1. General condition
Covering conditions such as the level of tension / fatigue, qualitative level of consciousness or GCS and client verbal response.
2. Vital signs
Includes examining:
Blood pressure: should be examined in a different position, assess the pulse pressure, and pathological conditions.
Pulse rate.
Respiratory rate.
Temperature.
3. Main complaint
Assessed onset, duration, quality and characteristics, severity. Location, precipitating factors, related manifestations:
Typical complaints (esophagus): heartburn, regurgitation, and dysphagia.
Atypical Complaints (extra esophagus): chronic cough, hoarseness, pneumonia, pulmonary fibrosis, bronchiectasis, and non-cardiac chest pain.
Another complaint: weight loss, anemia, hematemesis or melena, odynophagia.
4. Past medical history/Previous health
Other gastrointestinal diseases.
Drugs that affect gastric acid.
Allergy / immune response reaction.
5. Family medical history
Physical Examination
1. General condition: The general condition may include an impression of illness including facial expressions and patient positioning, awareness may include qualitative assessment.
2. Examination of vital signs: pulse (frequency, rhythm, quality), blood pressure, respiration (frequency, rhythm, depth, respiratory pattern) and body temperature.
3. Examination of the skin, hair and lymph nodes.
Skin: The color (pigmentation, cyanosis, jaundice, pale, erythema and others), turgor, skin moisture and the presence / absence of edema.
Hair: color, luxuriance, distribution and other characteristics.
Lymph nodes: the shape and signs of inflammation that can be assessed in the anterior cervical region, inguinal, occipital and retroauricular.
4. Examination of the head and neck
Head: the shape and size of the head, the hair and scalp, the crown of the head (fontanelle), seen from the eyes of vision, palpebrae, eyebrows eyelashes, conjunctiva, sclera, pupil, lens,
Ear: ear canal, tympanic membrane, mastoid, auditory acuity,
Nose and mouth: lips, gums, tongue, salivation.
Neck: Neck stiffness, size, shape, position, consistency, and presence or absence of pain swallow.
5. Chest examination: Examination of the chest is the organ of the lung and heart. In general, the form asked the chest, lungs state which includes symmetric, the movement of the breath.
6. Examination of the abdomen: about the size or shape of the abdomen, abdominal wall, bowel, abdominal wall tension or tenderness, and palpation in the liver, spleen, kidneys, bladder that determined the presence or absence and the enlargement of the organ, then examination of the anus, rectum and genetal.
7. Examination of the limbs and neurologic: checked for range of motion, balance and gait, the grip, the leg muscles, and others.
