Physical Findings

The next portion of the record contains the previous medical history (PMH). This subsection contains information about previous illness, accidents, medications, and the presence or absence of allergies

Following the previous medical history (PMH), you usually find the information about the family history (FH) and the social history (SH) of the patient. The family history describes the history of cancer and other diseases in the patient's family. The subsection on social history should contain information about smoking, use of alcohol and drugs, birth control pills, and other possible carcinogens. Sometimes this subsection will include work history, especially if the patient has worked in an environment that might be conducive to the development of cancer.

The review of systems (ROS) comprises the next section of the record. During this review, the physician systematically questions the patient about his well-being, problems associated with head, ears, eyes, nose, throat (HEENT); heart, chest; gastraintestinal (GI) tract, and genitourinary (GU) system problems; unusual bleeding tendencies (hematopoietic problems).

The next portion of the record contains the physical examination (PE) of the patient. It begins with a general description of the patient's condition together with a recording of vital signs.

The physical examination begins with the head, eyes, ears, nose, and throat (HEENT) and moves downward, covering such areas as the neck, chest, heart (cardiac), vascular system, lungs, abdomen, genitals, rectum, extremities, and lymph nodes. A general check is then made of the musculoskeletal and nervous systems.

The medical history and physical examination section of a medical record often end with the physician's impression of the diagnosis.