Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 22. Reporting and Recording

SUBJECTIVE DATA—THE HISTORY

Subjective data are the positive and negative pieces of information that the patient offers. Record the patient’s history, especially during an initial visit, to provide a comprehensive database. Arrange information appropriately in specific categories, usually in a particular sequence such as chronologic order with most recent information first. Include both positive and negative data that contribute to the assessment. Use the following organized sequence as a guide.

IDENTIFYING INFORMATION

Record data recommended by health care facility.

Patient’s name

Identification number/social security number

Age, gender

Marital status

Address (home and business)

Phone numbers

Occupation, employer

Insurance plan, number

Date of visit

For children and dependent adults, names of parents or next of kin

Put identifying information on each page of record.

SOURCE AND RELIABILITY OF INFORMATION

Document who is providing the history and relationship to patient.

Indicate when an old record is used.

State judgment about reliability of information.

CHIEF CONCERN/PRESENTING PROBLEM/REASON FOR SEEKING CARE

Description of patient’s main reasons for seeking health care, in patient’s own words with quotation marks. Paraphrase only if this makes the patient’s concern more clear.

Include duration of problem.

HISTORY OF PRESENT PROBLEM

List and describe current symptoms of chief concern and their appearance chronologically in reverse order, dating events and symptoms.

List any expected symptoms that are absent.

Identify anyone in household with same symptoms.

Note pertinent information from review of systems, family history, and personal/social history along with findings.

Where more than one problem is identified, address each in a separate paragraph, including the following details of symptom occurrence:

Onset: When problem first started, chronologic order of events, setting and circumstances, manner of onset (sudden versus gradual)

Location: Exact location, localized or generalized, radiation patterns

Duration: How long problem has lasted, intermittent or continuous, duration of each episode

Character: Nature of symptom

Aggravating/associated factors: Food, activity, rest, certain movements; nausea, vomiting, diarrhea, fever, chills, etc.

Relieving factors: Prescribed treatments and/or self-remedies, alternative or complementary therapies, their effect on the problem; food, rest, heat, ice, activity, position, etc.

Temporal factors: Frequency; relation to other symptoms, problems, functions; symptom improvement or worsening over time

Severity of symptoms: Quantify on a 0 (minimal) to 10 (severe) scale; effect on patient’s lifestyle

MEDICAL HISTORY

List and describe each of the following with dates of occurrence and any specific information available:

General health and strength over lifetime as patient perceives it; disabilities and functional limitations

Hospitalization and/or surgery: Dates, hospital, diagnosis, complications

Injuries and disabilities

Major childhood illnesses

Adult illnesses and serious injuries

Immunizations: Polio, diphtheria-pertussis-tetanus, tetanus toxoid, hemophilus influenza type b, hepatitis A and B, measles, mumps, rubella, varicella, Prevnar, influenza, anthrax, smallpox, cholera, typhus, typhoid, meningococcal, pneumococcal, bacille Calmette-Guérin (BCG), last purified protein derivative (PPD) or other skin tests, unusual reaction to immunizations

Medications: Past, current, recent medications (prescribed, nonprescription, complementary therapies, home remedies); dosages

Allergies: Drugs, foods, environmental

Transfusions: Reason, date, number of units transfused, reactions

Emotional status: History of mood disorders, psychiatric attention or medications

Recent laboratory tests (e.g., glucose, cholesterol, Pap smear, mammogram, prostate-specific antigen)

Family history

Present information about age and health of family members in narrative or pedigree form, including at least three generations.

Family members: Include parents, grandparents, aunts and uncles, siblings, spouse, children. For deceased family members, note age at time of death and cause, if known.

Major health or genetic disorders: Include hypertension; cancer; cardiac, respiratory, kidney, or thyroid disorders; strokes; asthma or other allergic manifestations; blood dyscrasia; psychiatric difficulties; tuberculosis; diabetes mellitus; hepatitis; or other familial disorders. Note spontaneous abortions and stillbirths.

PERSONAL/SOCIAL HISTORY

Include information according to concerns of patient and influence of health problem on patient’s and family’s life:

Cultural background and practices, birthplace, position in family

Marital status

Religious preference, religious or cultural proscriptions for medical care

Home conditions: Economic condition, number in household, pets, presence of smoke detectors, presence and security of firearms

Occupation: Work conditions and hours, physical or mental strain, protective devices used; exposure to chemicals, toxins, poisons, fumes, smoke, asbestos, or radioactive material at home or work

Environment: Home, school, work; structural barriers if handicapped, community services utilized; travel; exposure to contagious diseases

Current health habits and/or risk factors: Exercise; smoking; salt intake; weight control; dental hygiene diet, vitamins and other supplements; caffeine-containing beverages; alcohol or recreational drug use; response to CAGE, TACE, or RAFFT questions (see Appendix) related to alcohol use; participation in a drug or alcohol treatment program or support group

Sexual activity: Protection method, contraception

General life satisfaction, hobbies, interests, sources of stress, adolescent’s response to HEEADSSS questions (see Appendix)

REVIEW OF SYSTEMS

Organize in general head-to-toe sequence, including an impression of each symptom.

Record expected or negative findings as absence of symptoms or problems.

When unexpected or positive findings are stated by patient, include details from further inquiry as you would in the present illness.

Include the following categories of information (sequence may vary):

General constitutional symptoms

Diet

Skin, hair, nails

Head and neck

Eyes, ears, nose, mouth, throat

Endocrine

Breasts

Heart and blood vessels

Chest and lungs

Hematologic

Lymphatic, immunologic

Gastrointestinal

Genitourinary

Musculoskeletal

Neurologic

Psychiatric

OBJECTIVE DATA—PHYSICAL FINDINGS

Objective data are the findings resulting from direct observation—what you see, hear, and touch.

GENERAL STATEMENT

Age, race, gender, general appearance

Nutritional status, weight, height, frame size, body mass index

Vital signs: Temperature, pulse rate, respiratory rate, blood pressure (two extremities, two positions)

MENTAL STATUS

Physical appearance and behavior

Cognitive: Memory, reasoning, attention span, response to questions

Speech and language: Voice quality, articulation, content, coherence, comprehension

Emotional stability: Anxiety, depression, disturbance in thought content

SKIN

Color, integrity, temperature, hydration, tattoos, scars

Presence of edema, excessive perspiration, unusual odor

Presence and description of lesions (size, shape, location, inflammation, tenderness, induration, discharge), parasites

Hair texture and distribution

Nail configuration, color, texture, condition, presence of clubbing, nail plate adherence, firmness

HEAD

Size and contour of head, scalp appearance and movement

Facial features (characteristics, symmetry)

Presence of edema or puffiness, tenderness

Temporal arteries: Characteristics

EYES

Visual acuity, visual fields

Appearance of orbits, conjunctivae, sclerae, eyelids, eyebrows

Pupillary shape, consensual response to light and accommodation, extraocular movements, corneal light reflex, cover-uncover test

Ophthalmoscopic findings of cornea, lens, retina, optic disc, macula, retinal vessel size, caliber, and arteriovenous crossings

EARS

Configuration, position and alignment of auricles

Otoscopic findings of canals (cerumen, lesions, discharge, foreign body) and tympanic membranes (integrity, color, landmarks, mobility, perforation)

Hearing: Air and bone conduction tests, whispered voice, conversation

NOSE

Appearance of external nose, nasal patency, flaring

Nasal mucosa and septum, color, alignment, discharge, crusting, polyp

Appearance of turbinates

Presence of sinus tenderness or swelling

Discrimination of odors

MOUTH AND THROAT

Number, occlusion and condition of teeth; presence of dental appliances

Lips, tongue, buccal and oral mucosa, floor of mouth (color, moisture, surface characteristics, ulcerations, induration, symmetry)

Oropharynx, tonsils, palate (color, symmetry, exudate)

Symmetry and movement of tongue, soft palate and uvula; gag reflex

Discrimination of taste

NECK

Mobility, suppleness, strength

Position of trachea

Thyroid size, shape, tenderness, nodules

Presence of masses, webbing, skinfolds

CHEST

Size and shape of chest, anteroposterior versus transverse diameter, symmetry of movement with respiration

Presence of retractions, use of accessory muscles, diaphragmatic excursion

LUNGS

Respiratory rate, depth, regularity, quietness or ease of respiration

Palpation findings: Symmetry and quality of tactile fremitus, thoracic expansion

Percussion findings: Quality and symmetry of percussion notes, diaphragmatic excursion

Auscultation findings: Characteristics of breath sounds (pitch, duration, intensity, vesicular, bronchial, bronchovesicular) unexpected breath sounds

Characteristics of cough

Presence of friction rub, egophony, whispered pectoriloquy

BREASTS

Size, contour, venous patterns

Symmetry, texture, masses, scars, tenderness, thickening, nodules, discharge, retraction, or dimpling

Characteristics of nipples and areolae

HEART

Anatomic location of apical impulse

Heart rate, rhythm, amplitude, contour

Palpation findings: Pulsations, thrills, heaves, or lifts

Auscultation findings: Characteristics of S1 and S2 (location, intensity, pitch, timing, splitting, systole, diastole)

Presence of murmurs, clicks, snaps, S3 or S4 (timing, location, radiation intensity, pitch, quality)

BLOOD VESSELS

Blood pressure: Comparison between extremities with position change

Jugular vein pulsations and distention, pressure measurement

Presence of bruits over carotid, temporal, renal, and femoral arteries, abdominal aorta

Pulses in distal extremities

Temperature, color, hair distribution, skin texture, nail beds of lower extremities

Presence of edema, swelling, vein distention, Homans sign, or tenderness of lower extremities

ABDOMEN

Shape, contour, visible aorta pulsations, venous patterns, hernia

Auscultation findings: Bowel sounds in all quadrants, character

Palpation findings: Aorta, organs, feces, masses, location, size, contour, consistency, tenderness, muscle resistance

Percussion findings: Areas of different percussion notes, costovertebral angle tenderness

Liver span

FEMALE GENITALIA

Appearance of external genitalia and perineum, distribution of pubic hair, inflammation, excoriation, tenderness, scarring, discharge

Internal examination findings: Appearance of vaginal mucosa, cervix, discharge, odor, lesions

Bimanual examination findings: Size, position, tenderness of cervix, vaginal walls, uterus, adnexa, ovaries

Rectovaginal examination findings

Urinary incontinence with bearing down

MALE GENITALIA

Appearance of external genitalia, circumcision status, location and size of urethral opening, discharge, lesions, distribution of pubic hair

Palpation findings: Penis, testes, epididymides, vasa deferentia, contour, consistency, tenderness

Presence of hernia or scrotal swelling

ANUS AND RECTUM

Sphincter control, presence of hemorrhoids, fissures, skin tags, polyps

Rectal wall contour, tenderness, sphincter tone

Prostate size, contour, consistency, mobility

Color and consistency of stool

LYMPHATIC

Presence of lymph nodes in head, neck, epitrochlear, axillary, or inguinal areas

Size, shape, consistency, warmth, tenderness, mobility, discreteness of nodes

MUSCULOSKELETAL

Posture: Alignment of extremities and spine, symmetry of body parts

Symmetry of muscle mass, tone and muscle strength; grading of strength, fasciculations, spasms

Range of motion, passive and active; presence of pain with movement

Appearance of joints; presence of deformities, effusions, warmth, tenderness, or crepitus

NEUROLOGIC

Cranial nerves: Specific findings for each or specify those tested, if findings are recorded in head and neck sections

Cerebellar and motor function: Gait, balance, coordination with rapid alternating motions

Sensory function, symmetry (touch, pain, vibration, temperature, monofilament)

Superficial and deep tendon reflexes: Symmetry, grade

ASSESSMENT

The assessment section is composed of your interpretations and conclusions, their rationale, the diagnostic possibilities, and present and anticipated problems—what you think.

For each new and existing problem on the problem list, make a differential diagnosis list with rationale based on subjective and objective data. Describe disease progression or complication.

PLAN

The plan describes the need to invoke diagnostic resources, therapeutic modalities, and other resources and the rationale for these decisions—what you intend to do.

Diagnostic tests ordered or performed

Therapeutic treatment plan

Patient education

Referrals initiated

Future visit to evaluate plan