History
Personal Data
History of present illness
- Site
- Onset
- Character
- Radiation
- Associations
- Time course
- Exacerbating/relieving factors
- Severity
Constitutional Symptoms
- Fever, chills, appetite changes
- Joint pain, stomach pain, headache
- Enlargement neck gland, N/V
Respiratory System
- Cough, SOB, chest pain, hemoptysis & phlegm
History
- Review of systems
- Past medical history
- Surgical history
- Allergy and medication
- Travel and sexual history
- Social history, Family history
Signs and Symptoms
- Fever and/or chills
- Nausea and/or vomiting
- Body aches
- Headache
- Cough
- Runny nose or nasal congestion
Additional Signs and Symptoms
- Earache
- Sneezing
- Weakness
- Lack of appetite
- Redness and/or swelling of the tonsils and back of the throat
- White patchy areas on the tonsils (exudate).
- Swollen and/or tender lymph nodes in the neck.
- A muffled or hoarse voice.
Physical Exam
- General appearance, Vital Signs
- Using a lighted instrument.
- Inspection, Gently feeling (palpating).
- Listening to breathing with a stethoscope.