HISTORY OF PRESENT ILLNESS
HISTORY TAKING AND PHYSICAL EXAMINATION GUIDE TO DOCUMENTATION
VITAL SIGN MEASUREMENT
description of the circumstances describing the chief compliant
Expanding on the client’s chief complaint or positive response in the review of systems, develop questions
to obtain information about the following:
Location/Radiation, Quality, Quantity, severity (1-10), onset and duration, Frequency, Aggravating Factors,
Relieving Factors, Associated Symptoms, Effect on client’s functional status in own words.
BLOOD PRESSURE
PULSE
RESPIRATIONS
TEMPERATURE
RELEVANT READINGS FROM INTERMITTENT AND CONTINUOUS MONITORS
REVIEW OF SYSTEMS
PHYSICAL ASSESSMENT
Neurologic/Psychiatric
Convulsions, seizures, stroke, syncope, paralyses, tremor, incoordination, parathesias, difficulties with
memory or speech, sensory or motor disturbances, or muscular coordination (ataxia, tremor), Predominant
mood "nervousness" (define), emotional problems, anxiety, depression, previous psychiatric care, unusual
perceptions, hallucinations.
Head/Eyes/Ears/Nose/Mouth/Throat
Headaches (location, time of onset, duration, precipitating factors), vertigo, lightheadedness, injury
Blurred vision, double vision, tearing, blind spots, pain, hearing loss, ear pain, tinnitus. Nose bleeding,
colds, obstruction, discharge, Dental difficulties, gingival bleeding, dentures, sore throat. Neck stiffness,
pain, tenderness, masses in thyroid or other areas. Intolerance to extremes of hot and cold.
Neurologic/Psychiatric
Alert and oriented to person, place, time. Cooperative. Speech clear, appropriate, posture relaxed.
Recent/remote memory intact. Cranial nerves II-XII intact. Sensation to pinprick, light touch intact. Motor:
no atrophy, weakness or tremors bilaterally. Ambulates with steady gait. Negative Romberg’s sign.
Performs alternating movement. DTR’s intact. Note if falls precaution is in effect and restraints in use.
Head/Eyes/Ears/Nose/Mouth/Throat
Normocephalic, atraumatic. Facies symmetric, no weakness or involuntary movements noted.
Visual acuity intact.20/20/ OD, OS. Full visual fields intact by confrontation. No ptosis, no lidlag, discharge
PERRLA. Corneal reflex symmetric no strabismus. Conjunctive clear, sclera white. Pinna no masses,
lesions, tenderness, drainage. Whispered words heard bilaterally. Rhinne: AC>BC. Weber: no
lateralization. Nares patent, no tenderness, lesions, discharge. Pharynx pink, no lesions, dentition in good
repair, uvula rises on midline, positive gag reflex.
Cardiovascular
No JVD. No heaves, no thrills. Heart sounds: S1, S2 no S3 S4 gallop or murmurs. Regular rate and
rhythm. Indicate cardiac rhythm on continuous cardiac monitoring. If murmur note grade, timing,
location, quality and radiation. Record weight and I/O.
Peripheral vascular
Color pink, no lesions, varicosities, symmetric bilaterally. Hair present. No edema, calf tenderness, all
perpheral pulses present (Grade +), no changes in temperature. Capillary refill < 3 seconds. Note use of
antithrombotics devices.
Respiratory
Respirations even and unlabored, no use of accessory muscles. Trachea midline. Chest symmetric, AP
diameter not increased. No tenderness on palpation. Lung fields resonant. Diaphragmatic excursion (4-7
cm) and = bilaterally. Lungs clear to auscultation, no adventitious sounds. Record presence of adjunct
oxygen therapy, use of pulse oximetry and presence of thoracic tubes.
Gastrointestinal
Abdomen flat, symmetric. No lesions, herniations, gas patterns, venous patterns or pulsations.
Normoactive bowel sounds in all quadrants. Tympanitic to percussion. Abdomen soft nontender. Liver
span (7cm). Murphy’s sign negative. No organomegaly. No rebound tenderness, McBurney’s point
negative. Femoral pulses present bilaterally. No lymphadenopathy. Record bowel elimination pattern. Note
presence of gastrointestinal tubes, drains, and dressings. Indicate tolerance to diet type and use of
capillary blood sugar measurements
Genitourinary
External genitalia no lesions or discharge. Describe urinary pattern: continence, frequency, volume, color,
odor clarity. Document presence of indwelling catheter noting size, type and if irrigation is in progress.
Cardiovascular
Chest pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea, nocturnal paroxysmal
dyspnea, edema, cyanosis, hypertension, heart murmurs, anemia, bleeding problems, history of heart
disease
Peripheral vascular
Pain, numbness, swelling in extremities, temperature changes, discoloration or changes in color, varicose
veins, infections, or ulcers. Claudication, asymmetry.
Respiratory
History of lung disease, pain (location, quality, relation to respiration), shortness of breath, wheezing,
stridor, cough (time of day, of productive, amount in tablespoons or cups per day and color of sputum),
hemoptysis, respiratory infections, tuberculosis (or exposure to tuberculosis), fever or night sweats.
Gastrointestinal
Changes in appetite, dysphagia, indigestion, food intolerances, abdominal pain, heartburn, nausea, vomiting,
hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul
smelling), flatulence, hemorrhoids, recent changes in bowel habits, use of laxatives, surgical incisions,
presence of drains. History of ulcers, cirrhosis, gallbladder disease, appendicitis.
Genitourinary
Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine,
stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute retention or incontinence,
change in libido, potency, genital lesions, discharge, venereal disease, presence of indwelling catheters,
stents.
(Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, vaginal discharge,
post-menopausal bleeding, dyspareunia, number and results of pregnancies (gravida, para)
Musculoskeletal
Pain, swelling, redness or heat of muscles or joints, limitation, of motion, muscular weakness, atrophy,
cramps. History of arthritis, osteoporosis, calcium supplementation, fractures, strains, sprains.
Skin/Breast
Rash, itching, change in pigmentation, excessive moisture or dryness, presence of wounds, presence of
invasive devices, alterations in texture, changes in hair growth , texture or loss, nail changes. Breast lumps,
tenderness, swelling, nipple discharge
Note if menses is in progress, date of menstrual flow, quality and quantity of bleeding.
Musculoskeletal (TMJ, Neck, shoulders, elbows, wrists, hands, spine, hips, knees, ankle, feet)
No joint pain, tenderness, FROM. Extremities symmetric, no tenderness, weakness, discoloration, or
swelling. Maintains flexion against resistance. Vertebra nontender, no curvature, no deformity.
Skin/Breast
Skin pink warm dry to touch. No lesions, hyper/hypopigmentation. Hair even distribution, texture, no pest
inhabitants. Nails no clubbing, cyanosis, and discoloration. Breasts symmetric: no lesions, lumps, changes
in pigmentation or nipple discharge. No lymphadenopathy.