UNIVERSITY OF SAN CARLOS – SCHOOL OF

HEALTHCARE PROFESSIONS

History Taking
And Physical
Examination
A GUIDE FOR HEALTH CARE STUDENTS PART I.

Al Julian Francois Y. Navales, RPh

2019
PART I. The Comprehensive Patient History
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Essential Elements of Clinical Care:
• Empathic Listening
• The ability to interview patients of all ages, moods and backgrounds
• Techniques for examining
• Clinical Reasoning
Ethics and Professionalism in Interviewing:
Ethics. It is set of principles crafted through reflection and discussion to define right
and wrong.
Medical Ethics. The principles that guide our professional behavior, which are neither
static nor simple. Ethical considerations, especially in medical practice vary depending
on the situation(s).
Building Blocks of Professional Ethics in Patient Care
Non-maleficence. In Latin: primum non nocere, states that as a healthcare
professional, your primary goal is to not do harm. “First, do no harm”.
In the context of interview and physical examination, giving information that is
incorrect or not related to the patient’s problem can do harm.
Avoiding relevant topics, such as the controversial topics of sexual practices, vices
etc., or creating barriers to open communication can also do harm
Beneficence. As a healthcare professional, you must do things for the good of the
patient. Your actions should be motivated by what is in the patient’s best interest and not
yours.
Autonomy. Patients have the right to determine what is in their own best interest.
Patient care is therefore collaborative between the clinician and the patient.
Confidentiality. Privacy is fundamental to our professional relationships with our
patients. Violating patient confidentiality entails a violation of the trust of the patient,
and a patient who does not trust healthcare professionals will not be as cooperative as a
patient who does.
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What is a Patient History/ Health History?
The health history is an interview with a purpose. Its primary goal is to listen and to improve the
well-being of the patient through a trusting and supportive relationship. It is both PATIENT-
CENTERED and CLINICIAN-CENTERED. It encourages the patient to express what is most
important to them and expresses their personal concerns in addition to symptoms giving the
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personal context of patient’s symptoms and disease.

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 Patient Centered Interviewing. It involves following the patient’s lead to
understand their thoughts, ideas, concerns and requests, without adding additional
information from the doctor’s perspective. Voluntarily giving or adding information
to the patient (as in yes or no questions), adds bias and disrupts your results.
Clinician-Centered Interviewing. The clinician takes charge of the interaction
to meet his own need to acquire the symptoms, their details, and other data that will help
him identify a disease.
Types of Patient History:
Comprehensive:

• Appropriate for new patients

• Provides fundamental and personalized knowledge about the patient
• Strengthens your relationship with the patient
• Helps identify or rule out physical causes related to the patient’s concern(s)
• Provides baseline for future assessments
• Creates platforms for health promotion through education and counseling
• Develops proficiency in the essential skill of physical examination
Focused:

• Appropriate for established patients, especially for routine and/or urgent care visits
• Addresses focused concerns or symptoms
• Assesses symptoms restricted to a specific body system
• Applies examination methods relevant to assessing the concern or problem as precisely
and carefully as possible (Selective)
Components of the Comprehensive Assessment of the Adult:

• Identifying Data and Source of History, Reliability

• Chief complaint
• History of Present Illness
• Past History
• Family History
• Personal and Social History
• Review of Systems

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The fundamentals of skilled interviewing:
Active listening. The process of closely attending to what the patient is communicating.
Empathic responses. It is identifying the patient’s pain and feeling it as your own.
Adding empathy to your responses gives comfort to the patient and allows him/her
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to discuss more about his or her problems or illnesses.

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 Guided questioning. Facilitates the flow of the interview. Examples are:

• Moving from open-ended to focused questions general to specific

• Avoid leading questions
• Using questioning that elicits a graded response numerical
• Asking a series of questions, one at a time
• Offering multiple choices for answers
• Clarifying what the patient means
• Encouraging with continuers words or gestures encouraging the patient to say
more
• Using echoing simple repetition of patient’s last words Patient expands
Non-verbal communication skills. Observing the patient’s non-verbal language gives
the interviewer clues of the patient’s mood, anxiety, discomfort, etc.
Validation. The acknowledgement of the legitimacy of what the patient is feeling.
Reassurance. Comes from making the patient feel confident that the problems have
been understood and are being addressed and not necessarily that you guarantee a cure.
False hopes can also be detrimental. Premature reassurance may block further disclosures
Partnering. Clinician and patient are partners for the betterment of the patient
Summarization. It identifies what you know and do not know, giving you a chance to
notice mistakes, lapses. It also checks if the patient’s story is consistent.
Transitions. Make clear what the patient should expect or do next. Example: “The next
part of this interview may make you feel uncomfortable, tell me if you feel any discomfort.”
Empowering the patient. Patients are responsible for their own care.
The Patient’s Perspective. (Mnemonic: FIFE)

• Patient’s feelings
• Patient’s ideas about the nature and cause of the problem
• Effect of the problem on the life and function of the patient
• The patient’s expectations of the disease, the clinician, or of health care

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The Sequence and Context of the Interview
Preparation. Involves the following:

• Setting goals, reviewing the records (if applicable)

• Reviewing your behavior, appearance and approach professionalism
• Adjusting The environment private and comfortable as possible
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Interview Proper: Involves the following:

• Greeting the patient and establishing rapport

• Taking notes
• Establishing the agenda of the interview
• Inviting the patient’s story
• Identifying and responding to emotional queues
• Expanding and clarifying the patient’s story
• Generating and testing a diagnostic hypothesis (if applicable)
• Sharing the treatment plan (if applicable)
• Closing the interview
• Reflection and evaluation

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Advanced Interviewing: Difficulties encountered.
The Challenging Patient. Interviewing patients may precipitate a number of reactions
and behaviors that are challenging, difficult, and sometimes even threatening. Your ability
to handle these situations will evolve throughout your career. Always remember the
importance of listening to the patient and clarifying the patient’s concerns.
The Silent Patient. Novice interviewers are often uncomfortable with periods of silence
and feel obligated to keep the conversation going. Silence has many meanings and
purposes. Patients usually fall silent for short periods to collect thoughts, remember
details or decide whether you can be trusted with the information. So be attentive, be
respectful and convey encouragement to continue when the patient is ready.
The Confusing Patient. Some patients present with a confusing array of multiple
symptoms and chief complaints. They seem to have every symptom that you ask about.
With these patients, focus on the context of the symptom, emphasizing the patient’s
perspective, and guide the interview into a psychosocial assessment.
The Patient with impaired capacity. Some patients cannot provide their own
histories because of delirium, dementia, or mental health conditions. Others are unable to
remember certain parts of their history, such as events related to a seizure or passing out,
or simply if the patient is a child. Under these circumstances, you need to determine if the
patient has a decision-making capacity, if not, you might need a surrogate informant
to assist you with the history and decision-making.
The Talkative patient. Patients who are talkative tend to veer off-course of the
interview and can be as difficult to interview as the silent or confused patient. This
problem has no perfect solution but usually, this technique works. Give the patient the free
rein for the first 5 to 10 minutes to make him/her comfortable, listening closely to the
conversation and determining his/her personality etc. Perhaps, the patient needs a good
listener and is expressing pent-up concerns, or the patient’s conversational style is like
telling stories. Then take charge, and do guided questioning. Do not show your impatience
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because your patient will not be comfortable with you.

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 The Crying Patient. Crying signals strong emotions, ranging from sadness, to anger or
frustration. Pausing, gentle probing and responding with empathy gives the patient
permission to cry. Crying is usually therapeutic, as is your quiet acceptance of the patient’s
distress or pain. Usually, if the patient is crying, wait for him/her to finish and recover,
then carry on with the interview. Giving the patient a tissue and holding his/her shoulder
would help. Most patients would compose themselves soon and resume their story, usually
divulging more information because of your acceptance of his/her crying.
The Angry or Disruptive Patient. Sick people have reasons to be angry. Being sick in
itself is very uncomfortable. They usually feel that their suffered a loss, they lack their
accustomed control over their own lives, and they feel relatively powerless in the health
care system. They may direct this anger toward you. Accept the angry feelings from
patients. Allow them to express their feelings without getting angry in return. Be
professional; avoid joining patients in their hostility towards another health care
professional, clinic, hospital, pharmacy, institution, etc. You can validate their feelings
without agreeing with their reasons. Try not to debate with the patient.
Patient with language barrier. Countries like the Philippines have a plethora of
languages and dialects. This makes communication difficult, especially if the person you
are talking to does not speak your dialect. Try to speak the most common tongue in the
country, in our case, Filipino and English. Some people also have limited proficiency in
the national language, so in this case try to speak with broken English or Broken Filipino;
a few broken words can help both you and the patient understand each other. Speaking to
a non-proficient patient with correct syntax and grammar might confuse him/her, but
speaking in broken sentences like “Pain, stomach right, cough, sakit dito” might be easier.
Lastly, if you really cannot understand each other, try to find someone to translate for you.
Patient with low literacy or low health literacy. Many Filipinos cannot read and
write. This lack of reading skills may explain why the patient has not taken medications
and has not followed the recommendations for treatment. With patient’s like these, be
sensitive to their quandary, and do not confuse their degree of literacy with intelligence.
The Hearing-impaired patient. There are patients who are deaf, or hard of hearing.
Find out the patient’s preferred method of communication. If the patient cannot hear or
speak, try to use sign language. If you do not know how to use sign language, try to do the
interview with writing. Take note that even hearing-impaired patients who use English
may not follow Standard English grammar or syntax.
The Patient with Visual Impairment. When meeting with a blind or visually
impaired patient, verbal communication is the most important. Furthermore, non-verbal
communication, which includes, gestures, physical contact, may help. If the room is
unfamiliar, orient the patient as to where he is or where he is going. Remember to give full
explanations because gestures and postures cannot be seen.
The patient with limited intelligence. Patients with moderately limited intelligence
can usually give adequate histories. If you are unsure about the patient’s level of
intelligence, make a smooth transition to the mental status examination and assess simple
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calculations, vocabulary, memory and abstract thinking. For patients with severe mental
retardation, turn to family or significant others and guardians to elicit the patient’s history.
Do not be judgmental.

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 The patient seeking personal advice. Patients may ask you for advice that fall outside
the range of your clinical expertise, in our case, medications. Instead of responding to very
personal questions, ask about the different approaches that the patient has considered and
the related pros and cons, others who have provided advice and what supports are
available for different choices. Letting the patient talk through the problem with you is
more valuable and therapeutic than providing the answer yourself.
The Seductive patient. Sometimes, there are patients who find you and whom you find
physically attractive. Similarly, patients might make sexual overtures or exhibit flirtatious
behavior. The emotional and physical intimacy of the clinician-patient relationship may
lead itself to these sexual feelings. If you become aware of these feelings yourself, accept
them as a normal human response. Denying these feelings make it more likely for you to
act inappropriately. When patients make seductive advances, make it clear to him/her that
your relationship is strictly professional, not personal. If they continue, find a chaperone
to accompany you or the patient. Reflect on your image, has your clothing or demeanor
been seductive? Have you been overly warm with the patient? Evaluate yourself.
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Sensitive Topics.
Health care professionals talk about many subjects that are emotionally charged. These are
usually the following:

• Sexual history
• Mental health history
• Alcohol and prescribed and illicit drug use
• Intimate partner and family violence
• Death and dying
Guidelines for Broaching Sensitive Topics

• Most Important Rule: Be nonjudgmental

• Explain why you need to know certain sensitive information
• Find opening questions for sensitive topics
• Consciously acknowledge whatever discomfort you are feeling. Denying your discomfort
may lead you to avoid the topic altogether, distorting your findings.
Look into other strategies for becoming more comfortable with sensitive areas. Examples include:
general reading about these topics in medical and lay literature; talking openly to selective
colleagues and teachers about your concerns, taking special courses or trainings to explore your
own feelings and reactions and ultimately, reflecting on your own life experience.
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COMPREHENSIVE ADULT HEALTH HISTORY – COMPONENTS
Initial Information
Date and Time of Interview. Date is always important. Document the time you
evaluate the patient especially in urgent, emergent or hospital settings.
Identifying Data. Include age, gender, marital status, occupation, source of history,
referral (if hospital setting)
Reliability. Subjective on part of the interviewer. Note if the patient is vague in
describing symptoms, whether or not the details are confusing. Your judgment reflects the
quality of the information provided by the patient. Note this at the end of the interview,
but should be written in the initial information.
Patient History
History of Present Illness. Complete, clear, and chronologic account of the problems
prompting the patient to seek care. The narrative should include the onset of the problem,
setting in which it has developed, manifestations, treatments, alleviating factors.
Each principal symptom should be well characterized with descriptions of the following:

• Location
• Quality
• Quantity or Severity (Pain Scale)
• Timing (Including onset, duration, frequency)
• Setting at which it occurs
• Associated manifestation
It is important to include pertinent positives and pertinent negatives from sections from
the Review of Systems related to the Chief Complaint(s).
The Present illness should reveal the patient’s responses to his or her symptoms and what
effect the illness had on the patient’s life. Data flows spontaneously from the patient, the
task of oral and written organization is yours.
Medications taken should also be included, including the name, dose, route, and frequency
of use. Also, list home remedies, non-prescription drugs, herbal medications, etc.
Past History. Includes diseases and other relevant medical histories not included in the
History of Present Illness. This also includes previous hospitalizations, blood transfusions,
psychiatric history and surgical history.
Childhood illnesses
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Measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever,

scarlet fever, polio, and the chronic childhood illnesses (juvenile diabetes
insipidus, asthma, etc.)

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 Adult Illnesses
Medical History: Illnesses such as diabetes, hypertension, hepatitis,
asthma, HIV
Includes hospitalizations, treatment given, occasionally the
laboratory procedures performed, and the results such as: Chest X-
ray, ECG, etc.
Surgical History: Dates, indications and types of operations
Example: June 2018 – Appendectomy – Chong Hua Hospital
Obstetric and Gynecologic History: DONE ONLY ON FEMALE PATIENTS.
Obstetric history, menstrual history, methods of contraception (if applicable),
sexual function (if applicable).
Obstetric history
In terms of Gravidity and Parity.
A woman of reproductive age (WRA) that has gotten
pregnant twice and has given birth twice is considered
Gravida-2, Para-2 (G2P2).
If the woman has gotten pregnant twice but no child
survived the pregnancies (stillborn, abortion, miscarriage),
she is considered Gravida-2, Para-0 (G2P0).
Note what type of delivery:
Caesarian. Also known as C-section. Try to ask the patient
why C-section was performed instead of NSVD.
NSVD – Normal Spontaneous Vaginal Delivery
Menstrual History:
Include the onset of menstruation (menarche)
Frequency and timing of menstruation
Ex. “Menstruation is every 28 days, lasts for 4 days”
Estimated amount of blood discharge
Ex. “Approximately 250mL blood discharge per discharge.
Alternatively, it can be in terms of pads or tampons used. “3
pads consumed daily”
Include the age of menopause (if patient is in menopause)
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 Psychiatric History. Include the illness and period, diagnosis, hospitalizations,
treatments
Example: Diagnosed with Bipolar Disorder – 2018 – Chong Hua Hospital
treated with Valproic acid tab PO OD.
Immunizations
Note: this area is prone to misinformation. Take into consideration
that most geriatric patients were not fully immunized, as the vaccines were
not available during their childhood or there were no mandatory
vaccination programs before.
This also includes immunizations in adulthood such as:
Pneumococcus vaccine, Influenza vaccine, Tetanus vaccines, Rabies
vaccine, etc.
Screening Tests. Include the date the tests were perform, the location and the
results if possible.
Tuberculin tests, pap smears, mammograms, stool tests, colonoscopy, CBC,
etc.
Family History
Family History. Outline or diagram the age and health, or age and cause of death of each
immediate relative, especially parents and children.
Review each of the following conditions and record whether or not they are present or
absent in the family:

• Hypertension
• Coronary artery disease
• Diabetes
• Hypercholesterolemia and Hypertriglyceridemia
• Thyroid or renal disease
• Arthritis
• Tuberculosis
• Asthma or lung diseases such as COPD
• Mental illnesses including depression, suicide, substance abuse
• Allergies
• Cancer
Personal and Social History. This captures the patient’s personality and interests,
environment and social support and coping styles. It should include the following.

• Religion and religious practices

• Occupation
• Highest educational attainment
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• Job history
• Military service (if applicable/ relevant)

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 • Financial Situation (if applicable / relevant)
• Setting of the residence
• Location/ address of the residence
• Setting of the home
o Example: “The patient lives in a well-ventilated 2-storey house is located near the
outskirts of the city beside a riverbank, away from major roads.
• Sanitary Practices.
o Type of comfort room of the patient’s home
o Type of water used for drinking and other uses
• Activities of Daily Living
o Average routine of the patient / how the patient’s day usually goes
o Exercise and Diet
o Favorite food or drinks
o Frequency of meals
o Usual consistency of the meals
o Frequency of urination and defecation
• Social Practices
• Smoking history
o In pack years
• History of alcohol use
o Note the type of alcoholic beverage usually taken, the amount taken and frequency
• History of illicit drug use

Review of Systems. These are the yes-no questions that come at the end of the interview. Most
questions pertain to symptoms but on occasion, you can include diseases like pneumonia or
tuberculosis. The review of systems may uncover problems that the patient has overlooked,
particularly in areas unrelated to the present illness.
Remember, the Review of Systems is subjective.
Standard Series of Review of System Questions:
General: Usual weight, recent weight change, weakness, fatigue, fever
Skin: Rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails,
changes in size and color of moles
Head: headache, head injury, dizziness, lightheadedness
Eyes: visual acuity, glasses or contact lenses, pain, redness, excessive tearing, diplopia,
spots, specks, flashing lights, glaucoma, cataracts, last examination
Ears: hearing, tinnitus, vertigo, earaches, ear infections, discharges, use of hearing aids
(if hearing impaired)
Nose and Sinuses: Frequent Colds, nasal stuffiness, discharge, itching, rhinitis,
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epistaxis, sinusitis

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 Mouth and throat: condition of teeth and gums, bleeding gums, dentures if any, sore
tongue, dry mouth, frequent sore throats, hoarseness, last dental examination
Neck: Swollen glands, goiter, lumps, pain, stiffness in the neck
Breasts: Lumps, pain, discomfort, nipple discharge, self-examination practices
Respiratory: Cough, presence sputum (color, quantity, and consistency), hemoptysis,
dyspnea, wheezing, pleurisy, asthma, bronchitis, pneumonia, tuberculosis, last chest x-ray
Cardiovascular: Heart trouble, palpitations, hypertension, rheumatic fever, heart
murmurs, chest pain or discomfort, dyspnea, orthopnea (note how many pillows),
paroxysmal nocturnal dyspnea, edema, results of past ECG and other cardiovascular tests
Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, bowel movements,
stool color and size, change in bowel habits, pain with defecation, rectal bleeding, black or
tarry stools (melena), hematochezia (defecation of blood), hemorrhoids, constipation,
diarrhea, abdominal pain, food intolerance, flatulence, jaundice, liver or gallbladder
(stones, etc.), trouble, hepatitis
Peripheral Vascular: Intermittent claudication, leg cramps, varicose veins, past clots
in veins, swelling in calves, legs or feet; color change in fingertips or toes in cold weather,
swelling with redness or tenderness
Urinary: Frequency of urination, polyuria, nocturia, enuresis urgency, burning or pain
during urination, hematuria, urinary infections, kidney or flank pain, kidney stones,
ureteral colic, suprapubic pain, incontinence, dribbling, hesitancy
Genital: Male: hernias, discharges from or sores on the penis, testicular pain or masses,
scrotal pain or swelling, history of STIs and their treatments, Sexual habits. Female: age
of menarche, regularity, frequency, duration of periods, amount of bleeding, bleeding
between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual
tension, menopause, vaginal discharge, itching, sores, lumps, STIs and treatments,
pregnancies and type of deliveries, sexual practices
Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache
Psychiatric: nervousness, tension, mood, including depression, memory change, and
suicide attempts (if relevant).
Neurologic: Changes in mood, attention, speech, changes in orientation, memory,
insight, judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis,
numbness or loss of sensation, tingling, tremors, involuntary movements, seizures
Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusion
reactions
Endocrine: heat or cold intolerance, excessive sweating (hyperhidrosis), excessive thirst
(polydipsia), excessive hunger (polyphagia), polyuria, goiter, swelling of the thyroid gland,
weight abnormalities.
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Reference(s): Bate’s Guide to Physical Examination and History Taking, 11th Edition, Unit 1: Foundations of Physical Assessment

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SAMPLE PATIENT HISTORY: (This is a case of a real patient)

Date and Time of Interview: Jan. 21, 2019 at 2:30pm

Referral: No
Source: Patient
Reliability: 95%

General Information:
This is a case of patient R.B., a 26 year-old, Filipino Female, Single, Roman Catholic, self-
employed and is currently living in Brgy. Apitong, Tacloban City. She was admitted for the
first time at Eastern Visayas Regional Medical Center on January 23, 2019, at 9:00 AM
Chief Complaint: Dyspnea
History of Present Illness:
2 Months PTA, patient’s extremities started to swell and her abdomen was noticeably
getting larger. She had no problems with her activities of daily living (ADLs), but noted a
minor discomfort when walking. No consult was done. No fever, no cough, no nausea, no
vomiting, no chest pain, no dyspnea. Patient continued her maintenance medication of
Furosemide (Lasix) taken OD.
1 Month PTA, patient started manifesting dyspnea and 2-pillow orthopnea, relieved by
sitting upright. She continued her maintenance medication and did not seek consult.
Hours PTA, patient’s condition worsened, now associated with severe dyspnea and sudden
onset of localized non-radiating chest pain with PRS of 6/10, thus prompting consult and
admission at EVRMC.
History of Past Illness:
Childhood Illnesses:
(+) Mumps
(-) Chickenpox
(-) Whooping cough
(-) Asthma
(-) Measles
Adult Illnesses:
(+) Rheumatic Heart Disease – Admitted in Mother of Mercy Hospital, Tacloban
City (2015) – Given Furosemide (Lasix) OD as maintenance
(-) History of: Diabetes, Hypertension, Asthma, Hepatitis
Surgical History:
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No Surgical History

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 Obstetric and Gynecologic History
Menarche: 10 years old
Last Menstrual Period (LMP): 2 years ago (2017)
Cycle: Every 2 months, lasting for 4 days, minimal blood discharge
Pads consumed daily: 1
Psychiatric History:
No psychiatric history
Hematologic History:
No history of blood transfusions
Allergies:
No known allergies
Immunization:
Complete (as claimed)
Screening tests:
2D-Echo – Sept. 2018
ECG – January 23, 2019
Chest Radiograph – January 23, 2019

Family History
Patient comes from a Family of 8 and is the 5th among 6 children (3 male, 3 female).
Her father is deceased due to a stroke last 2018. Patient’s mother had a mild stroke at 55
years old but is still alive.
Patient’s siblings are alive and apparently well. No history of diabetes, allergies,
kidney disease, TB, arthritis, anemia, epilepsy, mental illness, drug addiction and other
heredofamilial diseases were mentioned.

Personal and Social History

Patient was born and raised in Tacloban City and is currently residing in Brgy.
Apitong, Tacloban City. She lives with her mother and 2 siblings in a 1-storey house located
mountainside. Their house is well ventilated and has a water-sealed toilet. They experience
flooding during heavy rains.
Patient’s source of drinking water is mineral water, tap water for other uses.
Patient was a freshman BS-Education student but was advised to stop schooling
due to her condition. She is currently working as a sales person in their own sari-sari store.
Patient usually wakes up at 6:00AM, and spends most of her day doing light chores
and watching television. She usually retires to bet at 9:00PM but falls asleep at around
3:00AM.
Patient eats 3x a day, with a usual diet consisting of rice, vegetables, meat, fish,
milk, chicken. She is fond of salty food and dislikes sweets. She drinks about 8 glasses of
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water a day.
Patient does not smoke nor drink alcoholic beverages.

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Review of Systems:
General: (+) Weight loss approx. 4% since onset of sickness, (+) Easy fatigability, (+)
Appetite loss, (+) Body malaise, (+) Fever and chills
Skin: (-) Dryness, (-) Rashes, (-) Pruritus, (-) Pallor, (-) Changes in hair and nails
Head: (+) Dizziness, (-) Headache, (-) Lightheadedness, (-) Head injury
Eyes: (-) Redness, (-) Itchiness, (-) Excessive lacrimation, (-) Pain,
(-) Vision impairment, (-) Diplopia
Ears: (-) Vertigo, (-) Hearing loss, (-) Tinnitus, (-) Earache, (-) Infection, (-) Abnormal
discharges
Nose and Sinuses: (-) Colds, (-) Nasal Stuffiness, (-) Itchiness, (-) Epistaxis, (-) Sinus
congestion
Neck: (-) pain, (-) stiffness, (-) lumps, (-) Selling of glands and nodes
Breast: (-) pain, (-) discomfort, (-) discharges, (-) lumps
Respiratory: (-) productive cough, (-) hemoptysis, (-) pleurisy, (+) Dyspnea, (+)
orthopnea (2-pillow)
Cardiovascular: (+) Chest pain, (+) palpitations, (-) HTN, (+) ECG exam (1/23/2019)
Gastrointestinal: (-) Abdominal pain, (-) constipation, (-), dysphagia, (-)
hematochezia, (-) melena, (-) heartburn, (-) flatulence, Bowel movement is once daily
with brown, formed stool
Urinary: (-) nocturnia, (-) enuresis (-) Hematuria, (-) dysuria, Urination 4x a day with
light yellow urine at approx. 250mL per voiding
Genital: (-) Abnormal discharges, (-) Sores, (-) Itchiness, (-) Dyspareunia, (-) Swelling,
(-) Pain
Peripheral Vascular: (-) intermittent claudication, (+) Varicose veins on both legs,
(+) Edema on both legs, (-) Leg cramps
Musculoskeletal: (-) muscle and joint pain, (-) Joint stiffness, (-) Backache, (-) history
of trauma
Psychiatric: (-) Sleep disturbance, (-) history of depression, (-) nervousness, (-)
memory changes, (-) mood swings
Neurologic: (-) fainting spells, (-) memory changes, (-) tremors, (-) numbness, (-)
seizures, (-) paralysis, (-) tingling sensations
Hematologic: (-) blood transfusion history, (-) history of blood donation, (-) easy
bleeding, (-) easy bruisability, (-) anemia
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) heat and cold intolerance, (-)
excessive thirst/ hunger

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