Nurs-6512 Assign wk3

Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Seidel: Mosby’s Guide to Physical Examination, 7 th

Edition

Checklists - History

History—Subjective Data

ID

Age, gender, DOB

CC

Reason for seeking care

HPI

O-onset

L-location

D-duration

C-character

A-aggravating/associated factors

R-relieving factors

T-temporal factors

S-severity

Medications, treatments

PMH

General health, surgeries, hospitalizations, illnesses, immunizations, medications,

allergies, blood transfusions, emotional status/psychiatric history

PERSONAL HISTORY

Cultural background, marital status, occupation, economic resources, environment

HEALTH HABITS

Tobacco, alcohol, illicit drugs, lifestyle, diet, exercise, exposure to toxins

HEALTH MAINTENANCE

Last PE; diagnostic tests (date, result, follow-up); self-exams (breast, genital,

testicular); last Pap smear, mammogram

FAMILY HISTORY

(Parents, siblings, children)

Cancer, DM, hypertension, heart disease, stroke

REVIEW OF SYSTEMS

GENERAL

Fever, chills, malaise, fatigue/energy, night sweats, desired weight

DIET

Appetite, restrictions, vitamins, supplements

SKIN, HAIR, NAILS

Rash, eruptions, itching, pigment changes

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2

HEAD AND NECK

Headaches, dizziness, head injuries, loss of consciousness

EYES Blurring, double vision, visual changes, glasses, trauma, eye diseases

EARS Hearing loss, pain, discharge, vertigo, tinnitus

NOSE

Congestion, nosebleeds, postnasal drip

THROAT AND MOUTH

Hoarseness, sore throat, bleeding gums, ulcers, tooth problems

GASTROINTESTINAL

Indigestion, heartburn, vomiting, bowel regularity/changes

LYMPH

Tenderness, enlargement

ENDOCRINE

Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes, increased

hat, glove, or shoe size

FEMALE

LMP, age at menarche, gravity, parity, menses (onset, regularity, duration,

symptoms), sexual life (number of partners, satisfaction), contraception, menopause

(age, symptoms)

MALE

Puberty onset, erections, testicular pain, libido, infertility

BREASTS

Pain, tenderness, lumps, discharge

CHEST AND LUNGS

Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, exposure to

TB

CARDIOVASCULAR

Chest pain, palpitations, number of pillows, edema, claudication, exercise tolerance

HEMATOLOGY

Anemia, easy bruising

GENITOURINARY

Dysuria, flank pain, urgency, frequency, nocturia, hematuria, dribbling

MUSCULOSKELETAL

Joint pain, heat swelling

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NEUROLOGIC Fainting, weakness, loss of coordination

MENTAL STATUS

Concentration, sleeping, eating, socialization, mood changes, suicidal thoughts