RLE 107 3 / 29 /21

DAY 1
A. HEAD TO TOE ASSESSMENT WITH PERTINENT FINDINGS
B. General. Usual weight, recent weight change, any clothes that fit more
tightly or loosely than before. Weakness, fatigue, fever.
C. Skin. (-)Rashes, (-)lumps, (-)sores, (-)itching, (-)dryness, (-)color change,
(-)changes in hair or nails.
D. Head, Eyes, Ears, Nose, Throat (HEENT). Head: (-)Headache, (-)head in-
jury, (-)dizziness, (-)lightheadedness.
Eyes: Vision 20/20, (-)pain, (-)redness, (-)excessive tearing, (-)double
vision, (-)blurred vision, (-)spots, (-)specks, (-)flashing lights,
(-)glaucoma, cataracts.
Ears: (-)tinnitus, (-)ver- tigo, (-)earaches, (-)infection, (-)discharge.
Nose and sinuses: (-) Frequent colds, (-)nasal stuffiness, (-)discharge, or
itching, (-)hay fever, (-)nosebleeds, (-)sinus trouble.
Throat (or mouth and pharynx): (-)bleeding gums (-)sore tongue, (-)dry
mouth, (+)frequent sore throats, (+)hoarseness, (+)Frequent Swallowing,
(+) recurrent tonsillitis
Neck. (+)Lumps, “swollen glands,” (-)goiter, (+)pain, (+)stiffness in the
neck.
E. Breasts. (-)Lumps, (-)pain or discomfort, (-)nipple discharge,
F. Respiratory. (-)Cough, (-)hemoptysis, (-)dyspnea, (-)wheezing,
(-)pleurisy. (-)asthma, (-)bron- chitis, (-)emphysema, (-)pneumonia, and
(-)tuberculosis.
G. Cardiovascular. (-)Heart trouble, (-)high blood pressure, (-)rheumatic
fever, (-)heart murmurs, (-)chest pain or discomfort, (-)palpitations,
(-)dyspnea, (-)orthopnea, (-)paroxysmal nocturnal dyspnea, (-)edema.
H. Gastrointestinal. (+)Trouble swallowing, (-)heartburn, (-)loss of appetite,
nausea, (-)rectal bleeding or (-)black or tarry stools, (-)hemorrhoids,
constipation, (-)diarrhea. (-)Ab- dominal pain, (-)food intolerance,
e(-)xcessive belching or passing of gas. J(-)aundice, (-)liver or gallbladder
trouble, (-)hepatitis.
I. Urinary. (-)Frequency of urination, (-)polyuria, (-)nocturia, (-)urgency,
burning or pain on urination, (-)hematuria, (-)urinary infections, (-)
kidney stones, (-)inconti- nence; in males, (-)reduced caliber or force of
the urinary stream, (-)hesitancy, (-)dribbling.
J. Genital. Male: (-)Hernias, (-)discharge from or sores on the penis,
(-)testicu- lar pain or masses, (-)history of sexually transmitted diseases
 and their treat- ments. (-)Exposure to HIV infection.
K. Peripheral Vascular. (-)Intermittent claudication, (-)leg cramps,
(-)varicose veins, (-)past clots in the veins.
L. Musculoskeletal. (-)Muscle or joint pains, stiffness, arthritis, gout, and
backache. (-)history of trauma.
M. Neurologic. (-)Fainting, (-)blackouts, (-)seizures, (-)weakness,
(-)paralysis, numb- ness or loss of sensation, (-)tingling or “pins and
needles,” (-)tremors or other in- voluntary movements.
N. Hematologic. (-)Anemia, (-)easy bruising or bleeding, (-)past transfusions
and/or transfusion reactions.
O. Endocrine. (-) Thyroid trouble, (-)heat or cold intolerance, (-)excessive
sweat- ing, (-)excessive thirst or hunger, (-)polyuria, (-)change in glove or
shoe size.
P. Psychiatric. (-)Nervousness, (-)tension, (-)depression, (-)mem- ory
change, (-) suicide attempts.

Q. NCP:

R. CHARTING