Anamnesis, Examination Basics

Question 1

What are the 8 parts of medical history taking?

Answer 1

1. Reason for admission (“primary complaint”)
2. History of present illness
3. Current complaints (+ “review of systems”)
4. Past medical history
5. Family medical history
6. “Social history” (drugs, alc, smoking, diet, etc.)
7. Medications
8. Allergies / Drug Rxns

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Question 2

What are the parts of the “review of systems”?

(8)

Answer 2

1. General (age, demeanor, height/weight, vitals)
2. Head and Neck (eyes, mouth, neck + nodes, etc)
3. Chest (cardiorespiratory)
4. Abdomen (digestion, stool, appetite)
5. Genitourinary (urine freq/color/pain, gyno, prost.)
6. Extremities
7. Skin + Joints
8. CNS

Question 3

What is included in the “general” part of a review of systems / negative physical exam?

(6 items)

Answer 3

1. age
2. demeanor (including patient “reliability”)
3. height/weight
4. BP
5. HR
6. Temperature

Question 4

What should be checked for / included in a negative physical exam of the head/neck?

(7 items)

Answer 4

1. Masses / node enlargement
2. Eye movement / pupil reactivity
3. Sclera + conjunctiva condition
4. Oral mucosa + teeth (incl. tongue + tonsils)
5. Trachea (“in the midline”)
6. Thyroid
7. Jugulars + carotid pulse

Question 5

What should be included in a negative physical exam of lung function?

5 + 1

Answer 5

1. Symmetry
2. Inspiratory expansion
3. Percussion (resonance + diaphragm lowers)
4. “Alveolar” breath sounds (no wheeze, rales, friction rub)
5. Symmetrical fremitus + bronchophony
6. (Vertebral/costovertebral angle tenderness absent)

Question 6

What should be included in a negative physical exam of the heart + major vessels?

5 items

Answer 6

1. Normal borders
2. Apex beat palpable (5th IC, 1 cm medial to MCL)
3. Normal S1/S2 (no added heart sounds, murmurs, friction rub)
4. No carotid bruits
5. Normal JVP

Question 7

What should be included in a negative physical exam of the abdomen?

7 items

Answer 7

1. At the level of the chest (not distended)
2. Soft + non-tender (no defense/rebound tender)
3. No masses
4. Liver dullness present, normal borders (incl. on inspiration)
5. Spleen + kidneys non-palpable
6. Normal bowel sounds
7. No bruits

Question 8

What should be included in a negative physical exam of the extremities?

Answer 8

1. No joint deformities
2. No edema
3. No varicose veins
4. Posterior tibial and dorsalis pedis pulses

Question 9

What should be included in a negative physical exam of the skin?

6 items

Answer 9

1. No cyanosis
2. No anemia
3. No jaundice
4. No rashes
5. Skin temp / moistness (warm + moist = normal)
6. No nail clubbing