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CS Hx Flashcards

(64 cards)

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1
Q

head

A

atraumatic, normocephalic

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2
Q

eyes

A

EOMI
PERRLA
normal eye fundus

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3
Q

nose

A

no nasal congestion

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4
Q

throat

A

no tonsillar erythema, exudates or enlargement

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5
Q

neck

A

supple
no JVD
normal thyroid
no cervical LAD

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6
Q

neurologic mental status

A

alert and oriented X 3

good concentration

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7
Q

cranial nerves

A

II-XII grossly intact

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8
Q

motor

A

strength 5/5 in all muscle groups

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9
Q

DTR

A

2+ intact and symmetric

babinski (-)

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10
Q

sensation

A

intact to sharp and dull

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11
Q

cerebellum

A

Romberg (-)

intact finger to nose

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12
Q

chest and lungs

A

clear to percussion bilaterally
no rales, wheezing, ronchi or rubs
no tenderness to palpation
tactile fremitus WNL

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13
Q

heart

A

PMI not displaced
regular rate and rhythm
normal S1, S2
nomurmurs, rubs or gallops

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14
Q

abdomen

A 
soft
 nontender
 nondistended
 BS (+)
 no hepatosplenomegaly
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15
Q

extremities

A

no clubbing, cyanosis or edema

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16
Q

mental status exam components

A 
speech
 cooperation
 affect
 eye contact
 attention
 registration/recall
 distant memories
 orientation
 three-step command
 serial 7s
 judgement
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17
Q

headache associated neurologic symptoms

A 
paresthesia
 visual stigmata
 weakness
 numbness
 ataxia
 photophobia
 dizziness
 auras
 neck stiffness
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18
Q

headache exacerbating factors

A 
stress
 fatigue
 menses
 exercise
 certain foods
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19
Q

headache alleviating factors

A

rest

medications

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20
Q

headache associated systemic symptoms

A 
nausea/vomit
 jaw claudication
 recent trauma
 dental surgery
 sinusitis symptoms
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21
Q

headache physical exam

A

inspection and palpation of head
ENT inspection
complete neurologic exam
funduscopic exam

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22
Q

confusion/memory loss

A 
include history from family members
 time course (chronic Vs. acute)
 associated symptoms --> constitutional, incontinence, ataxia, hypothyroid symptoms, depression
 delirium --> waxing/waning level of alertness
 falls
 medications --> recent and changes
 history of stroke or vascular disease
 syphillis
 alcohol use
 vitamin B12
 family history of Alzheimer
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23
Q

confusion/memory loss physical

A

neurologic exam
mini-mental
gait
general physical exam

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24
Q

depressed mood history

A 
onset
 duration
 sleep pattern
 apetite
 weight change
 drug and alcohol use
 life stresses
 excessive guilt
 suicidality
 social function
 anhedonia
 decreased energy
 decreased concentration
 psychomotor agitation or retardation
 family history of mood disorders
 prior episodes
 medications
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25
depressed mood physical
``` head and neck neurologic exam mental status exam mini-mental exam insight judgement ```
26
psychosis history
positive symptoms --> delusions, hallucinations, disorganized thoughts, catatonic behavior negative symptoms --> blunted affect, social withdrawal, decreased motivation, decreased speech/thought cognitive symptoms --> disorganized speech or thought patterns, paranoia age of first symptoms, hospitalizations previous medications alcohol and substance abuse mental status exam
27
dizziness history
lightheadedness Vs. vertigo +- hearing loss or tinnitus duration context (positioning, head trauma) associated symptoms --> visual disturbance, URI, nausea neck pain or injury medications history of atherosclerosis
28
dizziness physical exam
``` neurologic exam Romberg nystagmus tilt test gait Webber/Rinne head/neck exam cardiovascular exam ```
29
loss of consciousness history
presence or absence of preceding symptoms --> nausea, diaphoresis, palpitations, pallor, lightheadedness context --> exertional, postural, traumatic, stressful, painful, dehydration associated signs --> tongue biting, incontinence, tonic-clonic movements, confusion pulmonary embolism risk factors history of heart disease, hypertension, diabetes, alcohol, drug use
30
loss of consciousness physical
``` vital signs orthostatics neurologic exam carotid and cardiac exam lung exam exam of lower extremities ```
31
numbness/weakness
``` distribution --> unilateral, bilateral, proximal, distal duration progression pain constitutional other neurologic symptoms history of diabetes, alcoholism, atherosclerosis neurologic exam musculoskeletal exam vascular exam ```
32
fatigue and sleepiness history
``` duration sleep hygine snoring waking up choking/gasping witnessed apnea overexertion stress depression emotional problems lifestyle changes shift changes at work diet/weight changes constitutional symptoms thyroid symptoms history of bleeding or anemia medications alcohol and drug use ```
33
fatigue and sleepiness physical
head and neck exam --> conjunctival pallor, oropharynx, lymphadenopathy, thyroid exam heart, lung, abdominal, neurologic exam consider rectal exam and occult blood test
34
night sweats history
``` onset, duration, severity, frequency, timing, patterns recent URIs, cough, hemoptsis, pleuritic chest pain lymphadenopathy, fever, rash malaise, weight loss itching, diarrhea, nausea/vomiting early satiety, anorexia alcohol history sexual exposure sick contacts exposure to high-risk populations menstrual history ```
35
night sweats physical
``` HEENT exam including throat and lymphadenopathy skin exam musculoskeletal for joint pain heart and lung abdominal for hepatosplenomegaly ```
36
insomnia
``` primary Vs. secondary duration trouble falling asleep Vs. multiple awakenings Vs. early morning awakening daytime sleepiness problems keeping patient awake --> arthritis pain, diabetes polyuria snoring nightmares depression caffeine use recreational drug use jet lag shift work stressors sleep hygine mental status exam ```
37
sore throat
``` duration fever ear pain URI odynophagia swollen glands cough rash sick contacts HIV risk factors ENT exam --> oral thrush, tonsillar exudate, lymphadenopathy lung, abdominal, skin exams ```
38
cough/shortness of breath history
``` acute Vs. chronic description of sputum associated symptoms --> constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn exacerbating/alleviating factors timing, exposures smoking history lung disease allergies medications (ACEIs) ```
39
cough/shortness of breath physical
``` pulse oximetry nasal mucosa oropharynx heart lungs lymph nodes extremities --> clubbing, cyanosis, edema ```
40
chest pain history
location, quality, severity, radiation, duration context --> exertional, postprandial, positional, cocaine, trauma) associated symptoms --> nausea, sweating, dyspnea, palpitations, sense of doom exacerbating/alleviating factors --> medications prior history of similar symptoms history of heart, lung disease and diagnostic testing cardiac risk factors pulmonary embolism risk factors
41
chest pain physical
BP in both arms CV exam --> JVD, PMI, chest wall tenderness, heart sounds, pulses, edema lung exam abdominal exam
42
palpitations hystory
``` gradual Vs. acute context --> exertion, caffeine, anxiety associated symptoms --> lightheadedness, chest pain, dyspnea hyperthyroid symptoms bleeding or anemia heart disease ```
43
palpitations physical
``` endocrine/thyroid exam exophthalmos lid retraction lid lag gland size bruit tremor CV exam ```
44
weight loss
``` amount duration intentional? Diet history body image anxiety depression constitutional symptoms palpitations tremor diarrhea family history of thyroid disease HIV risk factors alcohol and drug use medications history of cancer ```
45
weight gain
``` amount duration timing --> relation to medication changes, smoking cessation, depression diet history hypothyroid symptoms menstrual irregularity past medical history alcohol and drug use physical --> complete exam including signs of Cushing --> hypertension, central obesity, moon face, buffalo hump, purple abdominal striae ```
46
dysphagia
``` solids Vs. solids and liquids progressive? Constitutional symptoms drooling regurgitation odynophagia GERD medications HIV risk factors history of smoking head and neck exam skin exam looking for scleroderma ```
47
nausea/vomitting
``` acuity of onset +- abdominal pain relation to meals sick contacts possible food poisoning possible pregnancy neurologic symptoms --> headache, stiff neck, vertigo, focal numbness associated symptoms --> GI or chest pain exacerbating and alleviating factors medications funduscopic exam complete exam ```
48
abdominal pain history
``` onset duration frequency quality intensity radiation timing (relation to meals) associated symptoms --> constitutional, GI, cardiac, pulmonary, renal, pelvic exacerbating and alleviating factors history of abdominal surgeries gallstones renal stones atherosclerosis alcohol and drug use domestic violence ```
49
abdominal pain physical
heart and lung exams abdominal exam --> guarding, rebound, Murphy, CVA palpation rectal exam pelvic exam (women)
50
constipation/diarrhea
``` frequency and volume of stools duration of change in bowel habits associated symptoms --> constitutional, abdominal pain, bloating, sense of icomplete evacuation, melena thyroid disease symptoms fiber and fluid intake medications (recent antibiotics) sick contacts, travel camping HIV risk factors diabetes pancreatitis alcohol and drug use history of colon cancer thyroid/endocrine exam abdominal and rectal exam female pelvic exam ```
51
upper GI bleeding
amount duration context --> after severe vomiting, alcohol ingestion, nosebleed associated symptoms --> constitutional, nausea, abdominal pain, dyspepsia medications --> warfarin, NSAIDs history of peptic ulcer liver disease osthostatic exam ENT, heart, lung, abdominal and rectal exams
52
blood in stools
``` melena Vs. bright blood amount duration associated symptoms --> constitutional abdominal/rectal pain, tenesmus, constipation/diarrhea trauma prior history prior colonoscopy medications (warfarin) history of bleeding or atherosclerosis orthostatics abdominal and rectal exam ```
53
hematuria
``` amount duration +- clots associated symptoms --> constitutional, renal colic, dysuria, irritative voiding medications history of vigorous exercise trauma smoking stones cancer easy bleeding lymph nodes GI, GU and rectal exams ```
54
urinary symptoms
duration obstructive symptoms --> hesitancy, diminished stream, incomplete bladder emptying, straining, postvoid dribbling irritative symptoms --> urgency, frequency, nocturia constitutional symptoms bone pain medications UTIs urethral stricture abdominal exam --> suprapubic percussion for distended bladder genital and rectal exam
55
erectile dysfunction
``` duration severity +- nocturnal erections libido stress or depression trauma associated incontinence medications past medical history --> hypertension, diabetes, high cholesterol, prostate surgery smoking, alcohol and drugs ```
56
amenorrhea
``` primary Vs. secondary duration possible pregnancy associated symptoms --> headache, decreased peripheral vision, galactorrhea, hirsutism, virilization, hot flashes, vaginal dryness, symptoms of thyroid disease history of anorexia nervosa excessive dieting vigorous exercise pregnancies D&Cs uterine infections breast exam complete pelvic exam ```
57
vaginal bleeding
``` pre Vs. postmenopausal duration amount menstrual history relation to last menstrual period associated discharge pelvic or abdominal pain urinary symptoms trauma medications history of easy bleeding or bruising abnormal pap smears ```
58
vaginal discharge
``` amount color consistency odor duration associated vaginal burning pain pruritus recent sexual activity last menstrual period contraceptives tampons history of similar symptoms history of STDs abdominal and pelvic exams ```
59
dyspareunia
``` duration timing associated symptoms --> vaginal discharge, rash, painful menses, GI symptoms, hot flashes adequacy of lubrication libido sexual history sexual trauma domestic violence history of endometriosis or PID ```
60
abuse
``` establish confidentiality directly question about physical, sexual or emotional abuse question about fear and safety history of frequent accidents/injuries mental illness drug use complete + pelvic exam ```
61
joint/limb pain
``` location quality intensity duration pattern small Vs. large joints number of joints involved swelling redness warmth associated symptoms --> constitutional, red eye, oral or genital ulceration, diarrhea, dysuria, rash exacerbating and alleviating factors trauma medications DVT risk factors alcohol and drug use family history of rheumatic disease HEENT, musuloskeletal and neurovascular exam ```
62
low back pain
``` location quality intensity radiation context --> moving furniture, bending/teisting, trauma timing --> disturbs sleep associated symptoms --> cosntitutional, incontinence exacerbating and alleviating factors history of cancer recurrent UTIs diabetes renal stones IV drug use smoking ```
63
child with fever
``` severity duration associated localizing symtoms appetite rash sick contacts day care immunizations past history HEENT, neck, heart, lung, abdominal and skin exams ```
64
behavioral problems in childhood
``` onset severity duration triggers psysical violence use of weapons substance use developmental history environment school performance neurologic exam ```

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