Fire: Created page with "{{Navbox | name = Medical records and physical exam | title = Medical examination and history taking | state = {{{state|autocollapse}}} | listclass = hlist | group1 = Medical history | list1 = * Chief complaint * History of the present illness * Systems review * Nursing assessment * Allergies ** Medications * Past medical history * Fa..."

2024-02-27T07:35:11Z

Created page with "{{Navbox | name = Medical records and physical exam | title = Medical examination and history taking | state = {{{state<includeonly>|autocollapse</includeonly>}}} | listclass = hlist | group1 = Medical history | list1 = * Chief complaint * History of the present illness * Systems review * Nursing assessment * Allergies ** Medications * Past medical history * Fa..."

New page

{{Navbox
| name = Medical records and physical exam
| title = [[Physical examination|Medical examination]] and [[Medical history|history taking]]
| state = {{{state<includeonly>|autocollapse</includeonly>}}}
| listclass = hlist

| group1 = [[Medical history]]
| list1 =
* [[Chief complaint]]
* [[History of the present illness]]
* [[Review of systems|Systems review]]
* [[Nursing assessment]]
* [[Allergy|Allergies]]
** [[Medication]]s
* [[Past medical history]]
* [[Family history (medicine)|Family history]]
* [[Social history (medicine)|Social history]]
* [[Psychiatric history]]
* [[Progress note]]s
* Mnemonics
** [[SAMPLE history|SAMPLE]]
** [[OPQRST]]
** [[SOAP note|SOAP]]
** COASTMAP

| group2 = [[Physical examination]]
| list2 = {{Navbox|child
| evenodd = swap

| group1 = General/[[IPPA]]
| list1 =
* [[Physical examination|Inspection]]
* [[Auscultation]]
* [[Palpation]]
* [[Percussion (medicine)|Percussion]]

| group2 = [[Vital signs]]
| list2 =
* [[Thermoregulation|Temperature]]
* [[Heart rate]]
* [[Blood pressure]]
* [[Respiratory rate]]

| group3 = [[HEENT examination|HEENT]]
| list3 =
* [[Eye examination]]
** [[Ophthalmoscopy]]
** [[Swinging light test]]
* [[Hearing test|Hearing]]
** [[Weber test|Weber]]
** [[Rinne test|Rinne]]

| group4 = [[Respiratory examination|Respiratory]]
| list4 =
* [[Respiratory sounds]]

| group5 = [[Cardiovascular examination|Cardiovascular]]
| list5 =
* [[Cardiac examination]]
* [[Peripheral vascular examination]]
* [[Heart sounds]]
* Other
** [[Abdominojugular test]]
** [[Ankle–brachial pressure index]]

| group6 = [[Abdominal examination|Abdominal]]
| list6 =
* [[Liver span]]
* [[Rectal examination]]
* [[Stomach rumble|Bowel sounds]]

| group8 = Musculoskeletal
| list8 =
* [[Knee examination]]
* [[Hip examination]]
* [[Shoulder examination]]
* [[Elbow|Elbow examination]]
* [[GALS screen]]

| group9 = [[Neurological examination|Neurological]]
| list9 =
* [[Mental status examination|Mental status]]
** [[Mini–mental state examination]]
* [[Cranial nerve examination]]
* [[Upper limb neurological examination]]

| group10 = Neonatal
| list10 =
* [[Apgar score]]
* [[Ballard Maturational Assessment]]

| group11 = [[Pelvic examination|Gynecological]]
| list11 =
* [[Well-woman examination]]
* [[Pap test]]
* [[Breast examination]]

| group12 = [[Preparticipation physical evaluation|Sports]]
| list12 =
* [[Athletic heart syndrome]]
* [[Sudden cardiac death of athletes|Sudden cardiac death]]
* [[Relative energy deficiency in sport|RED-S]]

}}

| group4 = [[Assessment and plan]]
| list4 =
* [[Medical diagnosis]]
* [[Differential diagnosis]]

}}<noinclude>
{{Documentation|content=
{{collapsible option}}

[[Category:Medicine procedure templates]]

}}</noinclude>

Template:Medical records and physical exam - Revision history