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History and Physical Exam Guide
NRP/516 Version 2
University of Phoenix Material
HISTORY AND PHYSICAL EXAM GUIDE
I. History
Name
Age/DOB
Source of history and reliability
Race
CHIEF COMPLAINT (CC)

In terms of nature and duration; briefly, in patient’s own words
HISTORY OF PRESENT ILLNESS (HPI)

Last feeling well

General health

Onset

Character

Location

Radiation

Duration

Frequency

Time of day occurring

Severity/disability

Progression

Change in character

Associated phenomena

Occupation and relation of symptoms to work activities

What makes it better

What makes it worse

Prior history of same

Contact with others with same problem

Prior treatment

Current treatment, if any

Previous studies

Other diseases/illnesses that may influence PI

Patient’s perception of problem

Patient’s concern

Patient’s expectations of treatment/provider
PAST MEDICAL HISTORY (PMH)

Adult medical illness (MI, angina, HTN, DM, hypercholesterolemia, CVA, TIA, CA,
asthma, COPD, PUD, thyroid, arthritis, psychiatric, AIDS, TB, and such)

Surgery (appe, chole, TAH, breast, gyn, BTL, cesarean section, GI, CABG, GU/TURP,
ortho, CA, and such)

Childhood illnesses - non-episodic, (such as rheumatic fever)
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History and Physical Exam Guide
NRP/516 Version 2

Trauma (MVA, GSW, stab wound, fractures, falls)

Date of most recent PE (PAP, mammo, PSA, stool guaiac, flex sig, CXR, HIV test)
MEDICATIONS (prescription & OTC with dose & frequency)
ALLERGIES (meds., IVP dye, food, insects, animals, occupational) List reaction to each.
SOCIAL HISTORY (SH)

Marital status - (single married, widowed, divorced)

Sexual orientation - heterosexual, homosexual, bisexual

Occupation, educational level, religion

Diet, exercise regimen, water intake

Sleep pattern

Place of birth, place of residence
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Smoker (cigarettes, pipe, cigar, marijuana); chewing tobacco

Alcohol, caffeine intake (quantify)

IVDU, crack cocaine, PCP, amphetamines, LSD
IMMUNIZATIONS & TRAVEL (foreign only)

Childhood: Hep B, DTP-DTaP, Hib, Polio(IPV,OPV), MMR, Td, Influenza, Varicella, Hep
A, Hep B, Pneumovax

PPD status: Hx BCG, Immune globulin
FAMILY HISTORY (FH)

Parents, siblings, children, step family

Genetic diseases, (Tay Sachs, sickle cell, CF, etc)

DM, HTN, CVA, ASHD, CA, hyperlipidemia, colon polyps, kidney disease, psychiatric
illness, TB, arthritis

Genogram
REVIEW OF SYSTEMS (ROS)

General: Pt’s perception of current state of health

HEENT: headache, diplopia, blurred vision, eye pain or redness, cataracts, glaucoma,
loss of visual field, hearing loss, tinnitus, vertigo, sinus infections, postnasal drip, nasal
polyps, epistaxis, teeth/gums, oral cavity ulcers or growths, sore throat, hoarseness, use
of glasses, contacts, or dentures.

Pulm: cough, sputum, hemoptysis, dyspnea, pleuritic chest pain, wheezing, asthma,
recurrent infections - bronchitis or pneumonia, occupational exposures (asbestos,
pneumonoconiosis)

Cardiac: chest pain or pressure, palpitations, orthopnea, PND, SOB, pedal edema, heart
murmur, high blood pressures, high cholesterol.

GI; wt gain/loss, nausea, vomiting, diarrhea, constipation, hematemesis, melena,
BRBPR, change in stool caliber, hemorrhoids, hepatitis, ulcer, GB dysphagia, belching or
flatus, abd pain; pain radiation, what improves or increases pain, change in appetite,
hernia
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History and Physical Exam Guide
NRP/516 Version 2
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GU: dysuria, hematuria, nocturia, frequency, polyuria, decreased force of urination,
hesitancy, incontinence, nephrolithiasis, UTIs.

Female: menarche, menopause, menstrual cycle character, PMS, date last LMP,
dysmenorrhea, postmenopausal bleeding, vag discharge, STDs, DES exposure,
endometriosis, BCP method, breast lumps, nipple discharge, # pregnancies - live births,
lost pregnancies, (GPA), dyspareunia, sexual dysfunction.

Male: hernia, testicular masses or pain, penile discharge, penile sores, prostate firmness, size (grade 1 - 4/4), sexual dysfunction, STDs.

Neuro: dizziness, syncope, seizures, vertigo, paresthesias, weakness, tremor, memory
disturbance.

Rheum: arthritis, joint stiffness or swelling, myalgias, back pain.

Vascular: phlebitis, varicose veins, claudication, cramping,

Endo: polyuria, polydipsia, polyphagia, cold-heat intolerance, thyroid, osteoporosis

Heme: anemia, ease of bruising or bleeding, prior transfusions & reactions, blood type,
lymph node enlargement, pain fatigue, fever, chills, night sweats.

Derm: rashes, changes in moles, birthmarks, skin dryness, pruritus, pigmentation
change; lumps

Psych: depression, agitation, panic/anxiety, manic episodes, personality changes,
hallucinations.
II. Physical exam (PE)

General appearance (well developed, well nourished, race, sex, in no apparent distress)

VS: (BP, P, RR, Wt, Ht)

HEENT: Head (normocephalic) scalp; Eyes: PERLA, EOM, retinal vessels, lids,
conjunctiva, sclera, visual fields and acuity: Ears: pinnae, ext auditory canal, tympanic
membrane with light reflex, Rinne’, Weber, acuity. Nose: mucosa, septum, polyps.
Throat/oral; lips, buccal mucosa, palate, tongue, tonsils, gingiva, teeth/dentures, gag
reflex

Neck: trachea/larynx, thyroid (goiter, nodules, bruit), carotid artery (contour, bruit),JVD.

Respiratory/thorax: contour, resp. expansion, breath sounds (wheezes, rales, rhonchi,
rub, tubular, egophony, whispered pectoriloquy), resonance, diaphragmatic movement,
intercostal muscle retraction, chest/abd paradoxical movement.

Cardiac: PMI, cardiac apex (4-5th ICS, MCL) palpable lift, thrill or sustained impulse,
heart sounds (S1, S2, S3, S4, systolic click, opening snap, pericardial knock), murmur
(systolic, diastolic, continuous, radiation, location, duration, loudness, pitch, quality).

Abdomen: appearance, bowel sounds, scars, distension, bruits, ascites, fluid waves,
liver, spleen, aorta, tenderness, guarding, rebound, tympany, umbilicus, kidneys, CVA
tenderness, ventral hernia, bladder, masses.

GU: Male escutcheon, penis, scrotum, testicles, varicocele, hydrocele, hernia (inguinal or
femoral). Female: escutcheon, ext genitalia, Skene’s & Bartholin’s glands, urethra,
speculum exam (cervix, uterus, adnexa, lymph, nodes; rectovaginal).

Rectal; external lesions, hemorrhoids, fissures, sphincter tone and tenderness, masses,
stricture, prostate size & nodules, stool appearance & guaiac.

Musculoskeletal: appearance, joint swelling, deformity, tenderness, bony proliferation,
range of motion, muscle group atrophy, hypertrophy, spasm, fasciculations , strength,
spinal contour(kyphosis, scoliosis), range of motion and tenderness.

Nodes: auricular (pre & post), occipital, tonsillar, cervical (superficial, posterior & deep
chain), submandibular, submental, supraclavicular, infraclavicular, epitrochlear, & axillary.

Breast: symmetry, skin changes, nipple retraction or discharge, masses, tenderness.
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History and Physical Exam Guide
NRP/516 Version 2
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Vascular: arterial pulse contour & bruits (radial, ulnar, brachial, carotid, aorta, femoral,
popliteal, post tibial, dorsalis pedis. Grading; 1+ decreased, 2+ normal, 3-4+ increased.
Varicose veins, venous insufficiency, (edema, stasis ulcers, pigmentation).

Extremities/skin: clubbing, cyanosis, edema, color, pigmentation, turgor, texture,
temperature, lesions, nailbeds, hair.
Neuro:



Mental Status;

Alertness – LOC, attention & concentration, mood & behavior, thought content.

Orientation – name, place of location, date, time.

Memory – immediate (recall 7 numbers)

Calculation – subtract serial 7’s from 100
Gen. Info - current events, presidents, personalities,(entertainment, sports, authors,
political capital cities

Abstract concepts – “a rolling stone gathers no moss” etc.

Speech – aphasia, dysarthria, dysphonia; language

Cortical integration – Agnosia, apraxia
Cranial nerves:

I Olfactory – smell

II Optic – visual acuity, visual fields, ocular fundi

III Oculomotor – EOM

IV Trochlear – EOM

V Trigeminal – corneal reflex, facial sensation, temporal & masseter muscle strength

VI Abducens – EOM

VII Facial – facial movements & taste

VIII Acoustic – hearing, Weber, Rinne’

IX / X Glossopharyngeal / Vagus – swallowing, rise of palate, gag reflex

XI Spinal accessory – sternocleidomastoid & trapezius strength

XII Hypoglossal – tongue movement, strength

Motor (upper/lower motor neurons): muscle groups/strength (muscle tone, atrophy),
fasciculation, clonus, gait, Romberg, involuntary movement (tremor, rigidity, tic, chorea,
athetosis, asterixis, ataxia); coordination (finger- nose, heel-shin, pronation-supination, rapid
alternating movements of fingers/foot

Sensory: pain (sharp/dull), temperature, fine touch, joint position & motion, vibration, twopoint discrimination, stereognosis, graphesthesia, proprioception

Reflexes: biceps, triceps, brachioradialis, quadriceps, cremasteric, abdominal, Achilles,
Babinski
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