History and Physical Flashcards
What are the parts of the HPI?
- Location
- Radiation
- Quality
- Severity/Intensity
- Timing (onset, duration)
- Frequency/Pattern
- Setting
- Aggravating Factors
- Alleviating Factors
- Associated Manifestations
- Associated Active Problems
- Past Experience With Symptoms (Prior Treatment, Response)
- Significant +/-
- Psychosocial Context
- PPI
What are the parts of the Medical History?
- Adult Illnesses
- Immunizations
- Screenings
- Ob/Gyn History
- Psychiatric Illnesses
- Childhood Illnesses
- Injuries/Accidents
- Hospitalizations
- Operations/Procedures
What are the parts of the Ob/Gyn History?
- # of pregnancies
- Outcome of pregnancies
- Vaginal/Caesarean
- Last menstrual period
- Regularity of menses
- Fertility concerns
- Pap smear
What are the parts of the Therapies/Allergies?
- Medications
- Complementary/Alternative Medicine
- Allergies
- Drug Reactions
What are the parts of the Psychosocial History?
- Marital status/relationships
- Living arrangements/family structure/safety at home
- Employment history/job satisfaction/military service
- Significant life events and stressors
- Spiritual history/source of support
- Diet, sleep, exercise
- Tobacco, alcohol, drugs
- Sexual history
What are the parts of the Family History?
- Current health of first degree relatives
- History of significant illnesses
- Deaths
What are the parts of the ROS?
- Constitutional
- Integumentary
- Eyes
- Ears/Nose/Mouth/Throat
- Breasts
- Respiratory
- Cardiovascular
- GI
- GU
- Musculoskeletal
- Neurologic
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
What are the parts of the Constitutional ROS?
- Changes in appetite
- Changes in weight
- Fevers or night sweats
- Fatigue
What are the parts of the Integumentary ROS?
- Rashes
2. Change in color/size of a mole
What are the parts of the Eye ROS?
- Eye pain or discomfort
2. Changes in vision
What are the parts of the Ears/Nose/Mouth/Throat ROS?
- Hearing loss
- Dizziness/spinning
- Drainage from ears
- Congestion/stuffiness
- Drainage from nose
- Changes in voice/hoarseness
- Pain/ulcers in mouth
What are the parts of the Breast ROS?
- Lumps
- Pain
- Nipple discharge
- Rashes/skin changes
What are the parts of the Respiratory ROS?
- Cough
- Coughing up blood
- Wheezing
- Snoring/daytime tiredness
What are the parts of the Cardiovascular ROS?
- Shortness of breath (at rest, exercise, lying flat)
- Chest pain
- Palpitations
- Lightheadedness/fainting
- Leg/ankle swelling
What are the parts of the GI ROS?
- Abdominal pain/discomfort
- Change in bowel habits
- Trouble swallowing
- Vomiting blood
- Rectal bleeding/black stools
- Yellowing of the skin/eyes
What are the parts of the GU ROS?
- Problems holding/passing urine
- Blood in the urine
Males: - Discharge from/sores on the penis
- Testicular lumps/pain
Females: - Spotting between cycles
- Vaginal discharge
- Hot flashes
- Vaginal bleeding if post-menopausal
What are the parts of the Musculoskeletal ROS?
- Joint or muscle pain
2. Limitation of normal activity from joint, neck, or back
What are the parts of the Neurological ROS?
- Onset of weakness/numbness/loss of feeling in face/arm/leg
- Problems speaking
- Problems walking/unsteadiness
- Shaking
- Headaches
What are the parts of the Psychiatric ROS?
- Feelings of sadness/depressed mood
- Feelings of harming one’s self or others
- Feeling that others will harm you
- Loss of interest in doing pleasurable activities
What are the parts of the Endocrine ROS?
- Increased thirst or urination
- Bone fractures
- Heat/cold intolerance
What are the parts of the Hematologic/Lymphatic ROS?
- Prolonged or unusual bleeding
- Increased bruising
- New/tender lumps or glands
What are the broad aspects/systems of the Physical Exam?
WASH HANDS 1. General Appearance 2. Blood Pressure (Palpate radial pulses simultaneously, check blood pressure by palpation in 1 arm, check blood pressure by auscultation bilaterally) 3. Upper Extremities 4. Head (+ CN) 5. Neck 6. Chest 7. Breasts 8. Cardiac 9. Abdomen 10. Lower Extremities 11. Neuro WASH HANDS
What are the parts of the Upper Extremity exam?
Patient sitting on table, facing examiner:
- Inspect and plapate fingers (nails, joints), hands (palms), wrists, elbows, and arms (muscles, joints, skin)
- Test passive ROM in fingers, wrists, and elbows.
- Test active ROM in fingers, wrists, and elbows.
- Test muscle strength in hand/fingers, wrists, forearms, and arms.
What are the parts of the Head exam?
- Inspect head and neck (configuration, scalp, skin)
- Inspect eyelids, conjunctivae, and sclerae.
- Test visual acuity in both eyes (CN II) with pocket screener
- Test visual fields (CN II)
- Check extra-ocular muscles (CN III, IV, VI)
- Check for accommodation.
- Test pupillary reaction to light (CN II, III)
- Perform funduscopic exam.
- Test light touch of face (CN V).
- Ask patient to wrinkle forehead, smile and show teeth (CN VII).
- Test hearing (CN VIII)
- Inspect mouth with light source (teeth, gums, tongue, mucosa, ducts, tonsillar fossa, pharynx)
- Say ahh and cough (CN X).
- Protrude tongue (CN XII)
- Shrug shoulders and turn head against resistance (CN XI)
- Inspect external ears.
- Perform otoscopic examinations.
- Inspect nose and nasal cavities.
What are the parts of the Neck exam?
- Inspect, palpate, and test shoulder ROM including internal and external rotation.
- Check full ROM of neck.
Move to position behind patient
- Palpate the salivary glands and the head and neck lymph nodes.
- Palpate the trachea in the sternal notch.
- Palpate the thyroid gland.
What are the parts of the Chest exam?
- Inspect chest wall and skin.
- Observe for symmetry, check for excursion.
- Percuss spine and costovertebral angle.
- Percuss lung fields
- Check for tactile fremitus
- Auscultate the lungs
What are the parts of the Breast exam?
Move to front of patient
- Inspect breasts and nipples while patient’s arms are relaxed at sides, above head, pressed against hips, pressed against hips + leaning forward
- Palpate axillary nodes
Ask patient to lie flat.
3. Vertical stripe method
What are the parts of the Cardiac exam?
Raise patient to 30 degrees
- Identify and inspect internal and external jugular neck vein. Estimate CVP.
Lay the patient flat, stand on right side
- Auscultate carotid arteries
- Palpate carotid arteries
- Palpate suprasternal notch for abnormal pulsations or thrills.
- Inspect precordium for parasternal and apical impulses. Inspect anterior chest wall and skin.
- Palpate precordium for lifts, heaves, thrills, and pulsations. Identify and measure the size of the PMI.
- Auscultate heart in five locations using bell and diaphragm.
What are the parts of the Abdomen exam?
- Inspect abdomen and skin.
- Auscultate abdomen in 4 quadrants.
- Palpate superficially then deeply in 4 quadrants.
- Palpate for liver edge.
- Palpate for spleen tip.
- Percuss liver span in right MCL.
- Palpate for kidney
- Palpate for spleen with patient in right lateral decubitus position
- Palpate superficial inguinal nodes
- Palpate femoral pulses
- Auscultate femoral arteries.
What are the parts of the Lower Extremity Exam?
- Inspect, palpate, and test passive and active ROM in lower extremities.
- Test muscle strength in lower extremities
- Check for edema in lower extremities.
- Palpate dorsalis pedis pulses
- Palpate posterior tibial pulses
What are the parts of the Neuro Exam?
- Test light touch in all four extremities (distal to proximal)
- Test pain in all four extremities (distal to proximal)
- Test vibration in all four extremities
- Test position sense in all four extremities
- Test biceps reflexes bilaterally.
- Test triceps reflexes bilaterally.
- Test brachioradialis reflexes bilaterally.
- Test knee reflexes bilaterally.
- Test ankle reflexes bilaterally.
- Test plantar reflexes bilaterally.
- Finger-to-nose-to-finger bilaterally
- Check fine finger movements bilaterally
- Check heel-to-knee-to-shin bilaterally
ASK PATIENT TO STAND
- Observe patient’s gait
- Observe patient’s tandem walking
- Perform Romberg test
- Inspect spin and evaluate ROM
WASH HANDS
