1. InitialdgApproac Hi,dgmydgnamedgisdgSamantha.dgIdgamdgthedgregistereddgnursedgthatdgwilldgbedgcompletin
hdganddgHistorydgT gdgyourdgphysicaldgexam.dgIdgamdgjustdggoingdgtodggatherdgmydgsuppliesdganddgthendgwedgwill
ak-dging dggetdgstarted.dgPerformdghanddghygiene.
Neededdgsupplies:dggloves,dgalcoholdgswabs,dgcottondgball,dgcottondgswab,dgtonguedgde
pres-dgsor,dgophthalmoscope,dgotoscope,dgreflexdghammer,dgstethoscope
2. InitialdgApproac Obtaindgpatientdgidentificationdginformation.dg
hdganddgHistorydgT Candgyoudgtelldgmedgyourdgnamedganddgdatedgofdgbir
ak-dging th?dgHowdgolddgaredgyou?
Gender?
Race?
3. InitialdgApproac Whatdgbringsdgyoudgindgtoday?dgAredgyoudghavingdganydgpaindgordgotherdgiss
hdganddgHistorydgT ues?dgCandgyoudgtelldgmedgmoredgaboutdgthedgpain.
ak-dging UsedgOPQRST
Onset:dgwhendgdiddgthedgsymptomsdgfirstdgbegin?dgWasdgitdggradualdgordgsudden?dgProv
ocativedgordgPalliative:dgWhatdgweredgyoudgdoingdgwhendgthedgsymptomsdgstarted?dgwhatd
g makesdgitdgbetter?
QualitydganddgQuantity:dgCandgyodgdescribedgthedgpain?
RegiondgordgRadiation:dgcandgyoudgpointdgtodgwheredgthedgpaindgisdgat?dgDoesdgitdgradiatedga
ny-dgwhere?
Severity:dghowdgbaddgisdgthedgpaindgrightdgnowdgondgadgscaledgofdg0-
10?dgwhatdgisdgthedgworstdgitdghasd g been?
TimingdganddgTreatment:dghowdglongdgdodgthedgsymptomsdglast?dgAredgtheydgintermittentdgo
rd g doesdgitdgcomedganddggo?dgIsdgtheredganythingdgyoudgaredgdoingdgfordgthedgpain?
4. PastdgMedicaldgHis- Mustdgcompletedgbydgmemory!
dgtory -
GeneraldgHealth:dgwhendgwasdgyourdglastdgphysicaldgexam?dgDodgyoudgknowdgthedgdate?dg
Weredgtheredganydgconcerns?
-
ChronicdgIllnesses:dgdodgyoudghavedganydgchronicdgmedicaldgconditions?dgIfdgso,dgwhendg
,diddgtheydgstartdganddghowdgw
ere/aredgtheydgbeingdgtreate
d?
, -
Dodgyoudghavedgadgknowndghistorydgofdganydginfectiousdgdiseases?dgIfdgso,dgwhatdganddg
howdgwere/aredgtheydgtreated?
-Dodgyoudghavedganydgallergies?dgTodgmedication,dgfooddgordgenvironmental?
-
Havedgyoudgeverdghaddgsurgery?dgIfdgso,dgwhatdgsurgery?dgWeredgtheredgcomplications?dg
Diddgtheydgusedganesthesia?
-Havedgyoudgeverdghaddganydginjuries?
-Havedgyoudgeverdgbeendghospitalized?dgIfdgso,dgfordgwhat?
-
Aredgalldgofdgyourdgimmunizationsdgupdgtodgdate?dgIncludingdgyourdgchildhood,dgTdap,dgInflue
n-d g zadganddgCOVIDdgvaccines?
-
Ifdgfemale,dgdodgyoudgseedgadggynecologist?dgWhendgwasdgyourdglastdgwelldgwomandgexam?dg
WhendgwasdgyourdglastdgPAPdgSmear?dgDodgyoudgcompletedgmonthlydgselfdgbreastdgexams
5. SexualdgHistory:
?dgWhendgwasdgyourdglastdgperiod?
Thedg5dgPs
-Ifdgmale,dgdodgyoudgcompletedgmonthlydgtesticulardgexams?
Partners:dgAredgyoudgcurrentlydghavingdgsex?dgHowdgmanydgpartnersdgdodgyoudgcurrentlydg
have?dgAredgyoudgordgyourdgpartnerdghavingdgsexdgwithdgothers?
Practices:dgWhatdgkinddgofdgsexdgdodgyoudgparticipatedgin?dgOral,dggenitaldgordganal?
Protection:dgDodgyoudganddgyourdgpartner(s)dgusedgprotection?dgWhatdgkind?dgHavedgyoudg
receiveddgthedgHPVdgordgHepatitisdgA/Bdgvaccines?dgIfdgapplicable,dgdodgyoudgusedgpre-
exposured g prophylacticdgmedicationsdgordgPrEp?
, PastdgSTIs:dgHavedgyoudgeverdg
beendgtesteddgfordgSTIsdgordgHI
V?dgHavedgyoudgeverdgbeendgdia
gnoseddgwithdgandgSTIdgordgHI
V?dgIfdgso,dgdiddgyoudggetdgtrea
tment?dgDodgyourdgpartner(s
)dghavedgSTIs?
hdganddgHistorydgT gdgyourdgphysicaldgexam.dgIdgamdgjustdggoingdgtodggatherdgmydgsuppliesdganddgthendgwedgwill
ak-dging dggetdgstarted.dgPerformdghanddghygiene.
Neededdgsupplies:dggloves,dgalcoholdgswabs,dgcottondgball,dgcottondgswab,dgtonguedgde
pres-dgsor,dgophthalmoscope,dgotoscope,dgreflexdghammer,dgstethoscope
2. InitialdgApproac Obtaindgpatientdgidentificationdginformation.dg
hdganddgHistorydgT Candgyoudgtelldgmedgyourdgnamedganddgdatedgofdgbir
ak-dging th?dgHowdgolddgaredgyou?
Gender?
Race?
3. InitialdgApproac Whatdgbringsdgyoudgindgtoday?dgAredgyoudghavingdganydgpaindgordgotherdgiss
hdganddgHistorydgT ues?dgCandgyoudgtelldgmedgmoredgaboutdgthedgpain.
ak-dging UsedgOPQRST
Onset:dgwhendgdiddgthedgsymptomsdgfirstdgbegin?dgWasdgitdggradualdgordgsudden?dgProv
ocativedgordgPalliative:dgWhatdgweredgyoudgdoingdgwhendgthedgsymptomsdgstarted?dgwhatd
g makesdgitdgbetter?
QualitydganddgQuantity:dgCandgyodgdescribedgthedgpain?
RegiondgordgRadiation:dgcandgyoudgpointdgtodgwheredgthedgpaindgisdgat?dgDoesdgitdgradiatedga
ny-dgwhere?
Severity:dghowdgbaddgisdgthedgpaindgrightdgnowdgondgadgscaledgofdg0-
10?dgwhatdgisdgthedgworstdgitdghasd g been?
TimingdganddgTreatment:dghowdglongdgdodgthedgsymptomsdglast?dgAredgtheydgintermittentdgo
rd g doesdgitdgcomedganddggo?dgIsdgtheredganythingdgyoudgaredgdoingdgfordgthedgpain?
4. PastdgMedicaldgHis- Mustdgcompletedgbydgmemory!
dgtory -
GeneraldgHealth:dgwhendgwasdgyourdglastdgphysicaldgexam?dgDodgyoudgknowdgthedgdate?dg
Weredgtheredganydgconcerns?
-
ChronicdgIllnesses:dgdodgyoudghavedganydgchronicdgmedicaldgconditions?dgIfdgso,dgwhendg
,diddgtheydgstartdganddghowdgw
ere/aredgtheydgbeingdgtreate
d?
, -
Dodgyoudghavedgadgknowndghistorydgofdganydginfectiousdgdiseases?dgIfdgso,dgwhatdganddg
howdgwere/aredgtheydgtreated?
-Dodgyoudghavedganydgallergies?dgTodgmedication,dgfooddgordgenvironmental?
-
Havedgyoudgeverdghaddgsurgery?dgIfdgso,dgwhatdgsurgery?dgWeredgtheredgcomplications?dg
Diddgtheydgusedganesthesia?
-Havedgyoudgeverdghaddganydginjuries?
-Havedgyoudgeverdgbeendghospitalized?dgIfdgso,dgfordgwhat?
-
Aredgalldgofdgyourdgimmunizationsdgupdgtodgdate?dgIncludingdgyourdgchildhood,dgTdap,dgInflue
n-d g zadganddgCOVIDdgvaccines?
-
Ifdgfemale,dgdodgyoudgseedgadggynecologist?dgWhendgwasdgyourdglastdgwelldgwomandgexam?dg
WhendgwasdgyourdglastdgPAPdgSmear?dgDodgyoudgcompletedgmonthlydgselfdgbreastdgexams
5. SexualdgHistory:
?dgWhendgwasdgyourdglastdgperiod?
Thedg5dgPs
-Ifdgmale,dgdodgyoudgcompletedgmonthlydgtesticulardgexams?
Partners:dgAredgyoudgcurrentlydghavingdgsex?dgHowdgmanydgpartnersdgdodgyoudgcurrentlydg
have?dgAredgyoudgordgyourdgpartnerdghavingdgsexdgwithdgothers?
Practices:dgWhatdgkinddgofdgsexdgdodgyoudgparticipatedgin?dgOral,dggenitaldgordganal?
Protection:dgDodgyoudganddgyourdgpartner(s)dgusedgprotection?dgWhatdgkind?dgHavedgyoudg
receiveddgthedgHPVdgordgHepatitisdgA/Bdgvaccines?dgIfdgapplicable,dgdodgyoudgusedgpre-
exposured g prophylacticdgmedicationsdgordgPrEp?
, PastdgSTIs:dgHavedgyoudgeverdg
beendgtesteddgfordgSTIsdgordgHI
V?dgHavedgyoudgeverdgbeendgdia
gnoseddgwithdgandgSTIdgordgHI
V?dgIfdgso,dgdiddgyoudggetdgtrea
tment?dgDodgyourdgpartner(s
)dghavedgSTIs?
