Pertinent Negatives

Headache: Note

1. Onset of headache: was it sudden or progressive? What was the patient doing at the time of onset? Was there an injury? 2. Character of headache: is it like other headaches the patient has had, or is it the worst of his/her life? 3. Exacerbating/alleviating factors: worsened by position, lights, loud noises, movement, etc? 4. Does the patient usually get headaches? 5. Associated symptoms of particular interest: focal weakness, speech changes, visual changes (blurred or double vision, etc.--be specific), fevers, vomiting (especially after trauma).

Back Pain: Risk Factors

IV drug use--at-risk for epidural abscess Cancer--at risk for metastases Bowel or urinary incontinence--signs of cauda equina syndrome

Peds

No fever, rash, cough, vomiting, or behavioral changes. She has been eating well and has had normal wet diapers. The patient has had no previous hospitalizations.

Back Pain

Recent trauma or falls. She has not experienced any paresthesias, saddle anesthesia, or loss of bowel or bladder control.

Seizure

Same as syncope/LOC as well as: The patient denies any tongue biting or loss of bowel or bladder control. She did not hit her head and sustained no other injuries.

Pregnant Woman

Sexual activity and the risk factors for STD should be documented. Document if the patient reports vaginal bleeding or discharge.

Lac

Tetanus status. Tingling, numbness, or weakness. She has full range of motion of the digit.

Vomiting

fever, chills, lightheadedness, dizziness, abdominal pain, hematemesis, or changes in bowel or bladder habits. She reports that she has been able to drink fluids normally.

Peds: Important notes

-Birth history, regardless of child's age. Was the child born full-term? Complications in pregnancy, labor, or delivery? -Immunization status -Exposure to similar illness. Going to daycare or school is considered exposure to any and every illness common to man, so if the parents mention daycare, this should be documented as well. -Chronic medical problems, hospitalizations, previous surgeries

Allergic Rxn

Denies any rash, sore throat, trouble swallowing, voice changes, chest pain or tightness, shortness of breath, abdominal pain, nausea, or vomiting.

Suicide / Drug Abuse

Denies any suicidal or homicidal ideation or visual or auditory hallucinations. She reports no alcohol or drug ingestion. She states that she has otherwise been well with no fever, chills, cough, nasal congestion, nausea, vomiting, or changes in bowel or bladder habits.

Diarrhea

Fever, chills, abdominal pain, changes in bladder habits, melena, or hematochezia. She reports no recent antibiotic use, foreign travel, or sick contacts.

Flank Pain

Fever, chills, abdominal pain, nausea, vomiting, hematuria, or other changes in bowel or bladder habits. + back negatives

Headache

Fever, chills, dizziness, vision changes, speech difficulty, neck pain or stiffness, nausea, vomiting, or numbness, tingling, or weakness to the extremities. She reports no recent head trauma.

Shortness of Breath

Fever, chills, lightheadedness, diaphoresis, cough, chest pain, nausea, vomiting, or leg swelling or pain. She reports no recent illness or sick contacts.

Chest Pain

Fever, chills, lightheadedness, diaphoresis, cough, shortness of breath, nausea, vomiting, or leg swelling or pain.

Abdominal Pain

Fever, chills, nausea, vomiting, vaginal bleeding or discharge/testicular pain or swelling, or changes in bowel or bladder habits.

Cold Sx

Fever, chills, rash cough, nasal congestion or rhinorrhea, sore throat, or ear pain. She has had no headache, chest pain, or shortness of breath. She reports no recent sick contacts.

Dental Pain

Has MD or Dentist previously seen? ICurrently on pain medications and/or antibiotics and have they been effective? Does she have follow up with dentist scheduled? Denies radiation of pain, jaw pain, dental abscess, drainage, fever, chills, ear pain, or sore throat.

Fall / MVC

Head injury, losing consciousness with the incident and sustained no other injuries. Ambulatory following the fall/collision. *feel free to add syncope/LOC pertinent negatives and/or neuro pertinent negatives if there is a question of how or why the patient fell

Stroke Sx

Headache, vision changes, speech difficulty, confusion, chest pain, shortness of breath, nausea, vomiting, or numbness, tingling, or weakness to the extremities.

Syncope

No preceding lightheadedness, dizziness, vision changes, chest pain, shortness of breath, heart palpitations, nausea, vomiting, or numbness, tingling or weakness in her extremities. She reports feeling well prior to her syncopal episode and did not hit her head or sustain any other injuries with the incident. She has no history of syncope or seizures.