactile fremitus
percussion
auscultation
rhonchi
crackles
wheezes
breath sounds
rubs
egophony
whisper pectorilloquy
HEART
regular rate & rhythm
PMI
thrills
S1
S2
S3
S4
murmur Grade I/VI
murmur Grade II/VI
murmur Grade III/VI
murmur Grade IV/VI
murmur Grade V/VI
murmur Grade VI/VI
BREAST
normal symmetry
masses
retractions
tenderness
dimpling
nipple discharge
gynecomastia
ABDOMEN
obese
flat
distended
scaphoid
scars
(+) bowel sounds x 4
decreased bowel sounds
increased bowel sounds
abdominal tenderness
organomegaly
normal liver span
increased liver span
splenomegaly
guarding
rebound tenderness
abdominal bruits
costrovertebral angle tenderness
abdominal hernia
percussion
MALE GU
penis circumcised
inguinal masses
inguinal hernia
external lesions
scrotum enlarged
testicle mass
testicular tenderness
varicocele
urethral discharge
PELVIC EXAM
vulva masses
vulvar lesions
vaginal dryness
urethral discharge
vaginal discharge
vaginal mucosal erythema
cervical discharge
uterus normal size
uterus enlarged
uterus anteverted
uterus retroverted
uterus anteflexed
uterus retroflexed
uterus midposition
cervical erythema
cervical erosion
cervical tenderness
pelvic masses
adnexal masses
adnexal tenderness
cul-de-sac masses
cul-de-sac tenderness
ovaries palpated
ovary tenderness
suprapubic tenderness
cyctocele
rectocele
RECTAL
sphincter tone
rectal masses
hemorrhoids
rectal fissures
guaiac (occult blood)
stool in rectal vault
prostate tender
prostate enlarged
prostate nodules palpated
EXTREMITIES
warm
cold
capillary refill
joint swelling
range of motion
edema
cyanosis
clubbing
all pulses 2+/4 bilaterally
radial pulse
ulnar pulse
femoral pulse
popliteal pulse
posterior tibial pulse
dorsalis pedis pulse
Homan's sign
varicosities
NEURO
gait normal
gait abnormal
cranial nerves 2-12 grossly in tact
CN I intact
CN II intact
CN III intact
CN IV intact
CN V intact
CN VI intact
CN VII intact
CN VIII intact
CN IX intact
CN X intact
CN XI intact
CN XII intact
upper extrem strength bilat. equal
upper extremity DTR's 2+ bilat.
lower extrem strength bilat. equal
lower extremity DTR's 2+ bilat.
Babinski's sign
superficial touch sensation
deep pressure
superficial pain
positional sense
vibration sense
temperature
Romberg Test
rapid rhythmic
  alternating movements
finger-to-finger test
finger-to-nose test
heel-to-shin test
stereognosis
two-point discrimination
extinction phenomenon
graphesthesia
point location
nuchal rigidity
Brudinski's sign 
Kernig's sign 
PSYCH/MINI METAL EXAM
unkept appearance
poor hygiene
well groomed
cooperative
hostile
irritable
affect congruent
affect incongruent
affect blunted
affect flat
flight of ideas
circumstantially thoughts
preservation thoughts
verbigeration thoughts
loosening of associations
normal speech
slow speech
rapid speech
pressured speech
appropriate content of thought
obsessional content of thought
delusional content of thought
alert
retarded psychomotor activity
agitated
depressed
excited
hypothetical insight & judgment
disorganized insight & judgment
organized insight & judgment
convulsions
seizures
confusion
lethargic
delirium
stupor
coma
restless
paranoid ideation
neurotic ideation
suicidal ideation
homicidal ideation
auditory hallucination
visual hallucination
MINI MENTAL EXAM
Orientation =
  (one point each)
- year?
- season?
- day of the week?
- date?
- time?
- month?
- state?
- city?
- hospital
- floor?
Registration =
  (repeat 3 objects, one point each)
- apple
- hospital
- coat
Attention/Calculation
  (one point for each letter)
- spell "WORLD" backward
Memory
  (recall 3 objects, one point each)
- dog
- tree
- orange
Language
(Name 2 objects, one point each)
- watch
- pillow
Repeat "No if's, and's or but's"
  (1 point)
Follow commands (3 points)
 Take this paper in your right hand
 fold it in half, 
 and put it on the floor
Written command (1 point)
"Close your eyes"
Write a sentence 
  See the lazy fox run.
Visual Spatial (1 point)
  Copy 2 overlapping pentagons
Total Score = 30 point
Normal: 25-30
Mild intellect impaired = 20-25
Mod intellect impaired = 10-20
Severe intellect impaired = 0-10



DIFF_DIAGNOSIS



