Maxwell - Hx/PEx

Question 1

Chief complaint:

Answer 1

Health problem/ Complaint in pts own words.

Question 2

History of presenting illness:

Answer 2

Chronological order of time/ place of symptom(s):

1. Onset.
2. Duration.
3. Frequency.
4. Location.
5. Quality.
6. Quantity/Severity.
7. Aggravating/Alleviating factors.
8. Associated symptoms.
9. Self treatment.
10. Relevant lab values.
11. Pertinent negatives.

Question 3

PMHx:

Answer 3

1. General health.
2. CHILDHOOD illnesses (MMR, pertussis, chicken pox, RF, scarlet fever, polio).
3. ADULT illnesses.
4. ACCIDENTS/INJURIES.
5. IMMUNIZATIONS ==> DPT, MMR, polio, HBV, H.flu, S.pneumo, VZV.
6. SCREENING ==> Ht, urinalysis, TST, pap, mammogram, occult stool blood, cholesterol.

Question 4

Past surgical Hx:

Answer 4

1. Operation date, type, reason, outcome.
2. Blood transfusions.
3. Complications.

Question 5

FHx:

Answer 5

1. Age, health/ death of paretns, siblings, spouse, children.

CHECK:

1. DM.
2. Heart disease.
3. HTN.
4. Stroke.
5. Cancer.
6. Bleeding disorders.
7. Asthma.
8. Arthritis.
9. TB.
10. Epilepsy.
11. Mental illness.

Question 6

Social Hx:

Answer 6

1. Birthplace.
2. Education.
3. Employment.
4. Religion.
5. Marriage/divorce.
6. Living accommodations.
7. Persons at home.
8. Diet.
9. Exercise.
10. Hobbies.

Question 7

Medications:

Answer 7

1. Name.
2. Dose.
3. Frequency.
4. Duration.
5. Reason for taking.
6. Compliance.
7. Availability.

Question 8

Allergies:

Answer 8

Medications/ Substances causing reaction (rash, swelling, difficulty breathing, etc).

Question 9

Tobacco/ Alcohol/ Drugs:

Answer 9

1. Type.
2. Amount.
3. Frequency.
4. Duration.
5. Reactions.
6. Treatment.

Question 10

Review of systems (ROS) - General:

Answer 10

1. Weight change.
2. Fatigue.
3. Weakness.
4. Fever.
5. Chills.
6. Night sweats.

Question 11

ROS - Skin:

Answer 11

1. Skin.
2. Hair.
3. Nail changes.
4. Itching.
5. Rashes.
6. Sores.
7. Lumps.
8. Moles.

Question 12

ROS - Head:

Answer 12

1. Trauma.
2. Headache location/Frequency.
3. Nausea/Vomiting.
4. Visual changes.

Question 13

ROS - Eyes:

Answer 13

1. Glasses.
2. Contact lenses.
3. Blurriness.
4. Tearing.
5. Itching.
6. Acute visual loss.

Question 14

ROS - Nose, sinuses:

Answer 14

1. Rhinorrhea.
2. Stuffiness.
3. Sneezing.
4. Itching.
5. Allergy.
6. Epistaxis.

Question 15

ROS - Mouth, throat, neck:

Answer 15

1. Bleeding gums.
2. Hoarseness.
3. Sore throat.
4. Swollen neck.

Question 16

ROS - Breasts:

Answer 16

1. Skin changes.
2. Masses/lumps.
3. Pain.
4. Discharge.
5. Self exam.

Question 17

ROS - Cardiac:

Answer 17

1. HTN.
2. Murmurs.
3. Angina.
4. Palpitations.
5. Dyspnea on exertion.
6. Orthopnea.
7. PND.
8. Edema.
9. Last ECG.

Question 18

ROS - Respiratory:

Answer 18

1. SOB.
2. Wheeze.
3. Cough.
4. Sputum.
5. Hemoptysis.
6. Pneumonia.
7. Asthma.
8. Bronchitis.
9. Emphysema.
10. TB.
11. Last CXR.

Question 19

ROS - GI:

Answer 19

1. Appetite.
2. Nausea/Vomiting/Diarrhea/Constipation.
3. Indigestion.
4. Dysphagia.
5. Bowel movement frequency/change.
6. Stool color.
7. Bleeding (hematemesis, hemorrhoids, melena or hematochezia).
8. Abdominal pain.
9. Jaundice.
10. Hepatitis.

Question 20

ROS - Urinary:

Answer 20

1. Frequency.
2. Hesitancy.
3. Polyuria/Dysuria/Hematuria/Nocturia.
4. Incontinence.
5. Stones.
6. Infection.

Question 21

ROS - Genital (male):

Answer 21

1. Penile discharge or sores.
2. Testicular pain or masses.
3. Hernias.

Question 22

ROS - Genital (female):

Answer 22

1. Menarche.
2. Period regularity.
3. Frequency.
4. Duration.
5. Dysmenorrhea.
6. Last period.
7. Itching.
8. Discharge.
9. Sores.
10. Pregnancies + complications.
11. Miscarriages/abortions.
12. Birth control.
13. Menopause.
14. Hot flashes/ sweats.

Question 23

ROS - Genital (general):

Answer 23

1. STD.
2. History/Tx.
3. Sex interest.
4. Function.
5. Problems.
6. Contraception methods.

Question 24

ROS - Vascular:

Answer 24

1. Leg edema.
2. Claudication.
3. Varicose veins.
4. Thromboses/emboli.

Question 25

ROS - Musculoskeletal:

Answer 25

1. Muscle weakness.
2. Muscle pain.
3. Joint stiffness.
4. Range of motion.
5. JOINT instability, redness, swelling, arthritis, gout.

Question 26

ROS - Neurologic:

Answer 26

1. Loss of sensation/numbness, tingling.
2. Tremors.
3. Weakness/paralysis.
4. Fainting/blackouts.
5. Seizures.

Question 27

ROS - Hematologic:

Answer 27

1. Anemia.
2. Easy bruising/Bleeding.
3. Petechiae.
4. Purpura.
5. Transfusions.

Question 28

ROS - Endocrine:

Answer 28

1. Heat/cold intolerance.
2. Excessive sweating.
3. Polyuria.
4. Polydipsia.
5. Polyphagia.
6. Thyroid problems.
7. Diabetes.

Question 29

ROS - Psychiatric:

Answer 29

1. Mood.
2. Anxiety.
3. Depression.
4. Tension.
5. Memory.