General Diagnosis Flashcards
Name
legal requirement,establish rapport, clue to ethnic background
age
DJD=older patients; dis=middle age, strain/sprain=YA
Sex
osteoporosis-females; AAA-males; SLE/RA-females, BPH-males only
Height
tall-Marfan’s, gigantism, Klinefelter’s. short-down’s
Ethnic background
african-sickle cell; ashkenazi-tay-sachs
onset
<3mo=acute, >6mo=chronic, acute=better prognosis
Mechanism of injury
rear end collision=whiplash, rotation and extension=facet problem
provocative factors
flexion=disc lesion, lateral bend w/ extension=facet problem
palliative factors
rest=strain/sprain, not better w/ rest= bone CA
previous care
not better w/ NSAIDs=some bone tumors or psychological
quality
burning=radiuclopathy; dull deep ache=muscular or bone pathology
radiation
dermatome=radiculopathy, loin to groin=kidney stones, chest to L arm=MI
site
possible location of the disease and therefore focus of examination
severity
purpose of comparison to see if treatment is effective or not
timing
pain worse at night=bone CA or oesteomyelitis
associates symptoms
focus for review of systems and physical exam
serious illness
possible recurrence (CA), or complication of treatment
last physical exam
might shed light on possible diagnosis
injuries/accidents/trauma
hyperflexion or hyperextension=vertebral fx
medication
possible ADR; lipitor-muscle cramps, diuretics-muscle cramps
diagnostic studies
clue as to possible diagnosis
hospitalization/surgery
may be a complication of surgery or treatment
immunizations
may be linked w/ Guillan-Barre
marital status
unhappy-psychological pain (being single worse than smoking)
children
infertility-endometriosis; psychological stress
family history
inheritied diseases
diet
foods rich in omega 6s make RA and other diseases worse
exercise
overuse may aggravate condition like CTS or TOS
alochol use
abuse=avascular necrosis, pancreatitis, psychological stress
rec. drug use
IV use=osteomyelitis, coke=MI in YA
stress
linked w/ poor prognosis
hobbies
lack of interest-depression
occupation
sex work, asbestosis, silicosis
tobacco use
lung, bladder, esophageal CA
sleep
may be affected, bone CA, CHF, diabetes
consitutional
unexplained weight loss+CA; fever=osteomyelitis, fatigue=depression
allergies
recurrent infxns=multiple myeloma or HIV/AIDS
neruological
bladder/bowel controll issues=cauda equina syndrome
GI
blood in stool=colon CA; clay-colored stool=pancreatic CA
Respiratory
blood in sputum=lung CA or TB
ENT
recurrent sore throat=HIV/AIDS, multiple myeloma, leukmia
Gentiourinary
dysurnia=UTI, vaginal discharge=PID
Psychological
depression affects prognosis and healing time
Integumentary
butterfly rash-SLE, red shin bumps=sarcoidosis
Neck
small joint pains & swelling=RA; avoid upper cervical adjustment
Cardiovascular
chest pain worse w/ movement=musculoskeletal
Hematological
fatigue=leukemia; swollen nodes=lymphoma, bleeding=leukemia
Musculoskeletal
multiple aches/pain=polymyalgia rheumatica and fibromyalgia
Endocrine
Muscle cramps=hypoparathyroidism, heat intolerance=hyperparathyroidism
Underweight BMI
<18.5
Normal BMI
18.5-24.9
Overweight BMI
25-29.9
Class 1 Obese BMI
30-34.5
Class 2 Obese BMI
35-39.9
Class 3 Obese BMI
Over 40
Air conduction twice as long as bone conduction
normal
Both air and bone conduction are reduced in one ear
nerve conduction deafness
Bone conduction longer than air conduction (Rinne)
serous otitis media
Bilateral dilated pupils
cocaine, barbiturate, or amphetamine abuse
Bilateral pinpoint pupils
heroin abuse
Bilateral papilledema (swollen optic disc)
raised intracranial pressure; brain tumor
Blue sclera + fractures
Osteogensis Imperfecta
Macular hyperpigmentation or blurring of edges
macular degeneration
copper or silver wiring of retinal arterioles
hypertensive retinopathy
cupped optic disc
chronic glaucoma
enlarged tongue
hypothyroidism in infants
exophalmosis
hyperparathyroidism or optic tumor