Health History and Interview
The patient's own words about why they are seeking care today — always written in quotes.
What is the chief complaint?
This term describes a thyroid gland that is diffusely enlarged with multiple palpable nodules of varying sizes, often discovered incidentally on neck exam or imaging.
What is a multinodular goiter?
This term describes unequal pupil sizes and may indicate a neurological emergency when new and associated with altered mental status.
What is anisocoria?
This percussion note is heard over normal lung tissue.
What is resonance?
This heart sound is associated with ventricular hypertrophy and is called the "atrial kick."
What is S4?
A high-pitched rushing sound heard over the aorta, renal arteries, or iliac arteries during abdominal auscultation is called this
What is a bruit
The name of a hard, enlarged, left supraclavicular lymph node:
What is a Virchow's node?
This component of the Subjective Health History includes past illnesses, surgeries, hospitalizations, and immunizations.
What is the past medical history?
Pale, boggy, bluish-gray nasal turbinates on exam are the classic finding associated with this condition.
What is allergic rhinitis?
This finding on fundoscopic exam — a bright yellow spot lateral to the optic disc — is the center of central vision.
What is the macula/fovea?
Tactile fremitus is increased over this pathological process, where air is replaced by fluid or solid tissue.
What is a consolidation (pneumonia)?
The best location to auscultate the aortic valve.
What is the right 2nd intercostal space (sternal border)?
This percussion note is heard over a hollow, air-filled structure.
What is tympany?
What do "A" "B" "C" "D" and "E" stand for regarding melanoma criteria?
This section of the SOAP note contains measurable, observable, and reproducible data collected by the clinician.
What is objective?
The clinician assesses this sinus by pressing firmly below the medial aspect of each eye along the inferior orbital rim.
What are the maxillary sinuses?
This finding — white, creamy, curd-like plaques on the tongue and buccal mucosa that can be scraped off, revealing a red, bleeding base — is diagnostic of this infection.
What is candidiasis (thrush)?
This adventitious lung sound is described as a discontinuous, crackling sound heard on inspiration.
What are crackles (rales)?
S2 is produced by the closure of these two valves.
What are the aortic and pulmonic valves?
This anatomical landmark — the midpoint between the umbilicus and the right anterior superior iliac spine — is the classic location for appendiceal tenderness.
What is McBurney's point?
This triad — episodic vertigo, unilateral sensorineural hearing loss, and tinnitus — is the hallmark of this inner ear disorder.
What is Ménière's disease?
Ordering labs, prescribing medications, referrals, and patient education are all documented here.
What is the plan?
This extraocular movement test — following an object in an "H" pattern — assesses the function of these three cranial nerves.
What are cranial nerves III, IV and VI?
Exophthalmos — forward protrusion of the eyeball — is a classic physical exam finding associated with this endocrine disorder.
What is hyperthryroidism?
This low-pitched, continuous adventitious sound — sometimes described as a "snoring" quality — clears or changes with coughing and indicates secretions in large airways.
What is rhonchi?
This type of lower extremity ulcer presents with pale, punched-out borders, a necrotic or pale base, is located on the tips of toes or lateral malleolus, is extremely painful at rest, and is worsened by leg elevation
What is an arterial (ischemic) ulcer?
This technique — pressing deeply and releasing suddenly — elicits pain upon release and suggests peritoneal irritation.
What is rebound tenderness?
The general survey begins the moment the clinician does this — before a single word is spoken or a hand is laid on the patient.
What is observing (or first laying eyes on) the patient?
When a patient says "my chest tightens every time I walk upstairs," this symptom descriptor from OLDCARTS is being addressed.
What is the precipitating/palliative factors?
This bacterial pharyngitis — caused by Group A Streptococcus — presents with sudden onset sore throat, fever, tonsillar exudate, anterior cervical lymphadenopathy, and absence of cough. This 4-criterion clinical scoring tool is used at the bedside to estimate the probability of strep and guide testing decisions. (two answers)
What is streptococcal pharyngitis; what is the Centor criteria?
In the Weber test, a patient with left sensorineural hearing loss will lateralize sound to this side.
What is the right or unaffected side?
This triad — dullness to percussion, decreased breath sounds, decreased fremitus — is classic for this condition.
What is a pleural effusion?
This type of lower extremity ulcer presents with irregular, shallow borders, periwound hemosiderin staining, surrounding lipodermatosclerosis, and is located at the medial malleolus — worsened by prolonged standing and improved with leg elevation.
What is chronic venous insufficiency?
Acute, colicky, RUQ pain radiating to the right scapula, occurring after a fatty meal, in a middle-aged female is the classic presentation of disease involving this organ.
What is the gallbladder?
"Acute vs. chronic," "localized vs. diffuse," and "productive vs. nonproductive" are all examples of these.
What are semantic qualifiers?