Hx & PE by CC

Question 1

Headache

Answer 1

Hx - neuro ROS (ataxia, photophobia, dizziness, aura, neck stiffness, nausea, vomiting, jaw claudication, dental surg, trauma, sinusitis)

PE - inspect and palpate head, ENT, neuro, fundoscopy

Question 2

Confusion / Memory

Answer 2

Hx - stepwise v progressive, incontinence, fever/sweats, vascular RF, ataxia, depressive sx, alcohol use, vitamin def, HIV, syphilis, falls, med changes

PE - neuro (GAIT), mini mental (3/3 + clock), brief heart/lung/ab/extremities

Question 3

Vision Loss

Answer 3

Hx - sudden, gradual, see light, vascular RF, trauma to eye, meds, floaters/flashers, pain eye redness/tearing/itching/photophobia

PE - HEENT, fundoscopy, cardio, neuro

Question 4

Depression

Answer 4

Hx - SIGECAPS (sleep, interest, guilt, energy, conc, appetite, psychomotor, suicide), prior hospitalizations, prior meds used, duration sx, any manic sx? any psychosis?

PE - appearance, behavior, speech, mood, affect, thought process, thought content, cognition

Question 5

Psychosis

Answer 5

Hx - duration of sx, seeing/hearing tings that others do not? feel like you are being watched? drug use?

PE - appearance, behavior, speech, mood, affect, thought process, thought content, cognition

Question 6

Dizziness

Answer 6

Hx - vertigo (room spinning) v. LH, positional, episodic, new medications, arrhythmia, SOB, LOC, associated hearing loss, tinnitus, URI sx, nausea, vision problems, trauma

PE - neuro exam, Romberg, nystagmus, gait, hearing, Weber/Rinne, ENT, cardio

Question 7

LOC

Answer 7

Hx - exertional, LH/pallor/diaphoresis beforehand, palpitations, dehydration, tongue lac/tonic clonic movements, confusion afterward, PE RF, cardiac hx, alcohol or drug use

PE - orthostatics, cardio, pulm, neuro, CAROTIDS

Question 8

Numbness/Weakness

Answer 8

Hx - distribution, progression, pain, fevers, neuro sx, vascular RF, DM, alcohol use

PE - neuro, MSK, pulses

Question 9

Fatigue

Answer 9

Hx - sleep hygiene, waking/gasping, apneic episodes, depression sx, shift work, diet/wt loss/ thyroid sx, alcohol, drugs, caffeine

PE - ENT (oral exam), thyroid gland, heart, lungs, ab, neuro, pulses, RECTAL

Question 10

Night Sweats

Answer 10

Hx - associated sx (fevers, URI, cough, hemoptysis, CP, LNs, rash, malaise, wt loss, diarrhea, N&V, anorexia) or RF (sex intercourse, IV drugs, travel, prison time)

PE - FULL, including skin

Question 11

Insomnia

Answer 11

Hx - prob falling asleep or staying asleep, racing thoughts, pain or polyuria keeping you up, stressors, caffeine/substance use, sleep apnea, nightmares, depressive sx, restless leg shift work, sleep habits

PE - mental status, thyroid

Question 12

Sore Throat

Answer 12

Hx - fever, cough, sick contacts, sinusitis, duration, hoarseness, difficulty breathing, rash, HIV RFs

PE - ENT, lungs, palp spleen, skin

Question 13

Cough / SOB

Answer 13

Hx - Sputum prod, fevers/chills, exertional, hx COPD/asthma, hemoptysis, CP, allergies, wheezing, heartburn, CHF hx, tobacco use, other exposures

PE - HEENT, cardiac, lung, extremities (clubbing, cyanosis)

Question 14

CP

Answer 14

Hx - quality, radiation, exertion, associated sx, cardiac hx, lung history, RF (HTN, HLD, tob use, family hx), PE RF (hx clots, DVT sx, OCPs, recent travel, surg or cx treatment), prior episodes

PE - cardiac, pulm, abdomen, lower extremity (DVT?), BPs in both arms

Question 15

Palpitations

Answer 15

Hx - associated CP, SOB, syncope, hx arrhythmia, medications, hyperthyroid sx, caffeine/exertion/anxiety

PE - cardiac, pulses, thyroid gland/lid lag, eval for tremor

Question 16

Wt Loss

Answer 16

Hx - intentional?, amount, dietary changes, associated fevers or night sweats, cancer hx, screen for depression/body dysmorphia, hyperthyroid sx, tob/alcohol/drug use, HIV RF (IVDU, sex)

PE - complete physical

Question 17

Wt Gain

Answer 17

Hx - hypothyroid sx, depression screen, diet, exercise, med changes, smoking cessation, menstrual problems, hirsutism

PE - look for Cushing’s signs, edema

Question 18

Dysphagia

Answer 18

Hx - solids or liquids, progressing, pain, hx stroke or muscular disease, smoking hx, hoarse, drooling, regurgitation, wt loss, hx HIV, Raynaud’s

PE - HEENT, heart, lungs, abdomen, skin (scleroderm/crest)

Question 19

Neck Mass

Answer 19

Hx - size, growth, location, pain, mobile when swallowing, associated sx (SOB, difficulty swallowing, fevers, chills), full endocrine ROS

PE - HEENT, spleen

Question 20

N&V

Answer 20

Hx - duration, sick contacts, food intake, travel, BMs, headache/neuro sx, meds/chemo, prior abdominal surgeries, urinary sx, poss pregnancy, relation to meals, CP?

PE - FUNDOSCOPY, abdomen, heart and lung exam if needed

Question 21

Ab Pain

Answer 21

Hx - duration, sick contacts, nausea/vomiting/diarrhea, prior ab surgeries, travel, food intake, relation to meals, meds, location, alcohol history, urinary or vaginal sx, vascular RF (ischemic?)

PE - Ab exam (including CVA and special tests), poss FOBT, pelvic exam, poss cardiac and pulm

Question 22

Constipation/Diarrhea

Answer 22

Hx - bloody stools, sick contacts, duration, travel or camping, PO intake, relation to foods, ab surgeries in past, hx chron’s or UC, associated sx, diet/fiber, hyperthyroid sx, recent abx, HIV hx or RF, floating stools/greasy

PE - ab exam, pulses/perfusion, rectal, pelvic

Question 23

Upper GI Bleed

Answer 23

Hx - amount, duration, vomiting? alcohol use? nose bleed?, meds (A/C, NSAIDs, steroids), hx PUD, liver disease, AAA repair or bleeding problem, associated sx (dyspepsia, nausea, vomiting, fevers, cills, pain, diarrhea)

PE - HEENT (nares and oropharynx), heart, lung, ab, ORTHOSTATICS, rectal exam

Question 24

Bloody Stools

Answer 24

Hx - amount, bright red v. melena, personal or family hx colon cx, prior colonoscopy, hx hemorrhoids, painful defecation, anemia sx (LH, dizziness, fatigue), ab pain, constipation, diarrhea, feeling incomplete voiding, MENSES, TRAUMA, meds (a/c), hx of bleeding disorder, liver disease, renal disease, atherosclerosis, aortic valve, alcoholism, AAA repair

PE - HEENT, ab exam, rectal, orthostatics

Question 25

Hematuria

Answer 25

Hx - amount, duration, passing clot?, what point in stream of urine?, prior hx, diet (red dye or beets), menses, A/C, UTI sx (dysuria, inc frequency, fevers, chills), vag sx (discharge, pain), meds, rigorous exercise, trauma, smoking, hx kidney stones or cx

PE - Orthostatics, ab / CVA tenderness, pelvic exam, rectal exam, LNs

Question 26

Other Urinary Sx

Answer 26

Hx - duration, hesitancy, dec stream, sense of incomplete emptying, straining, post-void dribble, leak with cough or sneeze, urgency, frequency, nocturia, fevers, chills, bone pain, hx UTIs, hx urethral stricture, urinary instrumentation, kidney stones, DM, alcohol use

PE - Ab exam (bladder percussion), neuro exam (focused on lower extremities), rectal, pelvic

Question 27

Erectile Dysfunction

Answer 27

Hx - morning/ nocturnal erections, duration, severity, libido, stress/trauma, incontinence, gynecomastia, loss of body hair, med changes, smoking/alcohol/drug, hx of HTN, DM, HLD, atherosclerosis, prior prostate surgery, liver, thyroid or neuro disease

PE - cardiovascular, pelvic, rectal (prostate)

Question 28

Amenorrhea

Answer 28

Hx - PREGNANCY?, full menstrual hx, body hair/facial hair, voice changes, vaginal dryness, galactorrhea, hot flashes, headache, dec peripheral vision, thyroid sx, hx anorexia, dieting, exercise, prior D&C, prior pelvic infections, pregnancy hx, meds

PE - pelvic exam, neuro exam, breast exam

Question 29

Vaginal Bleeding

Answer 29

Hx - duration, full menstrual hx, #pads per day, hx pevlic infections, sexual intercourse hx, meds (A/C or OB meds), hx bleeding disorders, hx abnormal pap smear, trauma, urinary sx, ab pain, pelvic pain, pain with sex

PE - pelvic exam, ab exam

Question 30

Vaginal Discharge

Answer 30

Hx - duration, amount, relationship to menses, color/smell, sexual intercourse hx, hx pelvic infections, urinary sx, ab sx, burning/pain/itching, tampon and douching

PE - pelvic, ab exam

Question 31

Dyspareunia

Answer 31

Hx - duration, timing, vag sx (itching, burning, discharge, bleeding, rash), GI sx, hot flashes, dryness, menstrual hx (menopause??), trauma/ IPV, gyne hx (endometriosis, PID, surgeries)

PE - ab exam, pelvic exam

Question 32

Abuse

Answer 32

Hx - physical, sexual, emotional abuse, firearms in home, do you have a plan for safety, mental illness, drug use

PE - complete exam, pelvic

Question 33

Joint Pain

Answer 33

Hx - location, duration, exacerbating/alleviating factors, quality and intensity of pain, injury to area or vigorous exercise, numbness, tingling, weakness, swelling/redness/warmth, neuro sx (bowel/bladder anesthesia/ voiding problems), constitutional sx (fevers, chills, red eye, oral or genital ulcers, rashes, morning stiffness, diarrhea, dysuria), meds, DVT risk factors, family hx rheumatic disease

PE - examine each joint, HEENT, relevant neurovascular exam

Question 34

Low Back Pain

Answer 34

Hx - duration, intensity, quality, exacerbating/alleviating factors, radiation, wake from sleep?, certain time of day, activity level, bowel or bladder anesthesia, incontinence, numbness, weakness, any other joint sx?, fevers, chills, epidural anesthesia/procedures recently, IVDU, hx recurrent UTIs/kidney stones / DM, smoking

PE - ab exam, CVA tenderness, lower extremity neuro exam, palpate spine, straight leg test, hip exam, rectal exam

Question 35

Peds Fever

Answer 35

Hx - duration, sick contacts/daycare, immunizations, PO intake, wet diapers, lethargy/activity level, associated rash, rhinorrhea/cough/wheezing/diarrhea/ear pain or drainage, convulsions, what is the temp (how was it measured), acetaminophen use

PE - HEENT (ears), neck, heart, lung, ab, skin

PE -

Question 36

Peds GI

Answer 36

Hx - duration, sick contacts, daycare, immunizations, diarrhea, bloody stools, vomiting, PO intake, wet diapers, lactose intolerance, change in formula, exposures to animals/travel, meds, ab surgeries, relation to meals, wt changes, associated sx (fever, chills, pelvic, rash)

PE - HEENT, heart/lungs, ab, rectal, pelvic

Question 37

Peds Red Eye

Answer 37

Hx - unilateral/bilateral, drainage (color), hx allergies or other allergy sx, sick contacts, day care, ophtho hx, itching, pain, photophobia, tearing, immunizations, meds, ROS

PE - ophtho, HEENT

Question 38

Peds Short Stature

Answer 38

Hx - birth problems, genetic conditions, wt gain, growth hx, family hx, school performance/cog, developmental milestones, full ROS

PE - complete, include ht and wt

Question 39

Peds Behavioral Problems

Answer 39

Hx - what problems, dep sx, stressors/life changes, psychotic sx (hallucinations, delusions, paranoia), suicide, duration, triggers, physical violence, access to weapons, developmental hx, change in personality or school performance

PE - neuro