II. History: Chief Complaint

  1. Reason for the encounter

III. History: Present Illness (HPI)

  1. Components (8 HPI elements)
    1. Location
    2. Severity
    3. Timing
    4. Modifying factors
    5. Quality
    6. Duration
    7. Context
    8. Associated signs and symptoms
  2. Mnemonic: PQRST (plus context and associated factors)
    1. Palliative and Provocative (modifying factors)
    2. Quality
    3. Region and Radiation (location)
    4. Severity
    5. Timing (and duration)

IV. History: Past Medical

  1. Current medications
  2. Drug allergies
  3. Prior surgeries
  4. Prior hospitalizations
  5. Prior major illnesses or injuries
  6. Immunizations

V. History: Family

  1. Health status or cause of death of near relatives
    1. Parents
    2. Siblings
    3. Childrens
  2. Specific disease related to CC, HPI, ROS
  3. Hereditary Diseases for which the patient is at risk

VI. History: Social

  1. Occupational history
  2. Current employment
  3. Level of education
  4. Marital status or living arrangements
  5. Sexual history
  6. Habits
    1. Nutritional status
    2. Tobacco use
    3. Alcohol use
    4. Illicit Drug use

VII. History: Review of Systems (14 systems)

  1. See Review of Systems
  2. Constitutional
  3. Eyes
  4. Ears, nose, mouth, throat
  5. Cardiovascular
  6. Respiratory
  7. Gastrointestinal
  8. Genitourinary
  9. Musculoskeletal
  10. Skin (integument, includes Breast)
  11. Neurologic
  12. Psychiatric
  13. Endocrine
  14. Hematologic or Lymphatic
  15. Allergic or immunologic

VIII. Exam (12 systems)

  1. Constitutional
  2. Eyes
  3. Ears, Nose, Throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Skin (integument, includes Breasts)
  10. Neurologic
  11. Psychiatric
  12. Hematologic or Lymphatic

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