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Template:Medical records and physical exam

From WikiMD's medical encyclopedia

Medical examination and history taking
Medical history
* Chief complaint
  • History of the present illness
  • Systems review
  • Nursing assessment
  • Allergies
    • Medications
  • Past medical history
  • Family history
  • Social history
  • Psychiatric history
  • Progress notes
  • Mnemonics
    • SAMPLE
    • OPQRST
    • SOAP
    • COASTMAP
Physical examination
General/IPPA
* Inspection
  • Auscultation
  • Palpation
  • Percussion
Vital signs
* Temperature
  • Heart rate
  • Blood pressure
  • Respiratory rate
HEENT
* Eye examination
    • Ophthalmoscopy
    • Swinging-flashlight test
  • Hearing
    • Weber
    • Rinne
Respiratory
* Respiratory sounds
Cardiovascular
* Cardiac examination
  • Peripheral vascular examination
  • Heart sounds
  • Other
    • Abdominojugular test
    • Ankle-brachial pressure index
Assessment and plan
* Medical diagnosis
  • Differential diagnosis


Retrieved from "https://wikimd.org/w/index.php?title=Template:Medical_records_and_physical_exam&oldid=6447036"
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  • This page was last edited on 8 March 2025, at 19:41.
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