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15 Cards in this Set

  • Front
  • Back
Informant
source of information
Chief Complaint (CC)
reason for the visit
History of Present Illness (HPI)
onset, course, treatment for CC
Medications
list with doses/time of day, reason for medications, include OTC
Allergies
list and ask what happens
Past Medical History (PMH)
all hospitalizations; medical illness; trauma; OB/GYN hx; surgeries
Family History
blood relatives - review illnesses (i.e. HTM; DM; CA); age; ?deceased
Social History
place of birth; education; occupation; diet; exercise; caffiene intake; drug/ETOH use; tobacco use
Review of Systems (ROS)
list by symptoms; expand on postive symptoms
Physical Exam (PE)
complete from head to toe; includes neuro and mental status
General Appearance
describe patient’s appearance
Vital Signs
TPR; BP; weight; height
Skin
inspect color, lesions, moisture, edema
Head
includes face, scalp, neck
Head - inspect
general size & contour; facial expression; symmetry of neck; involuntary movements?; edema?; lesions?; active ROM;