Key Hx and PE Flashcards
1
Q
1 Headache Hx
A
Onset (acute v chronic) Location (unilateral v bilateral) quality (dull v stabbing) intensity (is it "worst headache of their life?") duration timing (disturb sleep?) associated neuro Sx (paresthesia, visual stagmata, weakness, numbness, ataxia, photophobia, dizziness, auras, neck stiffness) N/V jaw claudication recent trauma dental surgery sinusitis symptoms exacerbating factors (stress, fatigue, menses, exercise, certain foods) alleviating factors (rest, medications) patient and family hx of headache history of trauma
2
Q
1 Headache PE
A
VS inspection and palpation of entire head ENT inspection complete neuro exam fundoscopic exam
3
Q
2 Confusion/Memory Loss Hx
A
Must include hx of family members/caregivers when available.
Detailed time course of cognitive deficits (acute v chronic/gradual onset)
assoc sx (constitutional, incontinence, ataxia, hypothyroid symptoms, depression)
screen for delirium (waxing/waning level of alertness)
falls
medications (recent med changes)
Hx of stroke or other atherosclerotic vascular disease
syphilis
HIV risk factors
alcohol use
B12 def
fam Hx of alzheimers or other neuro diseases
4
Q
2 Confusion/Memory Loss PE
A
VS complete neuro exam minimental status exam gait general PE: ENT, heart, lungs, abdomen, extremities
5
Q
12 Sore Throat Hx
A
Duration Fever other ENT Sx (ear pain, nasal or sinus congestion) odynophagia swollen glands \+/- cough rash sick contacts HIV risk factors
6
Q
12 Sore Throat PE
A
VS ENT exam - look for oral thrush, tonsillar exudate, and lymphadenopathy lung abdominal (focus on splenomegaly) skin exam
7
Q
13 Cough/SOB Hx
A
acute/subacute vs chronic increased frequency of cough if chronic timing presence/description of sputum presence of hemoptysis assoc sx (constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heart burn) exacerbating/alleviating factors exposures smoking Hx Hx of lung disease posttussive emesis heart failure allergies medications (esp ACE inhibitors)
8
Q
13 Cough/SOB PE
A
VS + Pulse Ox examine nasal mucosa oropharynx heart lung lymph nodes extremities (clubbing, cyanosis, edema)