HISTORY & PHYSICAL EXAMINATION HPI (history of present illness) ALL CASES: OPD CSF AAA PAIN: OPD CSF LIQR AAA OPD CSF ABCDO FLUIDS: (Vomiting, Diarrhea, constipation, cough, vaginal discharge) O Onset of the symptom + precipitating factors P Progression D Duration C Constant /Intermittent S Settings F Frequency L Location of the symptom (forehead, wrist… ) I Intensity of the symptom (scale 1-10, 6/10) Q Quality of symptom..
BCDSPP(burning,Cramping,dull,Sharp,pulsating,pressure like) R Radiation of the symptom ( to left shoulder and arm) A Associated symptoms ( palpitations, shortness of breath) A Alleviating factors (sitting with my chest on my knees) A Aggravating factors (effort, smoking, large meals) A Amount B Blood C Color C Consistency C Content D Duration O Odor UG Hx: OPD-CSF-AAA + FINISH PUBC F Frequency (How frequent do u have to pass urine? ) I Incontinence (Do u have trouble holding Ux until u get to BR? ) N Nocturia ( do u have 2 wake up @ Night to go to BR? I Incomplete emptying (do u feel fullness even after Ux) S Stream (How is ur flow of urine? is it cont. or is there any dribbling after Ux? ) Strain (Do u have to strain during Ux) Stone (have u passed stones in the past? ) H Hematuria (did u notice any blood), Hesitancy (do u have 2 wait b4 starting Ux) P Pyuria (was there any pus in ur Ux? ) U Urgency (do u have 2 rush to BR to Ux? ) B Burning (dysuria) (does it burn) C COLOR 1 [email protected] com PMH (past medical history) PAM HUGS FOSS P Previous presence of the symptom (same CC), Past Medical problems (^BP, ^BS,U , idney prob. Rhinitis,Sinusitis, sthma,) A Allergies (drugs, foods, chemicals, dust … ) M Medicines (R U taking any prescription medications/any over-the-counter med. ), H Hospitalization for any illness in the past (Trauma, surgery) U Urinary changes ( esp if diabetic, elderly… ) G Gastrointestinal complains (diet changes, bowel movements… ) S Sleep pattern(difficulties falling/maintain asleep,wake up,snoring,med. to help sleep, how many hour, nightmares) F Family history (similar chief complaints/serious illness)/ Fevers, Chills/ Fatigue O OB/GYN history (LMP, abortions, para… LMP RTV CS PAP S Sexual habits (active/preferences/STD/no. of partners/contraception/pregnancy/ last pap smear) Q 1. “Mr. John, Are you Sexually Active? ” Q 2. “How Many Partners are you active with? ” Q 3. “Are your partners male or female or both? ” [Unless the SP says wife or husband in Q 2] Q 4. “Do you use protection during intercourse? ” Q 5. If yes in Q. 4 “What kind of protection do you use? ” Q 6. Ask about anal intercourse in male homosexuals Q 7. h/o STD’s; Rx for STD’s S Social Hx (job/house/smoking/alcohol/recreational drugs/….. ) WAD SAD TOES Social Hx WAD SAD TOES
W Weight A Appetite D Diet S Smoke (cigarettes, marijuana, how much, how many years) A Alcohol (what type of alcohol, how often, how much ,consider doing CAGE question. ) D recreational Drugs (what drug, how do you use it, any IV drug use? ) T Travel /Trauma O Occupation (what do you do for living? ) E Exercise S Stress HEADACHE OPD CSF LIQRAA + DIAGRAM Head trauma/Seizure/Weak,Numb Tears / visual changes Flu Vomit/ Speech Neck stiffness 2 [email protected] com Ped Hx (Child with fever) CUB FEVERS + PAM IF BIG DEALS-T C Colds-runny nose,cough,chest pain, fast respirations,SOB-CRY“how is ‘cry of ‘baby? U Urination-increased or decreased urination, # of diapers, any odour, colour of urine Ulcers in mouth B Bowel changes: Diarrhea-frequency, onset, mucus/pus/blood in stool, any crying during defecation Discharge Q’s (ABCD-O: Amount, Blood, Content, Consistency, Color, Constant/Intermittent, Duration, Odor/Onset) F Fever & chills E Ear pulling V Vomiting E Ear/eye discharge, Ear hearing, Eye vision R Rash S Seizure-any jerky movements, which part of body? Any leakage of urine or stool during fits, and postictal irritability or loss of consciousness. Stress (bet wet, DM) P Past medical/Past surgical Hx / Previous Hospitalizations.
A Allergies, effect on child/parents (bet wet, DM), Activities M Medications, Menstruating (female child >10yo) I Ill contacts F family history B Birth Hx I Immunizations G Growth n development, ht, wt, milestones SSC-WTD: S(1), S(6),C(9),W(12),T(15), D(30) smile, sit, crawl, walk, talk, dress wks: 1,6,9,12,15,30 D Day care / Difficult swallowing E Eating habits, feeding of baby A Appetite L Look of the baby or appearance, Last check-up S Sleep T Travel recently Premenopause : H Hot flashes A Atrophy of vagina D Dryness of vagina O Osteoporosis (council) C Coronary artery disease HADOC [email protected] com ObGyn Hx : LMP RTV CS PAP L LMP (when was ur LMP? ) M Menarchae (how old were u when u had ur 1st period? P Period (how many days ur period last? ) R Reglarity ( R ur periods regular? ) T Tampoons (how many pads do u use in a heavy day? ) V Vaginal DID: discharge, itching , dryness (have u ever had any vag discharge? ABCDO. do u have any vag. Itching? ) C Cramps (Dysmenorrhea) do u have abd cramp with ur period? S Spotting ( intermenstrual / post coital ) have u ever bled (. ) ur cycles?
Did u ever notice any bleeding after intercourse? P Pregnency ( Hx & complications) have u ever been pregnant? How many times? A Abortion/miscarriage (Any miscarriages or abortions? In ? month of ur pregnancy? ) P PAP smear(have u been getting regular PAP sm ? when did u have the last PAP sm ) (any Female>50 yo:ask about:1-R u taking vit D & Ca,2-have u ever tried HRT? ) If suspect abuse SAFE GARDS S Safety inquiry (Do you feel safe at home? ), Sex ever forced? A Alcohol abuse (does your hubby abuses alchol? ), Attacked Children?
F Friends/Family who are aware( Dos any1 f ur friend/Fam know of this) Fractures (Abuse ever resulted in fractures? ) E Emergency plan (u have emergency plan? ), Ever tried to leave/divorce? why not? G Guns at home (are there any weapons @ home? Attacked with it? ) A Afraid of husband R Relationships with husband (how is ur relationship with husband? do you feel Threatened when he is around? For how long? D Depression (lost wt/appetite/sleep), Drugs (does husband use recreational drugs) S Suicidal (idea/plan/attempt) (ever felt like ending it all up? ) 4 [email protected] com Diabetic pt “FU/Med Refill” D Duration of disease I Insulin regimen/ oral hypoglyemics regimen A A1c hg -> Gluc. monitoring (fast, home, HgA1c) B Blurry vision (retinopathy) E Extremity (foot ulcer/infection T Tingling/numbness (neuropathy) I Infections (resp/urinary) C Cardio Risk Factors (HTN, CHOL, Heart disease) Counseling DM & HTN M Medications (regularity) E Exercise ( for obese/sedentary life styles) D Diet Modification( Salt/Fatty foods) O Opthalmoscopic exams (annual routine) W Weight Management (/control) S Sugar Check ups
DIABETIC MEDOWS Neuro cases “LOC” P Palpitations A Aura “b4 problem” S Shaking (duration) S Spinning/ lightheaded B Bladder incontinence / Bowel incontinence L Loss of consciousness (duration) T Tongue biting/ tinnitus & hearing loss S Speech difficulties/ Sleep disturbance A Ataxia “gait” N Numbness/nausea & vomit D Difficulty breathing W Weakness I Injury (trauma) & fall C Confusion after the event / Visual disturbance H Headache PASS BLT SANDWICH -And to make sure you got it completely don’t forget the MinMental Stat.
Exam 5 [email protected] com MINI MENTAL O Orientation X3 “ time, place, persons” R Registration “I’m going to say 3 objects”… then repeat A Attention “spell world backwards” R Recall what were those 3 items again? L Language “Repeat after me.. “No, ifs, ands, or buts” 2 Identify two objects “what is this.. pen.. and this… paper” 3 Obey 3 commands “take a piece of paper, fold in ? , put on floor” R “Read 3 commands on this paper and do what it says” W Write a sentence D Draw, copy the image ORARL23RWD
Forgetfulness/ Memory Loss / Dementia/ Alzheimer’s FORGETS HIM + DEATH SHAFT F FAINTING / Flashes/ FHx of Alzheimer 0 ORTHOSTATIC HYPOTENSION R RUNNING URINE “INCONTINENCE” G GAIT E EYE[VISION] T TRAUMA, TINGLING S STRENGTH,SEIZURES H HEADACHE I INFECTION [SYPHILIS, MENINGITIS] M MOOD ADL – Activities of daily living D Dressing E Eating A Ambulation (can you find your way thru home) T Toiletry (do you manage your toiletry unassisted) H Hygiene IADL – Instrumental activities of daily living S Shopping H Housekeeping A Accounting F Food prep (do u do your cooking ) T Transportation (do you drive? How is your sight, hearing? 6 [email protected] com Foot / Heel / Knee / Back pain OPD-CSF-LIQORAAA +WET SURF-D -‘CIS’ W Work /Weakness / Walking habits /Wt loss E Eye infection redness T Trauma to foot /Tingling& Numbness / Tender S Stifness in other joints/leg Swelling /long Standing hours/morning Stiff/sound U Urethral discharge /ulcer R Rash/ Redness of skin of joint F Fever & chills& night sweat D Deformity / Dysurea IN CASE OF BACK PAIN ADD: CIS; Cancer Hx /IV DRUGS/ Steroids 4 long time Depression: (Psychiatric Hx Checklist) SIGME CAPS DHAT +2 (+MMSE: ORAL23RWD) S Sleep (difficulties falling/maintain asleep, wake up, snoring, med. o help sleep, how many hours, nightmares), Stress, Support I Interest, What do you do in your free time? How are you doing in your job? do you enjoy what you do? G Guilty M Mood. ( anxious, sad, hopeless, lonely? Memory problems E Energy C Concentration A Appetite, changes in your Weight P Psychomotor agitation/retardation (do you feel easily agitated or angry/do u feel not to do anything? ) S Suicide: thoughts, plan, attempts(do u have pills/guns @ home? D Delusions/Drugs H Hallucinations/Hopes A Attitude towards life (positive negative frame of mind) T Thyroid dysfunctions (ABCD HV for HYPOTHYROID) also need to ask : Do u realize that u have problem ? Do u want help? ( if patient was sent or asked by anyone to consult doc ) HYPOTHYROID APPETITE BOWEL-constipation COLD INTOLERANCE DEPRESSION HAIR FALL VOICE-Hoarseness 7 [email protected] com ABCD HV Hearing loss: P Pain D Discharge F FB I Imbalance N Noise R Ringing S Spinning T Trauma Dx ABD Signs PDF IN RST CKMG MIOR (MIOR assoc. ith Appendicitis) C Cullen $- periumbilical discoloration (Retroperitoneal He,pancreatitis, AAA rupture) K Kehr $ –sever Lt. Shoulder pain- Splenic rupture, ectopic pregnancy M Muphy’s $- Abrupt interruption of inspiration on palp of RUQ- acute cholecystitis G Gray-Turner $, Discoloration of flank (same as Cullen $) M Mc Burney’s $- Tenderness 2/3 from ASIS to Rt of umbilicus I Iliopsoas $, Hyperextention of R hip Cx ABD pain O Obturator $- Internal rotation of flexed R hip Cx ABD pain R Rovsing $- RLQ pain upon palpation of LLQ DD
Nasuea & Vomiting A Anorexia M Metabolic( DKA)/Meds O Obstruction (pyloric /Intestinal) P Pregnancy I Inflammation( Pyelo/Cholecysto/Appi/Pancreas/PID) N Neurological (BETA)= Bleed/Encephalitis/Tumor/Abscess G Gastroenteritis A MOPING 8 [email protected] com Cranial Nerves: 2 optic 3 4 6 5 7 Oculomotor Trochlear Abducent Trigeminal -Test visual acuity -Test pupillary reflexes (direct) -Test accommodation reflexes -Assess pupillary reactions to light -Assess corneal reflection -Perform H-test for EOM -Sensory: close eyes,touch face where? Motor: Assess strength of muscles of mastication;bite down and palpate masseter Ask patient to; -smile -wrinkle forehead, -blow out cheeks -close eyes -whisper, -Weber -Rinne tests Assess movements of the soft palate; swallow and palpate neck Assess strength of trapezius & sternocleidomastoid muscles; -shrug shoulders up -move neck to side against resistance Ask patient to protrude tongue (assess for fasciculation, atrophy & Deviations) -stick your tongue up -move it side to side facial 8 Vestibulocochlear 10 vagus 11 accessory 12 hypoglossal 9 [email protected] com – Mr. ? – Good morning Mr. , I am Dr. Khalil, an attending physician in this hospital. SHAKE HANDS First I’ll ask u few Qs. and do brief physical exam. Meanwhile if u have any Qs, feel free to ask me, ok? – Let me make u more comfortable DRAP PT. – I’ll be sitting & writing some notes while we’re talking, is that ok? …THANK U. – Please tell me what brought u in today Mr. ? …….. – I. C. , can u tell me more about …….. “c. c. ” Mr. I’d like to ask u few Qs. about ur health in the past, is that ok? Mr. now I’d like to ask u few Qs. bout ur habits, is that ok? Now I’d like to ask u few personal Qs. I assure u that all info. Will be kept confed. ok? Now, let me ask u few Qs. about health of your family members, ok? Does any body in ur family have any med. Conditions? Mr. thank u. I am done e history, let me summarize for it, As u mentioned, u have ….. Do u have any Qs. for me? Mr. Now I need to examine u. may I proceed? But 1st let me wash my hands. Ok? Mr. Thank u for ur cooperation. I am done e phys. Exam let me give my impression. Based on ur Hx & my PE, it seems that u might have….. ut it could be something else/ …or…, so to arrive at right D, I ‘ll run some tests & order imaging studies such as ….. once I’ve result we’ll meet again discuss various ttt. Options. – Do u have any Qs. for me? SHAKE HANDS & LEAVE ROOM 10 [email protected] com HISTORY HPI: OB/GYN: LMP…, regular periods every….. Weeks ,lasting….. Days. Menarche at age… Uncomplicated NSVD at full term.. Years ago. ROS: negative except as above. Allergies: NKDA Medications: none PMH: PSH: SH: smoke /alcohol / illicit drugs/sex / job /exercise FH: noncontributory PHYSICAL EXAM Patient is in no acute distress OR looks .. anxious,tired, …) ( The source of information is the patient’s mother. the mother of a …. -month/year-old female/male c/o her child having ….. ) VS: WNL (except for temp. Of …) HEENT: NC/AT, PERRLA, no conjunctival pallor. No fundoscopic abnormalities. Nose,mouth and pharynx WNL Neck: Supple, No LAD, thyroid normal, no carotid bruits. Chest: no tenderness, clear breath sounds bilaterally. Heart: RRR, normal S1/S2, no murmurs, rubs or gallops Abdomen: soft, non-tender, non-distended, +BS, no guarding, no hepatosplenomegally Extremities: no edema, normal DTR in lower extremities Skin: no rash Neuro:
MMSE: AOx3, spells backward, recalls 3 objects, Cranial nerves: 2-12 grossly intact, Motor: strength 5/5 throughout -sensory: intact to soft touch and pinprick, DTR: symmetric 2+ in all extremities (or lower extremities), – Babinski bilateral, Gait: normal, Cerebellar: – Romberg, rapid alternating movement and heel to chin test normal and symmetric 11 [email protected] com UWShort UWLong 1 16-31-37 2 1-13-1925-35-39 24 25 4-5-1822-24 29 15 28 20 21-40 12 7 43 10 FA Full 19 1-2 38 6 3 FA Mini CASE 23-24 Urine problem Alcoholism 19 Abd pain Heel pain Chest pain 13 8 31 5 6 7 4 6-26 10 38 42 34 11 UL pain 31 Shoulder pain 21 Knee pain 27 32 Back pain 37 Calf pain Vomiting “adult” 18 Vomiting “child-TEL” 7-8 33 Fever “child” 5-28 20-22 Diarrhea Rectal bleeding Constipation 9 Night sweat 21 Hemoptysis 9-10-40 12 Chronic cough 15-16-17 8 Fatigue 15 Wt loss 16 Wt gain 17 dysphagia 18 1 Headache 3 Depression 4 psychosis Anxiety Seizure –new onset Amenorrhea Menopause 25 26 Menstrual problems 26 Vaginal discharge 12 [email protected] com 12 23 13 30 9 33 14 16 17 18 19 20 21 22 23 12 36 13 27 23 6 2 22 41 30 36 41 3 17 32 34 14 11 39 30 14 15 30 10 5 7 6 27 28 14 8 32 27 29 11 2 [email protected] com 35 33 26 31 4 29 29 11 25 34 Forgetfulness Frequent falls DM New DM drug refill BA drug refill HTN drug refill HIV drug refill Vaginal bleeding Obesity Spells “LOC” Terminal cancer Confusion Tremors Pre-employment Domestic violence Sexual assault Insomnia Dizziness Numbness-weakness Jaundice “adult” Jaundice “Neonate” Enuresis Palpitations SOB Smoking cessation Hallucinations +ve Pregnancy test Pain with sex MVA Sore throat Difficult swallowing Hearing loss Blurred vision Erectile dysfunction Behavioral problem “child” Skin rash 3 FA cases GIT Trauma Resp Cardio Ped Neuro Endo Psych Renal ObGyn Pain DM/HTN Jaundice Fever Fatigue 1-2-5-11 3-21-27-31-37-38 4-9-10-41 6-20 7-8-28-30-36-39-40 12-14-18-22-23-29 13-24 15-16-17-34-35 19 25-26-32-33 FA cases 1-2-3-21-38-6-27-37 13-20-36 11-39 7-8 15-16-17 14 [email protected] com