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34 Cards in this Set
- Front
- Back
- 3rd side (hint)
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History
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identifying info, chief complaint, present illness, meds, allergies, tobacco,alcohol/drugs, past history, first degree relatives
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Past History
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childhood illnesses, adult illnesses, medical, surgical, ob/gyn, psychiatric
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ROS
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General, HEENT,neck, cardio, respiratory, GI
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Physical
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General survey, vitals, HEENT, neck, lymph nodes, thorax & lungs, cardio, abdomen, peripheral vascular, neurological
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Assessment
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Working DX
Differential DX |
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Plan
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Diagnostics
Therapeutics Education |
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Family history
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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
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ROS general
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usual weight, recent changes in weight, weakness, fever, fatigue
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ROS head
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headache, head injury, dizziness, lightheadedness
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ROS eyes
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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
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exam/problems w/vision
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ROS ears
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hearing problems, tinnitus, vertigo, earaches, infection, discharge
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ROS nose & sinus
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frequent colds, nasal congestion, discharge, itching, hay fever, nosebleeds, sinus trouble
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ROS throat
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condition of teeth and gums, bleeding gums, dentures, last exam, sore tongue, dry mouth, frequent sore throats, hoarseness
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ROS neck
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swollen glands, goiter, lumps, pain, stiffness of neck
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ROS respiratory
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cough, sputum (color, quantity)hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray.
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ROS cardio
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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
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Vitals
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temp, pulse, resp rate, BP, report to pt.
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Head exam
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inspect hair, scalp, skull, face, skin
palpate skull |
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Eye exam
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visual fields, inspect: eyebrows,lids, lacrimal apparatus, conjunctive, sclera, cornea, iris, pupils
Assess extraocular movements Fundoscopic exam |
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Ear exam
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Inspection, palpation of ear & mastoid tip, acuity: Gross hearing loss, Rinne & Weber tests, otoscopic exam
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Nose exam
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external inspection, internal inspection of nasal mucosa and turbinates, septum, paranasal sinuses (palpate frontal & maxillary)
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Mouth & Pharynx exam
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Inspect: Lips, oral mucosa, gums & teeth, hard palate, tongue/mouth floor,pharynx
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Neck exam
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palpate lymph nodes, inspect & palpate trachea & thyroid
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lymph nodes
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preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical, supraclavicular, infraclavicular
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Thorax & lung exam
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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 |
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Nose exam
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external inspection, internal inspection of nasal mucosa and turbinates, septum, paranasal sinuses (palpate frontal & maxillary)
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Mouth & Pharynx exam
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Inspect: Lips, oral mucosa, gums & teeth, hard palate, tongue/mouth floor,pharynx
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Neck exam
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palpate lymph nodes, inspect & palpate trachea & thyroid
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lymph nodes
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preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical, supraclavicular, infraclavicular
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Thorax & lung exam
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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 |
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Cardio exam
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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. |
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Abdomen exam
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inspect, palpate,percuss abdomen, live, spleen. Light and deep palpation of above.
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seven dimensions of a symptom
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1.bodily location, 2.quality, 3.quantity, 4.chronology, 5.setting, 6.aggravating and alleviating factors, 7.associated symptoms.
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Miscellaneous things to remember
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1. wash hands
2. warm hands & stethoscope 3. tell pt. to empty bladder before abdominal exam |
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