OPQRST

Question 1

O

Answer 1

onset

Question 2

P

Answer 2

pallative
provoking
positioning

Question 3

Q

Answer 3

Quality

Question 4

R

Answer 4

Radiating

Question 5

S

Answer 5

severity
setting
sysmptoms
sick contacts

Question 6

T

Answer 6

Timing 
triggers 
trending 
temp 
Tx
travel 
Trauma

Question 7

History

Answer 7

CC
HPI
allergies 
meds
past medical 
past surgical 
Hospitalization (immunizations,screening, pap)
family Hx 
social Hx (TEDDEOS)

Question 8

ROS

Answer 8

General (headache, weight changes, malaise)
CV (chest pain, palpatations, murmurs)
Resp (Dyspenea, SOB, Cough, DOE)

Question 9

GEN: PE

Answer 9

WDWNWH
appears stated age
pleasent and cooperative

Question 10

Head PE

Answer 10

NCAT
scalp without lesions
No TTP

Question 11

Eyes PE

Answer 11

PEERLA
sclera
VA 20/20 OU
Optic disk symmetrical w/sharp margins B/L

Question 12

EARS PE

Answer 12

Auditory acuity intact B/L per whisper test
auditory canal patent
Tympanic membrane intact

Question 13

Nose PE

Answer 13

nasal mucosa pink and moist
nasal septum intact without deviation
Maxillary and frontal sinuses no tenderness to palpations B/L

Question 14

Throat PE

Answer 14

lips, tongue, and oral mucosa pink moist without lesions

tonsils no swelling without erythema

Question 15

Neck PE

Answer 15

trachea midline,

thyroid w/o enlargemnets or TTP