General diagnosis - hypothesis driven hx Flashcards
(53 cards)
name
legal requirement, establish rapport, clue to ethnic background
age
DJD=older; disc=middle age; strain/sprain=young adults
sex
osteoporosis=female; AAA=male; SLE/RA=female; BPH=male only
weight
obesity may contribute to DJD, diabetes and hypertension
ethnic background
African=Sickle Cell Disease, Ashkenazi Jews=Tay Sachs disease
height
Tall=Marfan’s, gigantism, Klinefelter’s syndrome; short=Down’s
HPI
History of the presenting illness
Onset
<3m=acute, >6m=chronic, acute=better prognosis
Mechanism of injury
Rear end collision=whiplash, rotation and extension=facet problem
Provocative factors
flexion=DH, lateral bending and extension= facet problem
Palliative factors
Rest=sprain/strain, not better with rest= bone cancer
Prvious care
Pain not better with NSAIDs= some bone tumors or psychological
Quality
burning=radiculopathy; deep dull ache=mm or bone pathology
Radiation
Dermatome=radiculopathy; loin to groin= kidney stones; chest to left arm=MI
Site
Possible location of the disase and therefore focus of examination
Severity
Purpose of comparison to see if treatment is effective or not
Timing
Pin worse at night= bone cancer or osteomyelitis
Associated Symptoes
focus for review of systems and PE
PMH
Past medical history
Serious illness
possible recurrence or complication of treatment
last PE
Might shed light on possible Dx
Injuries/accident/truama
Hyper-flexion of hyper-extension= vertebral fx
Medication
Possible drug side effect: Lipitor-mm aches, diuretics-mm cramps
diagnostic studies
clue as to possible Dx
