Components of a Complete History and Physical Examination

1. Source of History and Reliability of the Source

2. Chief Complaint (CC)

3. History of Present Illness (HPI)
   (including a complete and thorough system review of the affected system[s])

4. Other History

   1. Medical

   2. Surgical

   3. Allergies and their Manifestations

   1. Medication

   2. Environmental

   4. Medications

   1. Name

   2. Dose

   3. Frequency and Route of Administration

5. Family History

6. Personal and Social History

   1. Alcohol

   2. Tobacco

   3. Drug Abuse

   4. Travel

7. Review of Systems (ROS)

   1. General

   2. Skin

   3. Eyes and Vision

   4. Ears and Hearing

   5. Nose and Throat

   6. Respiratory

   7. Cardiac

   8. Gastrointestinal

   9. Genito-Urinary

   10. Gynecological

   11. Neurological

   12. Psychiatric

   13. Musculo-skeletal

   14. Hematologic

   15. Endocrine

8. Physical Examination

1. Vital Signs

   1. Temperature

   2. Pulse

   3. Respirations

   4. Blood Pressure

   5. Height

   6. Weight

2. General Appearance

3. Skin and Glandular

4. Head

   1. General

   2. Eyes

   3. Ears

   4. Nose

   5. Mouth

      1. Teeth

      2. Tongue

      3. Throat

5. Neck

   1. Thyroid

6. Thorax and Breasts

7. Lungs

8. Cardiovascular

   1. Heart

   2. Pulses

9. Abdomen

   1. Inspection

      1. Color

      2. Shape/Distention

      3. Skin Abnormalities

   2. Auscultation

   1. Bowel Sounds

   2. Bruits

   3. Palpation

   1. Firmness

   2. Tenderness

   3. Organomegaly

   4. Masses

   4. Percussion

   1. Resonance/Dullness

   2. Tenderness

   3. Liver Span

10. Genitalia

11. Rectal

12. Extremities

    1. Color and Temperature

    2. Range of Motion

    3. Strength

13. Back

14. Neurological

    1. Level of Consciousness

    2. Orientation

    3. Sensory Function

    4. Motor Function

    5. Cerebellar Function

9. Initial Diagnostic Studies

   1. Laboratory

      1. Blood

      2. Urine

   2. Radiographic/Sonographic

   3. Cardiographic

   4. Scintigraphic (Nuclear Medicine)

   5. Other

10. Assessment (Differential Diagnosis)
    The primary possibilities, in order of likelihood, as demonstrated by this history and physical. Why is number 1 more likely than number 2, etc.?

11. Plan
    What can be done to rule in or rule out each of the diagnostic possibilities?

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