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55 Cards in this Set
- Front
- Back
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Constipation
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Surgery, multiple Sclerosis, Spinal cord trauma
Thyroid Oxycodone Occult blood Low fiber diet Excess calcium Diabetic gastroparesis |
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HPI
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OCD PSF AAA
Pain = + LIQR Fluids + ABCDO O Onset of the symptom (sudden/gradual…) C COURSE “Constant /Intermittent” D Duration P Progression + precipitating factors S Settings F Frequency L Location of the symptom (forehead, wrist...) I Intensity of the symptom (scale 1-10, 6/10) Q Quality of symptom..BCDSPP (burning,Cramping,dull,Sharp,pulsating,pressure like) R Radiation of the symptom ( to left shoulder and arm) A Associated symptoms ( palpitations, shortness of breath) A Alleviating factors (sitting with my chest on my knees) A Aggravating factors (effort, smoking, large meals) |
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fluids
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abcccdo
A Amount B Blood C Color C Consistency C Content D Duration O Odor |
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UG Hx
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OCD PSF AAA +FINISH CUP
F Frequency (How frequent do u have to pass urine?) I Incontinence (Do u have trouble holding Ux until u get to BR?) N Nocturia ( do u have 2 wake up @ Night to go to BR?) I Incomplete emptying (do u feel fullness even after Ux) S Stream (How is ur flow of urine? is it cont. or is there any dribbling after Ux?) Strain (Do u have to strain during Ux) Stone (have u passed stones in the past?) H Hematuria (did u notice any blood) Hesitancy (do u have 2 wait b4 starting Ux) C COLOR U Urgency (do u have 2 rush to BR to Ux?) P Pyuria (was there any pus in ur Ux?) Pain (Burning) |
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PMHx
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PAM HUGS FOSS
P Previous presence of the symptom (same CC) Past Medical problems (4B5,4BS,U67,8idney prob., Rhinitis,Sinusitis,Asthma,) A Allergies (drugs, foods, chemicals, dust ...) M Medicines (R U taking any prescription medications/any over-the-counter med.), H Hospitalization for any illness in the past (Trauma, surgery) U Urinary changes ( esp if diabetic, elderly...) G Gastrointestinal complains (diet changes, bowel movements...) S Sleep pattern(difficulties falling/maintain asleep,wake up,snoring,med. to help sleep, how many hour, nightmares) F Family history (similar chief complaints/serious illness) Fevers, Chills,Night sweats Fatigue O OB/GYN history (LM5, abortions, para...) LMP RTV CS PAP S Sexual habits (active/preferences/STD/no. of partners/contraception/pregnancy/ last pap smear) Are you Sexually Active?How Many Partners are you active with?Are your partners male or female or both? protection? anal intercourse? hx stds? |
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Social Hx
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WAD SAD TOES
W Weight / who do u live with? A Appetite D Diet S Smoke (cigarettes, marijuana, how much, how many years) A Alcohol (what type of alcohol, how often, how much ,consider doing CAGE question.) D recreational Drugs (what drug, how do you use it, any IV drug use?) T Travel /Trauma O Occupation (what do you do for living?) E Exercise S Stress |
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Headache hx
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OCD PSF LIQR AAA + face down,
head trauma/seizure/weak/numb tears/visual change flu/nasal congestion vomit/speech neck stiffness |
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Peds Hx
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CUB FEVERS + PAM IF BIG DEALS T
C Colds-runny nose,cough,chest pain, fast respirations,SOB CRY“how is ‘cry of ‘baby?” U Urination-increased or decreased urination, # of diapers, any odour, colour of urine Ulcers in mouth B Bowel changes: Diarrhea-frequency, onset, mucus/pus/blood in stool, any crying during defecation Discharge Q’s (ABCD-O: Amount, Blood, Content, Consistency, Color, Constant/Intermittent, Duration, Odor/Onset) F Fever & Chills& Night sweats/Headache E Ear pulling V Vomiting E Ear/eye discharge, Ear hearing, Eye vision R Rash /Rigidity “Neck” S Seizure-any jerky movements, which part of body? Any leakage of urine or stool during fits, and postictal irritability or loss of consciousness. Stress (bet wet, DM) Smoke @ home School performance P Past medical/Past surgical Hx / Previous Hospitalizations. / Pets @ home A Allergies, effect on child/parents (bet wet, DM), Activities M Medications, Menstruating (female child >10yo) I Ill contacts F family history B Birth Hx |
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BIG DEALS
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I Immunizations
G Growth n development, ht, wt, milestones SSC-WTD smile sit crawl walk talk dress Month 1 6 9 12 15 30 D Day care / Difficult swallowing E Eating habits/ feeding of baby/Diet change A Appetite / Appearance “Look of the baby” L Last check-up S Sleep T Travel recently |
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Ped NB
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NB:
+Oral Rehydration: Pedialyte or Home-made “1L of water<5 cups> +1/2 tsp. salt+6 tsp. sugar” +in WU: Scheduled |
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Premenopause
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HADOC
H Hot flashes A Atrophy of vagina D Dryness of vagina O Osteoporosis (council) C Coronary artery disease |
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ObGyne Hx
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LMP RTV CS PAP
L LMP (when was ur LMP?) M Menarchae (how old were u when u had ur 1st period? P Period (how many days ur period last?) R Reglarity ( R ur periods regular?) T Tampoons (how many pads do u use in a heavy day?) V Vaginal DID: discharge, itching , dryness (have u ever had any vag discharge?ABCDO. do u have any vag. Itching?) C Cramps (Dysmenorrhea) do u have abd cramp with ur period? S Spotting ( intermenstrual / post coital ) have u ever bled (.) ur cycles? Did u ever notice any bleeding after intercourse? P Pregnency ( Hx & complications) have u ever been pregnant? How many times? A Abortion/miscarriage (Any miscarriages or abortions?In ⍵ month of ur pregnancy?) P PAP smear(have u been getting regular PAP sm ?when did u have the last PAP sm ) (any Female>50 yo:ask about:1-R u taking vit D & Ca, 2-have u ever tried HRT?) |
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Amenorrhea
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FLAG HIV WC
F Fatigue L Libido A Anorexia nervosa /Anxiety & Depresion G Galactorrhea H Hair & skin changes ( for Hypothyroid/Hirsutism of PCOS) Headaches Hot flushes I Insomnia V Visual disturbance / voice change “Deep” W Wt change & Appetite & Diet C Cold intolerance & Constipation |
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Domestic abuse
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SAFE GARDS
S Safety inquiry (Do you feel safe at home?), Sex ever forced? A Alcohol abuse (does your husband abuse alcohol?) Addict (does husband use recreational drugs) F Friends/Family who are aware (Dose any1 f ur friend/Fam know of this) Fractures (Abuse ever resulted in fractures?) E Emergency plan (u have emergency plan?), Ever tried to leave/divorce?Why not? G Guns at home (are there any weapons @ home?) A Afraid of husband , Attacked Children?Attacked u with Guns? R Relationships with husband (how is ur relationship with husband? do you feel Threatened when he is around?, For how long? D Depression (lost wt/appetite/sleep) S Suicidal (idea/plan/attempt) (ever felt like ending it all up?) |
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Diabetic pt FU/med refill
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D Duration of disease
I Insulin regimen/ oral hypoglyemics regimen A A1c hg -> Gluc. monitoring (fast, home, HgA1c) B Blurry vision (retinopathy) E Extremity (foot ulcer/infection) T Tingling/numbness (neuropathy) I Infections (resp/urinary) C Cardio Risk Factors (HTN, CHOL, Heart disease) |
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Counseling DM and HTN
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MEDOWS
M Medications (regularity) E Exercise ( for obese/sedentary life styles) D Diet Modification( Salt/Fatty foods) O Opthalmoscopic exams (annual routine) W Weight Management (/control) S Sugar Check ups |
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Neuro LOC
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CAP HINTS GB + MMSE
C Confusion “after the event” Consciousness “LOC;duration?” A Aura “b4 problem;Sounds,Lights,Smell” P Palpitations H Headache/ Lightheaded /Hearing loss &Tinnitus I Incontinence “urine/Bowel” T Tongue biting/Trauma& fall N Nausea & vomit Numb, Tingling, Weakness S Sleep disturbance Sight “Vision” Speech difficulties Seizure “Shaking;duration?” Spinning G Gait B Breathing Difficulty last meal if MVA |
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LOC before and after ?
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Before LOC:
+ Aura + Palpitation + Dizzy + Vision + Nausea/vomit + Dif breathing During LOC: + Attending person? + “shaking/something coming from mouth” + Incontinence “urine/stool” + Tongue bitting After LOC: + Confusion + Concentration + Weakness/ting/numb + Gait + Headache |
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MMSE
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ORARL23RWD
O Orientation X3 “time, place, person” R Registration “I’m going to say 3 objects”… then repeat A Attention “spell world backwards” R Recall what were those 3 items again? L Language “Repeat after me.. “No, ifs, ands, or buts” 2 Identify two objects “what is this.. pen.. and this… paper” 3 Obey 3 commands “take a piece of paper, fold in ½, put on floor” R “Read 3 commands on this paper and do what it says” W Write a sentence D Draw, copy the image |
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Forgetfulness/Dementia/Alz/Memory Loss
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FORGETS HIM DEATH SHAFT MMSE "Orar enough"
F Fall/ FAINTING / Flashes/ FHx of Alzheimer 0 ORTHOSTATIC HYPOTENSION “Lightheadedness” R RUNNING URINE “INCONTINENCE” G GAIT E EYE “VISION” T TRAUMA/TINGLING & Numbness & Weakness S SEIZURES/ Sleep/ Speech/Support H HEADACHE I INFECTION [SYPHILIS, MENINGITIS] M MOOD “feel sad” ADL - Activities of daily living D Dressing E Eating A Ambulation (can you find your way thru home) T Toiletry (do you manage your toiletry unassisted) H Hygiene IADL - Instrumental activities of daily living S Shopping H Housekeeping A Accounting “pay bills” F Food prep (do u do your cooking ) T Transportation (do you drive? How is your sight, hearing?) |
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counseling forgetfulness
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COUNCELLING:
1-I would like to ask ur permission to speak with ur family 2-i would like u&ur family to meet a social worker to assess home safety&supervision NOTE: -History: ask for paper with medications -PE: Auscultate carotid bruit/Fundoscopy/MMSE “Recall” -WU: orthostatic V.S. |
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Foot/Heel/Knee/Shoulder/Back pain
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OPPD CSF LIQRAAA + WET SURF D CIS
W Weakness / Wt. loss E Eye infection redness / Exposure to COLD “effect” T Trauma /Tender /Tingling& Numbness / Tick bite S Stiffness in other joints/ Swelling /long Standing hours/morning Stiff/sound U Urethral discharge /ulcer / USE “Work ,Walking habits, sports” R Rash/ Redness of skin of joint / ROM / Rheumatologic dis. F Fever & chills& night sweat / Fatigue /Foot wear D Deformity/Disability “affect his work, need help @home” / Dysuria CIS Cancer Hx /IV DRUGS/ Steroids 4 long time |
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Depression
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SIGME CAPT + 2 + MMSE
S Sleep (difficulties falling/maintain asleep, wake up, snoring, med. to help sleep, how many hours, nightmares), Suicide: thoughts, plan, attempts (do u have pills/guns @ home? ) Stress Support I Interest, What do you do in your free time? How are you doing in your job? do you enjoy what you do? G Guilty M Mood. ( anxious, sad, hopeless, lonely? Memory problems E Energy C Concentration A Appetite, changes in your Weight Attitude towards life (positive/negative frame of mind) P Psychomotor agitation/retardation (do you feel easily agitated or angry/do u feel not to do anything?) Psychiatric “Delusions, Hallucinations, Hopes” T Thyroid dysfunctions (ABCD HV for HYPOTHYROID) also need to ask : Do u realize that u have problem ? Do u want help? ( if patient was sent or asked by anyone to consult doc ) |
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thyroid/dizziness
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abcd hv
THYROID ABCD HV APPETITE/DIET,BOWEL,COLD INTOLER.,DEPRESSION,HAIR/SKIN,VOICE-Hoarseness DIZZYNESS: -ROOM SPINNING>>EAR -LIGHT HEADEDNESS>>HEART/BRAIN DIZZINESS / PALPITATION ANY CASE OF BOTH,ASK ABOUT THE OTHER |
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Hearing Loss
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OPD CSF AAA + PDF IN RST
P Pain D Discharge F FB I Imbalance / Infection N Noise R Ringing S Spinning T Trauma / Tinnitus |
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ABD Signs
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CKMG MIOR
C Cullen $- periumbilical discoloration (Retroperitoneal He,pancreatitis, AAA rupture) K Kehr $ –sever Lt. Shoulder pain- Splenic rupture, ectopic pregnancy M Muphy’s $- Abrupt interruption of inspiration on palp of RUQ- acute cholecystitis G Gray-Turner $, Discoloration of flank (same as Cullen $) M Mc Burney’s $- Tenderness 2/3 from ASIS to Rt of umbilicus I Iliopsoas $, Hyperextention of R hip Cx ABD pain O Obturator $- Internal rotation of flexed R hip Cx ABD pain R Rovsing $- RLQ pain upon palpation of LLQ |
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Nausea/Vomiting
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A MOPING
A Anorexia M Metabolic( DKA)/Meds O Obstruction (pyloric /Intestinal) P Pregnancy I Inflammation( Pyelo/Cholecysto/Append/Pancreas/PID) N Neurological (BETA)= Bleed/Encephalitis/Tumor/Abscess G Gastroenteritis |
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Erectile Dysfunction
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LIM PENIS
L Libido I Injury (back-penis) M Medications (B#) P PMH “HTN,DM, peripheral vascular dis.”/ PSH “prostate” Pyrenoi’s dis. Performance anexiety E Erections at all “morning” N Nocturia I Incontinence “urine, stool” S Stress/Depression |
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Psych eval
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Orientation
Recall Attention/calculation Language Obeys commands Mood Affect/abstract Speech Thought process/content Insight Suicide Hallucinations |
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joint
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CITRUS
1.Color changes(bruising), Crackles upon movement 2.Infection recently(guess, pointing to reactive arthritis) 3.Trauma/Tick bite/Temperature local-warmth 4.Redness/Rash 5.Urinary discomfort(guess, this pointing to Reiters syndrome- uveitis/arthritis/urethritis) 6.Stiffness/ Swelling |
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headache ddx
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MM IT ACHES
Migraine Meningitis Increased Intracranial Pressure Tension headache/temporal arteritis AV malformations Cluster Headache Hypertension Eye Disordrs Sinusitis/Sub arachnoid/Systemic |
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shoulder ddx
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deforms
dislocation elderly abuse fracture osteoporosis/osteomyelitis rotator cuff injury myositis sac inflammation/bursitis/sprain |
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knee pain ddx
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septic arthritis
pseudo gout/paetello femoral pain/psoriatic arthritis osteoarthritis rheumatoid arthritis/reactive/reiters tophi, trauma, sports sac inflammation/bursitis |
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heel pain ddx
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foot pains
fat atrophy/foreign body osteomyelitis osteoperosis tarsal tunnel syndrome/tendonities (achilles) tumor plantar fasciitis Mc, perositis apophysitis calcaneal, arthritis, ischemia nerve entrapment stress fracture, calcaneal |
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vaginal bleed ddx
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a PV bleed
abortion /adenomyosis p pid/pcod vaginal injuries bleeding diathesis leiomyomas (fibroids) ectopic preg endometriosis/endocrine dub )anovulatory) |
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dark urine ddx
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Fellow Has DARK Pee
foods-beet/blackberry hematuria dehydration/drugs rifampicin, vit b alkaptonuria, rhabdyomyolysis kernicterius paroxysmal nocturnal hemolysis |
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blood in stool ddx
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DRAIN
diverticulosis, drgus rectal bleed (piles/fissures/hemorrhoids angiodysplasias/anal sex inflammatory bowel dis (UC/Crohns), infectious diarrhea, ischemic colitis, injury neoplasms |
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chest pain questions
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cough
hempotysis, heartburn emesis, diarrha, edema shortness breath, sweating, syncope temperature, tenderness on chest, tenderness legs palpitations |
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neck pain ddx
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MOTIV
1.Mets/Meningitis/Muscle strain 2.Osteoporosis(vertebral compression fracture)/OA 3.Trauma/TB(Potts disease) 4.InterVertebral disk herniation |
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joint pain ?s
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CITRUS-HP
1. C- COUGH history for Rh fever 2. I- SAME 3. T- SAME 4. R- RASH 5. U- UTI SYMPTOMS AND ULCERS(IN MOUTH) 6. S- SAME 7. H- HAIRLOSS (IN SLE) 8. P- PHOTOSENSITIVITY (SLE AGAIN) |
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back pain ddx
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SCOT MILS
1.Strain of muscle (sudden increase of physical activity) 2. Cauda equina (urinary/bowel incontinence, ED) 3. OA/Osteoporosis (other joints involvement,hx of fractures) 4.Trauma/TB( aka Potts disease)- exposure to TB, PPD 5.Mets/Multiple Myeloma ( app/weight changes, night sweats, fatigue, dysuric symptoms for male, obgyn - for females) 6.Intervertebral disk herniation ( numbness/ weakness anywhere) 7.Lumbar Stenosis ( pain increases with walking, prolonged standing and allevates by leaning forward position while sitting up) |
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dysphagia ?/ddx
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1.Heartburn (GERD,Achalasia)
2.Appetite changes/Anemia(anemia questions would be vegetarian diet, heavy menstrual flow,easy bruising) (Cancer, Plummer-Vinson) 3.Regurgitation/Reynaud phenomenon (Achalasia/CREST) 4.Dysphagia- details- onset, for solid, liquids etc 5.Cough at night (GERD) 6.Food cravings (Plummer Vinson) 7.Odor(halitosis) (Zenker diverticulum) 8.Overseas travel (Chagas disease) 9.Drugs, infections |
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picky eater ?
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1.Onset
2.Number of meals during day 3.Constipation/Cravings/Color of stool 4.Assosiated symptoms (fever+ROS) 5.Liquids amount 6.Lethargy 7.Immunization 8.Diet 9.Infection 10.Other complaints if present 11.Tiredness/To give rewards or panishment |
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picky eater ddx
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H-Habitual eating disorder
F-Fiber lack diet L-Lead poisoning I-Iron deficiency P-Parasitic infection |
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child w/ dm case
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T-DIABETES MISS H-MELLITUS
1. Type of diabetes 2. Description of symptoms at the time of diagnosis(thirst, frequent urination ) 3. Irritability 4. Abnormal thirst and urination at present time 5. Birth hx 6. Eating(diet) 7. Tiredness(fatigue) 8. Effect on child/parent 9. Sleep problems 10. Meds compliance 11. Injection site 12. Schedule for insulin 12. Sugar levels(management at home, lowest and highest numbers of glucose) 13. Hypoglycemia episodes(dizziness, sweating, hunger) 14. Mood 15. Exercise 16. LMP 17. LOC 18. Itch 19. Tingling/numbness 20. Urinary habits change 21. Super child- weight gain/ loss |
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assault/rape case ??
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DORRA SEXPLOER
1. Description of assault 2. Onset 3. Report of assault 4. Recognition of assailants 5. Assault objects 6. Sexual assault 7. Ejaculation 8. X-unknown- foreign objects used 9. Past menses 10. Latex- if condom was used 11. Oral, vaginal or anal intercourse 12. ER-estrogen replacement which is Contraception |
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enuresis ?
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ENURESIS
1. Enviromental changes(changing schools, parental divorce etc) 2. Nighttime awakening/Neuro problems 3. Urinary habits changes(frequency, amount, color etc) 4. Relative with similar issue 5. Eating/drinking late 6. Stress to a child and parents(to describe) 7. Interventions/drugs used before and effectivity 8. Snoring |
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jaundice
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1.Journey overseas/Joint pain
2.Abdominal pain/appetite changes 3.Up temperature( fever) 4.Nausea/vomiting 5.Diarrhea/constipation 6.Itch(rash)/Immunizations 7.Color of urine and stool 8.Eating habits -weight changes 9.Blood transfusion in the past |
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panic attack?
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1.Panic, paresthesia
2.Abdominal disturbances, anxiety 3.Nausea 4.Intensive fear of dying 5.Chest pain, chills, chocking 6.Sweating, shacking, shortness of breath |
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psych case
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VOICES HARM MEN
1.Visual hallucinations(onset, duration, context) 2.Open/close eyes(if patient can see "writtings" with close and open eyes) 3.Imperative ( voices can control patient) 4.Changes in vision/ vision loss 5.Ear(audio hallucinations- onset, duration, context) 6.Sleeping problems 7.Headache/head trauma 8.Attacking himself/others 9.Recreational drug use 10.Major changes in life 11.Mental illness in the family 12.Enjoying daily activities 13.Narcolepsy (sleepiness during the day) |
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insomnia case
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OD INSOMNIA STRIKE HIMS
1. Onset 2. Duration 3. Interruptions during night 4. Naps during the day 5. Snoring 6. On the clock(total time of sleep and time when pt is falling asleep) 7. Morning awakenings 8. Narcolepsy(daytime sleepiness) 9. Illness/ stress 10. Activity before patient goes to sleep(watching TV etc) 11. Sadness(mood) 12. Tremor 13. Irritability 14. K-Coffeine 15. Exercise 16. HI-Heat Intolerance 17. Menstrual irregularities 18. Sweating |
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psych case hx
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A-Appearance
B-Behavior C-Cooperation S-Speech T-Thought (process, content) A-Affect M-Mood P-Perception (AH/VH) L-Level of consciousness X3(person place time) I-Insight C-Cognition K-Knowledge fund/base E-Endings (suicidal, homicidal) R-Reliability |
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joint
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SPLINTER
S-Septic, Spondyloarthropathies P- Pseudogout/Gout L- Lyme Dz I- Infetion N-Neoplasia T-Truama E-Endocarditis R-Reiter’s Sy |
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smoking cessation counseling
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SPANCSTER
Stressor ( any stress in life/tension etc ) Problems ( Heart /Lung/ CA) Advantages ( Improved breathing & Increased energy) Nicotine Patch ( I can offer you reading materials ) Counsellors ( I can refer u/ give # ) Support systems ( I can refer u /give #) Taper down ( if u cant do cold turkey den just taper down a bit) Excercise Programs ( eg Swimming ) Rewards ( reward urself, treat urself with a dinner 4m money saved off of quitting) |
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std/hiv counseling
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STRIP BIMBO !
SAFE SEXUAL PRACTICES TRANSMISSION ( to partners ) RISKS ( acquiring more STD's) IMMUNIZATIONS ( for Influenza/ Pneumococcal ) PREVENTION COUNSELLING ( REFER TO SW /CAN GIVE #) BEHAVIOUR COUNSELLING (REFER / CAN GIVE #) INTERVENTIONAL COUNSELLING ( REFER /CAN GIVE #) MEDICATIONS BARRIER METHODS (CONDOMS OPPURTUNISTIC INFECTIONS/OBSERVATION (FOR LABS) |
