Exam: Review of systems and medical screening Flashcards
1
Q
Past Medical History
A
- Review of Systems– Medical Screening
- Checking for constitutional signs…general signs/symptoms that are present with illness involving any of the systems:
- Assess patient’s overall physical (weight changes, fatigue/lethargy) and emotional (anxiety, hopelessness) well‐being
2
Q
Nausea/ Vomiting screening
A
- low level nausea
> often goes unreported - inquire
> is there a reason for nausea? constant, intermittent, describe?
> any other new/unusual signs and symptoms?
> vomiting w or w/out nausea?
> are they taking OTC Meds? may mask nausea - referral
> persistent vomiting usually reported to physician
> nausea w increased need meds, other constitutional signs
3
Q
Nausea/vomiting may be caused by
A
- GI disorders
- Infection (hepatitis, influenza)
- MI
- Cancer
- Vestibular disorders
- Migraines
- Pregnancy
- Adverse drug reactions
4
Q
Fever/sweats/chills screening
A
- systemic response to a systemic illness
> have you been feverish or unusually hot, noted excessive sweating, or felt chilly and cold?
> have you been taking your temp? - Temp: significant if 99.5 or higher for >2 weeks
> accounts for self limiting virus
> absence of fever doesn’t rule out infection
> higher fever (ie. 102) = urgent referral
> complete full pt picture (fatigue, malaise, decreased thermoregulation in elderly)
> caution in post-op pts with signs of op-site infection - night sweats
> concerns: regular, interrupt sleep, have other sxs, fever, wt loss
> can also occur w menopause, some meds, room too warm, many other causes
5
Q
fever/sweats/chills caused by
A
- infections
- metastatic cancers
- rheumatic disorders
- menopause
be cautious of negative responses in these cases
- elderly - reduced thermoregulatory responses
- post-surgical
6
Q
weight changes screening
A
- are you experienceing any unexplained wt changes?
- 5 to 10% increase or decrease of BW over a 4-6 month period (time period definition varies)
> unexplained
> red flag response
-exceptions requiring referral
> pregnancy: >5lb wt gain in 1 week or >5 lb loss in first trimester
> CHF: > 2-3 lbs in a day
7
Q
Weight changes caused by
A
- metastatic cancers (unexplained, > 10 lbs over 6 mo)
- depression
- GI disorders
- infections
- anorexia nervosa
- chronic pulmonary, cardiac, or renal failure
- rheumatic disorders
- endocrine disorders, thyroid dysfunction, DM
8
Q
Parasthesia, weakness or balance problems screening
A
- are you experiencing any numbness or tingling in your…
- pins and needles
- are you experiencing any weakness in your arms or legs
- are you experiencing any dizziness or lightheadedness when you…
- have you had any difficulty maintaining your balance when you walk?
9
Q
parasthesia
A
- concern if bilateral, atypical pattern, or UE/LE together, other neuro sxs present (vision, taste, smell, hearing)
- saddle anesthesia
- possible disorders contributing
> neurologic disorders
> endocrine disorders
> renal disease
> adverse dug reactions
10
Q
Weakness
A
- concern if non-myotomal
- concern if any other neuro sx present
- urinary retention, increased frequency, overflow incontinence
- possible disorders contributing
> neurologic disorders
> endocrine disorders
> muscular injury/disease
> rheumatic disorders
11
Q
balance problems
A
- dizziness or lightheadedness? > vestibular issues > vascular insufficiency - possible disorders contributing > neurologic disorders > adverse drug reactions > msk injury/disease
12
Q
night pain
A
- difficulty sleeping or falling asleep due to sxs
- wakes at night due to sxs and unable to easily fall back asleep
- pain not relieved by lying down
- pain unchanged w/ position change or food
- frequency ( per week, per night)
- due to possible:
> infection
> neoplasm
> other… inflammation, OA
13
Q
Fatigue
A
- accounts for more than 20% PC visits/year in US
- normal fatigue- life, stresses, work, grief
- concern if interfering with function for more than 2 to 4 weeks
> especially if not related to above factors
> presentation may be subtle
14
Q
fatigue may be caused by
A
- psychosocial
- endocrine/ metabolic
- infections
- neoplasms
- cardiopulmonary
- connective tissue disease
- sleep disturbances
- medication use
15
Q
malaise
A
- sense of uneasiness or general discomfort
- out of sorts feeling
- something just isn’t right
- i feel like i’m coming down with something
- often associated with fever
- PT needs to inquire about this question since patients do not usually reveal this and is not on medical screening form. It is usually derived from pt comments.
