FDC Assessment Phase II Flashcards
Components of History Taking
Chief Complaint History of Present Illness Past Medical/Surgical History Family History Social History Medications Allergies
Components of Review of Systems
General Vision HEENT Pulmonary Cardiovascular GI Urinary MSK Neurologic Hematologic Endocrine Psych Skin
Components of Physical Exam
VITALS General Assessment HEENT Cardiac Pulmonary Abdominal MSK Skin Neurologic
VITALS PE
Take pulse and verbalize rate, rhythm and quality
-“80 BPM, regular rate and rhythm, 3+ pulse”
Take blood pressure on one arm - verbalize
Measure respiration and verbalize characters of respirations
-“18 RR, no signs of labored breathing”
HENT PE
External Inspection of EYES
-“pupils are equal in size, cornea clear, sclera clear, no conjunctival inflammation bilaterally”
Test PUPILLARY REACTION TO LIGHT (use light)
-“both pupils responded appropriately to light”
Inspect ORAL CAVITY (use light)
-“looking at teeth, gums, tongue mucous membranes for discoloration and swelling”
Inspect POSTERIOR PHARYNX (use light)
-“looking at posterior pharynx like uvula and tonsils for discoloration and swelling”
Palpate ANTERIOR CERVICAL and SUPRACLAVICULAR LYMPH NODES
-“no enlargement of anterior cervical and supraclavicular lymph nodes bilaterally”
Palpate THYROID
-“no swelling or tenderness noted, appears symmetrical”
Cardiovascular PE
Palpate precordium (around heart) and PMI -"did not feel any bounding of the heart"
Auscultate HEART with DIAPHRAGM at 4 locations (supine)
Auscultate HEART with BELL at APEX (supine)
Assess BOTH lower extremities for EDEMA
-“no signs of edema bilaterally”
Palpate PULSES - Radial, Posterior Tibial, Dorsalis Pedis
Pulmonary PE
Inspect FRONT, BACK, and RIBS for size, shape, symmetry and use of accessory muscles and RETRACTIONS
-“Chest is normal size and symmetrical and no use of accessory muscles or retractions seen”
Percuss POSTERIOR region in 3 places bilaterally
Auscultate 2x regions on FRONT and 3x regions on BACK
Abdominal PE
Inspect skin, shape, size, contour of ABDOMEN
-“looking for any rashes, masses, swelling and symmetry”
Auscultate 4 QUADRANTS of abdomen for 5-10 seconds each
Palpate LIGHT and DEEP in the 4 QUADRANTS (after auscultation)
Palpate LIVER edge (hook method)
-“palpating edge of the liver and I don’t find any hepatomegaly”
MSK PE
Inspect for ALIGNMENT of front/back of upper and lower extremities bilaterally
-“no signs of misalignment or hypertrophy/atrophy of muscles in upper and lower extremities”
Inspect JOINTS of upper and lower extremities bilaterally (HANDS and FEET)
-“no signs of swelling, redness or deformities in the joints of the upper and lower extremities”
Skin PE
Inspect SKIN/HAIR/NAILS all over
- “inspecting skin for any lesions, rashes, discoloration or scaling”
- do this while doing other PE sections
Neuro PE
Assess MENTAL STATUS - Self, Date and Location
- What is your name?
- What year is it?
- Where are you right now?
Assess SPEECH
-“You have been talking appropriately throughout the visit”
Assess CRANIAL NERVES 2-12
- 2 - pupil reaction to light (already did it)
- 3,4,6 - eye movements in all directions
- 5 - sensation of face (forehead, under eyes, jaw)
- 7 - lift eyes, close eyes, smile, puff cheeks
- 9, 10 - say ‘ahhhh’
- 11 - shrug shoulders and turn head against resistance
- 12 - stick out tongue
Assess MOTOR function
- 1x UPPER strength test
- 1x LOWER strength test
Assess GAIT
- ask patient to walk across the room
- “gait appears normal”
Assess deep tendon REFLEXES
- patellar reflex
- bicep tendon reflex
Assess LIGHT TOUCH
-ask patient to close eyes and test only the FEET to light touch
General ROS
Any recent fevers, chills or night sweats?
Any feelings of fatigue lately?
Vision ROS
Any blurry vision lately?
Any redness or itchy eyes?
HEENT ROS
Any pain in your ears?
Any stuffy or runny nose?
Any sore throats?
Does your neck feel sore or stiff?
Pulmonary ROS
Do you ever have trouble catching your breath?
Do you ever feel pain when taking a deep breath?
