Patients name, age, race, sex; referring person, physician or clinic. SOURCE AND RELIABILITY: Name and reliability of informant (patient, old chart, relative). HISTORY OF PRESENT ILLNESS (HPI): Describe the course of the patients illness, including when it began, character of the symptoms; location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives,other related diseases; past illnesses or surgeries, past diagnostic testing. PAST MEDICAL HISTORY (PMH): Past diseases, surgeries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, COPD, MI, Cancer, Tuberculosis. In children include birth history, prenatal history, immunizations, type of feedings. MEDICATIONS: ALLERGIES: Penicillin, etc FAMILY HISTORY: Medical problems in relatives; specifically ask about problems similar to patients illness. Asthma, MI, heart failure, hypertension, Cancer, Tuberculosis, diabetes, kidney diseases, hemophilia. SOCIAL HISTORY:: Alcohol, smoking, drug usage. Spouse, relationship and children; work, everyday activities and home situations; exposure to carcinogens or environmental agents. In children include: Sleep, play habits, grade in school. What's your political affiliation? Depending on the situation.(Further questions) REVIEW OF SYSTEMS (ROS): General: Weight gain or loss, appetite loss, fever, chills, fatigue, night sweats. Skin:Rashes, bruising, skin discolorations. Head: Headaches, dizziness, tenderness, lumps or masses; history of seizures, head trauma. Eyes: Visual changes, visual acuity, visual field deficits, diplopia, inflammation. Ears: Tinnitus, vertigo, pain, discharge. Nose: Nose bleeds, discharge, sinus diseases. Mouth & Throat: Dental diseases, hoarseness, sore throat, pain. Respiratory: Cough, shortness of breath, sputum (color, amount), chest pain; history of PTB; vaccination for influenza or pneumococcus. Positive Purified Protein Derivative (PPD Testing). Cardiovascular: Chest pain, orthopnea, paroxysmal nocturnal dysonea; dyspnea on exertion, claudication, extremity edema. Gastrointestinal: Odynophagia, dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, melena, hematochezia, constipation, bloody stool, change in bowel habits, jaundice. Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge, impotence, testicular masses, penile discharge. Gynecological: Gravida/para, abortions, LMP (frequency, duration), age of menarche, menopause; dysmenorrhea, contraception, vaginal bleeding; last pelvic exam and pap smear, breast masses, self-examination, mammography. Endocrine: Polyuria, polydipsia, polyphagia, skin or hair changes, cold or heat intolerance, hormonal therapy. Musculoskeletal: Joint pain or swelling, arthritis, myalgias. Skin: Easy bruising, bleeding tendencies. Lymphatics: Lymphadenopathy. Neuropsychiatric: Weakness, seizures, paresthesias, memory changes, emotional depression disturbances. PHYSICAL EXAMINATION Vital Signs: Temperature, heart rate, respiratory rate, blood pressure (right and left arm, sitting and standing height), weight. Skin: Rashes, scars, moles; capillary refill (in seconds). Lymph Nodes: Cervical, supraclavicular, auxiliary, inguinal nodes; size, mobility, tenderness, consistency. Head: Bruising, tenderness. In pediatric patients check fontanelles. Eyes: Pupils equal round and react to light and accommodation (PERRLA); extra ocular movement intact (EOMI); visual fields and acuity. Fundoscopy (fundi, papilledema, arteriovenous nicking, hemorrhages, or exudates), conjunctiva; scleral icterus, ptosis. Ear: Discharge, acuity, tympanic membranes (dull, shiny, intact, injected, bulging). Nose: Discharge, exudates, polyps. Pediatrics: Nasal flaring. Mouth & Throat: Mucus membrane color and moisture level; oral lesions, dentitions, tonsils, erythema. Neck: Jugular venous distention (JVD), thyromegaly, lymphadenopathy; range of motions, masses, bruits, hepatojugular reflex (HJR). Chest: Equal expansion, tactile fremitus, percussion, auscultation, rhonchi, crackles, rubs, breath sounds, egophony, whispered pectoriloquy. Heart: Point of maximal impulse (PMI), thrills (palpable tubulance); regular rate & rhythm (RRR), first & second heart sounds (S1 & S2); gallops, murmurs (grade 1-6), pulses (grade 0-2+). Breast: Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia. Abdomen: Contour (flat, scaphoid, obese, distended); scars, bowel sound, tenderness, organomegaly, masses, liver span; splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle tenderness (CVAT), inguinal masses. Genitourinary: External lesions, hernias, scrotum, testicles, varicoceles. Pelvic Exam: Vaginal mucosa, cervical discharge; uterus size & masses, adnexa, ovaries, suprapubic tenderness. Extremities: Joint swelling, range of motions, edema (grade 1-4+); cyanosis, clubbing, edema (CCE);pulses (radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homans sign,; cyanosis, varicosities. Rectal Exam: Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; presence or absence of stool in rectal vault, prostate (nodules, tenderness, size). Neurological: Mental status & affect; cranial nerves 1-12; gait, strength (graded 0-5); touch sensation, pressure, pain, position & vertigo; deep tendon reflexes (graded 0-4+) (biceps, triceps, patellar, ankle); Romberg’s test (ability of patient to stand erect with arms outstretched and eyes closed). Cranial Nerve Exam: I: Smell II: Visions & Visual fields; III, IV, VI: Pupil responses to light; positional & pursuit eye movements, ptosis. V: Facial sensation, ability to open jaw against resistance, corneal reflex. VII: Close eyes tightly, smile, shows teeth. VIII: Watch tick, Weber test; Rinne’s Test. IX, X: Palette moves in midline when patient says ah, speech. XI: Shoulder shrug & turns head against resistance. XII: Stick out tongue in midline. Heel to skin test. Labs: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC (hemoglobin, hematocrit, WBC count, platelets, differential); X-rays, ECG, Urine Analysis (UA), liver function tests (LFTs). MENTAL STATUS EXAM : Orientation: Registration: Attention/Calculation: Memory: Language: etc