Any pain?
The cough is uncomfortable, but not much in the way of pain.
any SOB?
No
Lung sounds?
That is physical exam... we'll get to that... but lets say he has faint bilateral rales.
Anything making it better or worse?
He thinks it would help if he could get out of his patrol today and take a rest. Otherwise, no.
Blood in stools?
No.
Blood in urine?
No.
Pain when urinate?
No.
What color is urine?
Straw colored.
Past Medical history?
Appendicitis 4 years ago treated surgically. He admits he's "had the clap a few times."
On any meds? If so what?
Malaria Prophylaxis. (Doxy)
Are you taking your malaria meds?
Most of the time.
What does his skin look and feel like?
Lets give you the benefit of the doubt and assume you're doing a thorough skin exam even though he's just presenting with cold symptoms.
When you examine his skin, you notice a rash that looks like this on the pressure points where his body armor sits. How would you describe this?
http://img834.imageshack.us/img834/3794/o276.jpg
Abd tenderness or pain?
No.
Diarrhea or constipation?
No.
What does nose, ears and throat look like?
Throat is mildly erythemetous, but no petichiae, no lesions, no exudate, and you're not seeing significant swelling of lymphatic tissues. Nose and ears unremarkable.
Has he been bitten by anything? (ie infected beaver)
Does the sorority girl on mid-tour leave count?
Any rash or sores?
See above.
Swelling anywhere?
No.
How has his appetite been?
He hasn't had much appetite today.
Has he eaten any local food or drank from unclean water source (streams rivers etc)
Just that one time when he was really thirsty.