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
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2
Q

1 Headache PE

A
VS
inspection and palpation of entire head
ENT inspection
complete neuro exam
fundoscopic exam
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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

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4
Q

2 Confusion/Memory Loss PE

A
VS
complete neuro exam
minimental status exam
gait
general PE: ENT, heart, lungs, abdomen, extremities
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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
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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
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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)
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8
Q

13 Cough/SOB PE

A
VS + Pulse Ox
examine nasal mucosa
oropharynx
heart
lung
lymph nodes
extremities (clubbing, cyanosis, edema)
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