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Chief Complaint ✔✔the reason why the patient came to see the physician.
History of Present Illness ✔✔explanation of the CC to determine the onset of the illness.
Past,family,and social history ✔✔summary of personal and family health problems as well as
social to include marital status, occupation, use of drugs, etc.
Body Processes necessary for life: ✔✔Body Temperature, Respiration, Heart Function
Vital Signs of body function: ✔✔temperature, pulse, respiration, blood pressure
Febrile ✔✔presence of fever
afebrile ✔✔absence of fever
,intermittent fever ✔✔fluctuating fever that returns to or below baseline
remittent fever ✔✔fluctuating fever that remains elevated and does not return to baseline
continuous fever ✔✔fever that remains constant; does not fluctuate
axillary temperature ✔✔least accurate; taken under the arm
tympanic temperature ✔✔useful for children; placed in the ear
rectal temperature ✔✔per rectum; most effective
normal adult pulse range ✔✔between 60-100 bpm
apical pulse ✔✔taken over the apex of the heart by auscultation
normal respiration rate ✔✔12-20 per minute (Adults)
, apnea ✔✔temporary complete absence of breathing
tachypnea ✔✔respiration rate greater than 40 per minute
bradypnea ✔✔decrease in the numbers of respiration
cheyne stokes ✔✔regular pattern of irregular breathing rate
orthopnea ✔✔decrease in numbers of respiration
hypoventilation ✔✔reduced amount of air enters the lungs resulting in decreased oxygen level
hyperpnea ✔✔abnormal increase in the depth and rate of breathing
hyperventilation ✔✔increased amount of air entering the lungs