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64 Cards in this Set
- Front
- Back
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head
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atraumatic
normocephalic |
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eyes
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EOMI
PERRLA normal eye fundus |
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nose
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no nasal congestion
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throat
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no tonsillar erythema, exudates or enlargement
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neck
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supple
no JVD normal thyroid no cervical LAD |
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neurologic mental status
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alert and oriented X 3
good concentration |
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cranial nerves
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II-XII grossly intact
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motor
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strength 5/5 in all muscle groups
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DTR
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2+ intact and symmetric
babinski (-) |
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sensation
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intact to sharp and dull
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cerebellum
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Romberg (-)
intact finger to nose |
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chest and lungs
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clear to percussion bilaterally
no rales, wheezing, ronchi or rubs no tenderness to palpation tactile fremitus WNL |
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heart
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PMI not displaced
regular rate and rhythm normal S1, S2 nomurmurs, rubs or gallops |
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abdomen
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soft
nontender nondistended BS (+) no hepatosplenomegaly |
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extremities
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no clubbing, cyanosis or edema
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mental status exam components
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speech
cooperation affect eye contact attention registration/recall distant memories orientation three-step command serial 7s judgement |
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headache associated neurologic symptoms
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paresthesia
visual stigmata weakness numbness ataxia photophobia dizziness auras neck stiffness |
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headache exacerbating factors
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stress
fatigue menses exercise certain foods |
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headache alleviating factors
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rest
medications |
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headache associated systemic symptoms
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nausea/vomit
jaw claudication recent trauma dental surgery sinusitis symptoms |
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headache physical exam
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inspection and palpation of head
ENT inspection complete neurologic exam funduscopic exam |
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confusion/memory loss
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include history from family members
time course (chronic Vs. acute) associated symptoms --> constitutional, incontinence, ataxia, hypothyroid symptoms, depression delirium --> waxing/waning level of alertness falls medications --> recent and changes history of stroke or vascular disease syphillis alcohol use vitamin B12 family history of Alzheimer |
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confusion/memory loss physical
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neurologic exam
mini-mental gait general physical exam |
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depressed mood history
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onset
duration sleep pattern apetite weight change drug and alcohol use life stresses excessive guilt suicidality social function anhedonia decreased energy decreased concentration psychomotor agitation or retardation family history of mood disorders prior episodes medications |
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depressed mood physical
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head and neck
neurologic exam mental status exam mini-mental exam insight judgement |
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psychosis history
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positive symptoms --> delusions, hallucinations, disorganized thoughts, catatonic behavior
negative symptoms --> blunted affect, social withdrawal, decreased motivation, decreased speech/thought cognitive symptoms --> disorganized speech or thought patterns, paranoia age of first symptoms, hospitalizations previous medications alcohol and substance abuse mental status exam |
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dizziness history
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lightheadedness Vs. vertigo +- hearing loss or tinnitus
duration context (positioning, head trauma) associated symptoms --> visual disturbance, URI, nausea neck pain or injury medications history of atherosclerosis |
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dizziness physical exam
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neurologic exam
Romberg nystagmus tilt test gait Webber/Rinne head/neck exam cardiovascular exam |
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loss of consciousness history
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presence or absence of preceding symptoms --> nausea, diaphoresis, palpitations, pallor, lightheadedness
context --> exertional, postural, traumatic, stressful, painful, dehydration associated signs --> tongue biting, incontinence, tonic-clonic movements, confusion pulmonary embolism risk factors history of heart disease, hypertension, diabetes, alcohol, drug use |
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loss of consciousness physical
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vital signs
orthostatics neurologic exam carotid and cardiac exam lung exam exam of lower extremities |
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numbness/weakness
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distribution --> unilateral, bilateral, proximal, distal
duration progression pain constitutional other neurologic symptoms history of diabetes, alcoholism, atherosclerosis neurologic exam musculoskeletal exam vascular exam |
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fatigue and sleepiness history
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duration
sleep hygine snoring waking up choking/gasping witnessed apnea overexertion stress depression emotional problems lifestyle changes shift changes at work diet/weight changes constitutional symptoms thyroid symptoms history of bleeding or anemia medications alcohol and drug use |
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fatigue and sleepiness physical
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head and neck exam --> conjunctival pallor, oropharynx, lymphadenopathy, thyroid exam
heart, lung, abdominal, neurologic exam consider rectal exam and occult blood test |
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night sweats history
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onset, duration, severity, frequency, timing, patterns
recent URIs, cough, hemoptsis, pleuritic chest pain lymphadenopathy, fever, rash malaise, weight loss itching, diarrhea, nausea/vomiting early satiety, anorexia alcohol history sexual exposure sick contacts exposure to high-risk populations menstrual history |
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night sweats physical
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HEENT exam including throat and lymphadenopathy
skin exam musculoskeletal for joint pain heart and lung abdominal for hepatosplenomegaly |
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insomnia
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primary Vs. secondary
duration trouble falling asleep Vs. multiple awakenings Vs. early morning awakening daytime sleepiness problems keeping patient awake --> arthritis pain, diabetes polyuria snoring nightmares depression caffeine use recreational drug use jet lag shift work stressors sleep hygine mental status exam |
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sore throat
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duration
fever ear pain URI odynophagia swollen glands cough rash sick contacts HIV risk factors ENT exam --> oral thrush, tonsillar exudate, lymphadenopathy lung, abdominal, skin exams |
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cough/shortness of breath history
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acute Vs. chronic
description of sputum associated symptoms --> constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn exacerbating/alleviating factors timing, exposures smoking history lung disease allergies medications (ACEIs) |
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cough/shortness of breath physical
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pulse oximetry
nasal mucosa oropharynx heart lungs lymph nodes extremities --> clubbing, cyanosis, edema |
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chest pain history
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location, quality, severity, radiation, duration
context --> exertional, postprandial, positional, cocaine, trauma) associated symptoms --> nausea, sweating, dyspnea, palpitations, sense of doom exacerbating/alleviating factors --> medications prior history of similar symptoms history of heart, lung disease and diagnostic testing cardiac risk factors pulmonary embolism risk factors |
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chest pain physical
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BP in both arms
CV exam --> JVD, PMI, chest wall tenderness, heart sounds, pulses, edema lung exam abdominal exam |
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palpitations hystory
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gradual Vs. acute
context --> exertion, caffeine, anxiety associated symptoms --> lightheadedness, chest pain, dyspnea hyperthyroid symptoms bleeding or anemia heart disease |
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palpitations physical
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endocrine/thyroid exam
exophthalmos lid retraction lid lag gland size bruit tremor CV exam |
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weight loss
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amount
duration intentional? Diet history body image anxiety depression constitutional symptoms palpitations tremor diarrhea family history of thyroid disease HIV risk factors alcohol and drug use medications history of cancer |
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weight gain
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amount
duration timing --> relation to medication changes, smoking cessation, depression diet history hypothyroid symptoms menstrual irregularity past medical history alcohol and drug use physical --> complete exam including signs of Cushing --> hypertension, central obesity, moon face, buffalo hump, purple abdominal striae |
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dysphagia
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solids Vs. solids and liquids
progressive? Constitutional symptoms drooling regurgitation odynophagia GERD medications HIV risk factors history of smoking head and neck exam skin exam looking for scleroderma |
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nausea/vomitting
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acuity of onset +- abdominal pain
relation to meals sick contacts possible food poisoning possible pregnancy neurologic symptoms --> headache, stiff neck, vertigo, focal numbness associated symptoms --> GI or chest pain exacerbating and alleviating factors medications funduscopic exam complete exam |
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abdominal pain history
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onset
duration frequency quality intensity radiation timing (relation to meals) associated symptoms --> constitutional, GI, cardiac, pulmonary, renal, pelvic exacerbating and alleviating factors history of abdominal surgeries gallstones renal stones atherosclerosis alcohol and drug use domestic violence |
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abdominal pain physical
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heart and lung exams
abdominal exam --> guarding, rebound, Murphy, CVA palpation rectal exam pelvic exam (women) |
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constipation/diarrhea
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frequency and volume of stools
duration of change in bowel habits associated symptoms --> constitutional, abdominal pain, bloating, sense of icomplete evacuation, melena thyroid disease symptoms fiber and fluid intake medications (recent antibiotics) sick contacts, travel camping HIV risk factors diabetes pancreatitis alcohol and drug use history of colon cancer thyroid/endocrine exam abdominal and rectal exam female pelvic exam |
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upper GI bleeding
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amount
duration context --> after severe vomiting, alcohol ingestion, nosebleed associated symptoms --> constitutional, nausea, abdominal pain, dyspepsia medications --> warfarin, NSAIDs history of peptic ulcer liver disease osthostatic exam ENT, heart, lung, abdominal and rectal exams |
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blood in stools
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melena Vs. bright blood
amount duration associated symptoms --> constitutional abdominal/rectal pain, tenesmus, constipation/diarrhea trauma prior history prior colonoscopy medications (warfarin) history of bleeding or atherosclerosis orthostatics abdominal and rectal exam |
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hematuria
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amount
duration +- clots associated symptoms --> constitutional, renal colic, dysuria, irritative voiding medications history of vigorous exercise trauma smoking stones cancer easy bleeding lymph nodes GI, GU and rectal exams |
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urinary symptoms
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duration
obstructive symptoms --> hesitancy, diminished stream, incomplete bladder emptying, straining, postvoid dribbling irritative symptoms --> urgency, frequency, nocturia constitutional symptoms bone pain medications UTIs urethral stricture abdominal exam --> suprapubic percussion for distended bladder genital and rectal exam |
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erectile dysfunction
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duration
severity +- nocturnal erections libido stress or depression trauma associated incontinence medications past medical history --> hypertension, diabetes, high cholesterol, prostate surgery smoking, alcohol and drugs |
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amenorrhea
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primary Vs. secondary
duration possible pregnancy associated symptoms --> headache, decreased peripheral vision, galactorrhea, hirsutism, virilization, hot flashes, vaginal dryness, symptoms of thyroid disease history of anorexia nervosa excessive dieting vigorous exercise pregnancies D&Cs uterine infections breast exam complete pelvic exam |
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vaginal bleeding
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pre Vs. postmenopausal
duration amount menstrual history relation to last menstrual period associated discharge pelvic or abdominal pain urinary symptoms trauma medications history of easy bleeding or bruising abnormal pap smears |
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vaginal discharge
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amount
color consistency odor duration associated vaginal burning pain pruritus recent sexual activity last menstrual period contraceptives tampons history of similar symptoms history of STDs abdominal and pelvic exams |
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dyspareunia
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duration
timing associated symptoms --> vaginal discharge, rash, painful menses, GI symptoms, hot flashes adequacy of lubrication libido sexual history sexual trauma domestic violence history of endometriosis or PID |
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abuse
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establish confidentiality
directly question about physical, sexual or emotional abuse question about fear and safety history of frequent accidents/injuries mental illness drug use complete + pelvic exam |
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joint/limb pain
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location
quality intensity duration pattern small Vs. large joints number of joints involved swelling redness warmth associated symptoms --> constitutional, red eye, oral or genital ulceration, diarrhea, dysuria, rash exacerbating and alleviating factors trauma medications DVT risk factors alcohol and drug use family history of rheumatic disease HEENT, musuloskeletal and neurovascular exam |
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low back pain
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location
quality intensity radiation context --> moving furniture, bending/teisting, trauma timing --> disturbs sleep associated symptoms --> cosntitutional, incontinence exacerbating and alleviating factors history of cancer recurrent UTIs diabetes renal stones IV drug use smoking |
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child with fever
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severity
duration associated localizing symtoms appetite rash sick contacts day care immunizations past history HEENT, neck, heart, lung, abdominal and skin exams |
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behavioral problems in childhood
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onset
severity duration triggers psysical violence use of weapons substance use developmental history environment school performance neurologic exam |
