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34 Cards in this Set

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  • Back
  • 3rd side (hint)
History
identifying info, chief complaint, present illness, meds, allergies, tobacco,alcohol/drugs, past history, first degree relatives
Past History
childhood illnesses, adult illnesses, medical, surgical, ob/gyn, psychiatric
ROS
General, HEENT,neck, cardio, respiratory, GI
Physical
General survey, vitals, HEENT, neck, lymph nodes, thorax & lungs, cardio, abdomen, peripheral vascular, neurological
Assessment
Working DX
Differential DX
Plan
Diagnostics
Therapeutics
Education
Family history
age, age & cause of death, Conditions: HTN, CA, high cholesterol, DM, stroke, thyroid dx, renal dx, arthritis, asthma, lung dx, mental illness, suicide, alcohol/drug abuse, allergies
ROS general
usual weight, recent changes in weight, weakness, fever, fatigue
ROS head
headache, head injury, dizziness, lightheadedness
ROS eyes
1.vision problems, 2.corrective lenses, 3.last exam, 4.pain, 5.redness, 6.excessive tearing, 7.double or blurred vision, 8.spots, 9.flecks, 10.flashing lights, 11.glaucoma, 12.cataracts
exam/problems w/vision
ROS ears
hearing problems, tinnitus, vertigo, earaches, infection, discharge
ROS nose & sinus
frequent colds, nasal congestion, discharge, itching, hay fever, nosebleeds, sinus trouble
ROS throat
condition of teeth and gums, bleeding gums, dentures, last exam, sore tongue, dry mouth, frequent sore throats, hoarseness
ROS neck
swollen glands, goiter, lumps, pain, stiffness of neck
ROS respiratory
cough, sputum (color, quantity)hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray.
ROS cardio
heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, results of previous EKG or cardio tests
Vitals
temp, pulse, resp rate, BP, report to pt.
Head exam
inspect hair, scalp, skull, face, skin
palpate skull
Eye exam
visual fields, inspect: eyebrows,lids, lacrimal apparatus, conjunctive, sclera, cornea, iris, pupils
Assess extraocular movements
Fundoscopic exam
Ear exam
Inspection, palpation of ear & mastoid tip, acuity: Gross hearing loss, Rinne & Weber tests, otoscopic exam
Nose exam
external inspection, internal inspection of nasal mucosa and turbinates, septum, paranasal sinuses (palpate frontal & maxillary)
Mouth & Pharynx exam
Inspect: Lips, oral mucosa, gums & teeth, hard palate, tongue/mouth floor,pharynx
Neck exam
palpate lymph nodes, inspect & palpate trachea & thyroid
lymph nodes
preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical, supraclavicular, infraclavicular
Thorax & lung exam
Inspection: resp pattern, nails, sounds, neck, chest shape.
Posterior chest: inspect, palpate for tenderness, expansion, fremitus, persussion of posterior chest and diaphragmatic excursion. auscultation of post. chest.
Anterior chest: Inspect, palpate( tenderness, expansion, fremitus), percussion, auscultation
Nose exam
external inspection, internal inspection of nasal mucosa and turbinates, septum, paranasal sinuses (palpate frontal & maxillary)
Mouth & Pharynx exam
Inspect: Lips, oral mucosa, gums & teeth, hard palate, tongue/mouth floor,pharynx
Neck exam
palpate lymph nodes, inspect & palpate trachea & thyroid
lymph nodes
preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical, supraclavicular, infraclavicular
Thorax & lung exam
Inspection: resp pattern, nails, sounds, neck, chest shape.
Posterior chest: inspect, palpate for tenderness, expansion, fremitus, persussion of posterior chest and diaghrmatic excursion. ausculation of post. chest.
Anterior chest: Inspect, palpate( tenderness, expansion, fremitus), percussion, auscultation
Cardio exam
auscultate carotids, palpate carotids
Heart: inspect,palpate precordium 30 degrees. Palpate apical impulse 30 deg and left lateral decubitus position
Auscultate apex, left lateral decub. position
Auscultate precordium, 30 deg.
Auscultate left sternal border and apex leaning forward.
Abdomen exam
inspect, palpate,percuss abdomen, live, spleen. Light and deep palpation of above.
seven dimensions of a symptom
1.bodily location, 2.quality, 3.quantity, 4.chronology, 5.setting, 6.aggravating and alleviating factors, 7.associated symptoms.
Miscellaneous things to remember
1. wash hands
2. warm hands & stethoscope
3. tell pt. to empty bladder before abdominal exam