SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE

OUTLINE FOR MEDICAL HISTORY

AND PHYSICAL EXAMINATION
Order of examination and type of information desired is indicated. Further
details may be necessary in individual cases. Use only approved
abbreviations in writing a history and physical examination.
HISTORY
Date, Name and Status of Examiner, e.g., John Doe, Senior Student.
CHIEF COMPLAINT
This is a simple statement in answer to the question, "What symptoms
brought you to the hospital?" Give duration.
PRESENT ILLNESS
1.

Include age, sex, and race.

2.

Give details of all symptoms and events concerned with the illness
with qualitative and quantitative appraisal. Give location, radiation,
character, severity, duration, and time course of symptoms. Describe
factors making symptoms worse or better.

3.

Description of events should be in chronological order. The

appearance of each symptom or event during the course of the
present illness should be related accurately to the time of the present
admission.

4.

It is essential to give negative as well as positive information relevant

to the symptoms and circumstances of a patient's disease.

5.

Make clear why the patient seeks aid at this particular time.

6.

List all medications and other treatments the patient has used for
this illness and the response to them.

PAST HISTORY
1.

Medications - Complete list of all medications (prescriptions, over the

counter, vitamins, supplements, eye drops, contraceptives) with
dosage and reason for use.

2.

Allergies - Drug or food reactions, environmental allergies. Describe

type of reaction.

3.

Medical history Details of current or past acute or chronic illness.

Include negative as well as positive information on common adult
medical problems as well as childhood illnesses.

4.

Surgical history - Include dates of and indications for surgical

procedures.

5.

Other hospitalizations

SOCIAL HISTORY
1.

Habits - Diet, exercise, sleep. Consumption of caffeine, tobacco,

alcohol, other drugs.

2.

Sexual history - Number of sexual partners, exposure to or history of

sexually transmitted diseases.

3.

Occupation Education, past and present work. Exposure to

occupational diseases and/or chemicals.

4.

Home environment Marital status. Others living at home. Ability to

perform ADLs and IADLS.

5.

Name and address of patient's physician(s).

FAMILY HISTORY
1.

Health status or cause of death of parents, brothers or sisters, with

current age or age at death.

2.

State presence or absence of conditions such as rheumatic disease,

gout, allergy, tuberculosis, renal disease, heart disease, diabetes,
cancer, mental and neurological disorders, epilepsy, migraine,
hypertension, blood diseases and obesity.

Report details and genogram if any hereditary disease is discovered

such as sickle cell anemia, muscular dystrophy, etc.

REVIEW OF SYSTEMS
1.

Constitutional Fever, chills, sweats, weight change, fatigue.

2.

Skin - Eruptions, itching, changes in pigmentation and texture.

3.

Head - Headaches, dizziness, vertigo, facial pain.

4.

Eyes - Vision, corrective lenses, diplopia, pain, lacrimation,

scotomata.

5.

Ears - Hearing, earache, discharge, tinnitus.

6.

Nose - Epitaxis, colds, congestion, discharge.

7.

Mouth and Throat - Dental difficulties, sore throat, hoarseness,

dysphagia, odynophagia.

8.

Neck - Stiffness, pain, tenderness, masses in thyroid or other areas.

9.

Lymph Nodes - Local or general glandular enlargement or

tenderness.

10.

Breasts

Lumps,

tenderness,

swelling,

nipple

discharge,

mammogram, breast self-exam.

11.

Respiratory - Pain, shortness of breath, wheezing, chronic cough,

sputum (amount and description), hemoptysis, pneumonia,
tuberculosis or exposure.

12.

Cardiovascular - Chest pain, MI, palpitations, dyspnea on exertion,

orthopnea, paroxysmal nocturnal dyspnea, edema, cyanosis,
hypertension, heart murmurs, varicosities, phlebitis, claudication,
rheumatic fever, hyperlipidemia.

13.

Gastrointestinal - Appetite and digestion, abdominal pain, ulcers,

eructation, nausea, vomiting, hematemesis, jaundice, diarrhea,
constipation, use of laxatives, abnormal stools (clay-colored, tarry,
bloody), steatorrhea, hemorrhoids, recent change in bowel habits.

14.

Genitourinary - Urgency, frequency, dysuria, pain, nocturia,

hematuria, polyuria, facial edema, oliguria. Unusual color of urine.
Stones, kidney or bladder infections, nephritis. Difficulty in starting
stream, dribbling, size of stream, retention or incontinence. Libido,
potency, genital sores, discharge.

15.

Menstrual and obstetric - Age at onset of menses, regularity, last

period, dysmenorrhea, menorrhagia, metrorrhagia, leucorrhea. Age
at menopause, menopausal symptoms, post-menopausal bleeding.
Number and outcome of pregnancies. Complications of pregnancy,
including toxemia. Last Pap smear.

16.

Musculoskeletal - Pain, swelling, redness, or warmth of muscles or

joints. Limitation of motion, muscular weakness, atrophy, cramps.
Fractures or other injuries.

17.

Metabolic - Polydipsia, polyuria,

intolerance to heat or cold.

18.

Hematological - Anemia, bleeding tendency, previous transfusions

and reactions, Rh incompatibility, hemoglobinopathy, splenomegaly
or splenectomy.

19.

Neuropsychiatric - Seizures, paralyses, tremor, incoordination,

syncope, numbness, paresthesias. Difficulties with memory, speech,
special senses, gait. Anxiety, depression, psychosis, previous
psychiatric care.

asthenia,

hormone

therapy,

PHYSICAL EXAMINATION
1.

Vital signs - Temperature, pulse and respiratory rates, blood

pressure, height, weight, body mass index. When indicated, take
blood pressure in both upper extremities, in lower extremities, and/or
in supine and standing positions.

2.

General appearance and mental status - Sex, body habitus, apparent

age, apparent state of health, gross deformities, distress.

3.

Skin - Texture, turgor, color, moisture, eruption, pigmentation, pallor,

spider angiomata, abnormalities of nails and hair. Inspection of entire

skin surface including scalp and between digits.
4.

Head - Deformities, scars, tenderness, bruits, facial edema.

5.

Eyes Lids and external ocular structures ptosis, lesions, swelling.

Conjunctivae and sclerae - injection, petechiae, jaundice, pallor.
Extraocular muscle function. Pupils - size, shape, reaction, equality.
Eyeballs - prominence, motion, tension. Iris - lesions. Corneal or
lenticular opacities. Vision, visual fields to confrontation. Fundi
discs, vessels, retina.

6.

Ears - Hearing, air and bone conduction, discharge, tophi, mastoid

tenderness, canals and tympanic membranes.

7.

Nose - Septal deviation or perforation, obstruction, sinus tenderness,

appearance of mucosa.

8.

Mouth and Throat - Breath, fissures. Mucosa lesions, color. Tongue

and subglossal area - coat, moisture, coloration, papillary atrophy,
tremors. Teeth and gingivae - pyorrhea, caries, lead line. Throat appearance of tonsils and mucosa. Have patient remove any dental
appliances.

9.

Neck - Scars. Thyroid (with and without swallowing), masses, venous

engorgement, abnormal pulsation, tracheal tug, position of trachea,
submandibular gland, resistance to flexion, range of motion.
Palpation and auscultation of carotids.

10.

Lymph Nodes - Size, consistency, mobility and tenderness of

cervical, axillary, supraclavicular, epitrochlear and inguinal nodes.

11.

Back and Spine - Vertebral tenderness, scoliosis, kyphosis, lordosis,

mobility.

12.

Thorax - Configuration, symmetry, mobility, scars, abnormal

pulsations or retractions, dilated veins.
Breasts - Masses,
tenderness, discharge, skin changes.

13.

Lungs Respiratory effort, use of accessory muscles, symmetry of

respiratory movements. Cough. Fremitus. Resonance, level of
diaphragm and excursion. Breath sounds in all areas, voice and
whisper, rales, rhonchi, wheezes, rubs.

14.

Heart - Apical impulse, thrills, heaves, heart borders. Rhythm. Heart

sounds, murmurs (characterize fully), gallops, friction rub. Unless
contraindicated, listen to heart in erect, recumbent and left lateral
decubitis positions. Cover all valve areas, neck and back.

15.

Abdomen - Scars, contour, dilated veins, spasm, bowel sounds,

tenderness (direct, indirect and rebound), hernia, costovertebral
angle tenderness. Location, size, shape, consistency, mobility,
tenderness of any mass or palpable organ, including liver, spleen,
kidneys, bladder. Distention, shifting dullness, fluid wave.

16.

Extremities - Character of peripheral arteries and veins. Presence of

varicosities. Color, temperature, deformities, limitation of motion,

clubbing of digits, edema.
17.

Genitalia Male: discharge, scars, lesions, scrotal masses. Female:

perineum and external genitalia, vagina, cervix, fundus, adnexae.
Tenderness, discharge, lesions, bleeding, ulcerations, masses.

18.

Neurological Sensory - vibratory, proprioception, pain. Motor muscle strength, tone, atrophy, tremors, fasciculations, spasticity,
clonus. Reflexes: superficial - abdominal, cremasteric; deep biceps, triceps, patellar, Achilles; abnormal reflexes Babinski.
Cerebellar Romberg, gait, coordination. Cranial nerves. Mental
status and sensorium.

19.

Rectal - Hemorrhoids, fissures, fistulae. Digital - sphincter tone,

tenderness, masses, prostate, stool or blood on examining finger.

LABORATORY AND OTHER STUDIES

PROBLEM LIST - A brief listing and grouping of positive historical, physical
and laboratory findings.
DISCUSSION/DIFFERENTIAL DIAGNOSIS
The discussion section should include a pertinent differential diagnosis
and a provisional or working diagnosis for each identified problem based
on the information available to you. This discussion should integrate the
patients' presentation with your textbook reading on the subject. Evidence
of reading from a major textbook should be evident in your discussion.
However, a listing of all of the causes for a specific problem is not
necessary. Simply provide those that are pertinent to the patient under
discussion. A provisional diagnosis (the most likely diagnosis for the
problem given the available information) should be identified. The
discussion should include answers to the questions of how a diagnosis
was reached and why you reached your conclusions. Reasons for
excluding some diagnoses and including others should be apparent. A
diagnostic plan (other studies you feel are important to further define the
problem) and a therapeutic plan (treatment you feel is most appropriate at
this point) for each problem should be included. Although you are free to
discuss your patient with residents and faculty, your written discussion
should be a reflection of your thoughts and reading.
Your Signature