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97 Cards in this Set
- Front
- Back
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Vital Signs (PE)
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BP/pulse/temp/height/weight
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General (PE)
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age/race/habitus/nutritional state/consciousness/ dress/distress/posture
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Skin (PE)
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color/texture/temp/moisture/nails/ lesions*
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Head (PE)
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configuration/tenderness/lesions*
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Hair (PE)
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distribution/quality
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Eyes (PE)
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vision/EOMs/pupils/lids/ conjunctiva/sclera/cornea/
lens/fundus |
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Ears (PE)
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hearing/auricle/canal/TM
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Nose (PE)
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external/internal/mucosa/
septum/sinuses |
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Mouth (PE)
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lips/mucosa/tounge/gingiva/teeth
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Throat (PE)
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palate/tonsils/pharynx/voice
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Neck (PE)
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ROM/thyroid(size, configuration, tumor)/ lymph nodes/trachea/swallow
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Shoulder (PE)
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ROM/symetry/strength
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Back (PE)
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ROM/spinous processes/CVA or muscle tenderness
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Chest (PE)
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configuration/expansion (symmetry)
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Lungs (PE)
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resonance/breath sounds
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Breasts (PE)
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symmetry/configuration/
tenderness/discharge/ axillary nodes/lesions* |
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Heart (PE)
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visible impulse/palpable sensation/S1/S2/murmur/
carotid arteries/JVP |
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Abdomen (PE)
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appearence/bowel sounds/
organ sizes/tenderness/ masses/lesiones* |
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Extremities and Joints (PE)
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symmetry/ROM/configuration/
tenderness/edema/muscle tone/ lesions* |
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Peripheral Pulses (PE)
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carotid/radial/femoral/dorsalis pedis/
posterior tibialis capillary refill |
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Genitalia-Male (PE)
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PENIS, SCROTUM, PROSTATE
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PENIS (PE)
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foreskin (present, retractable)/meatus (discharge, position, configuration, lesions*)
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SCROTUM (PE)
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testicles/epididymus/vas deferens/ (size, configuration, symmetry, lesions*, hernias translumination)
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PROSTATE (PE)
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size/configuration/texture/consistency/symmetry/lesions*
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Genitalia-Female (PE)
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EXTERNAL, VAGINA, CERVIX, UTERUS and ADENEXA
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EXTERNAL (PE)
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configuration/tenderness/lesions*
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VAGINA (PE)
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color/discharge/lesions*
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CERVIX (PE)
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color/discharge/mobility/
consistency/lesions* |
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UTERUS and ADENEXA (PE)
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size/configuration/symmetry/
position/masses/mobility/ tenderness |
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Rectum (PE)
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sphincter tone/tenderness/lesions*/stool (color, guaiac)
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Lesions* (PE)
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*(Include: size, shape, color, topography, distribution, texture, consistency, mobility and tenderness).
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Neurologic Exam (PE)
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Men (Mental Status Exam), Crave (Cranial Nerve Exam), Sensational (Sensory Exam), Moist (Motor Exam), Cervezas(Cerebellar Exam), Regularly (Reflex Exam)
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Mental Status Exam
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Orientation to person, time and place. Speech, attention, memory and reasoning.
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Cranial Nerve Exam
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Old(Olfactory) Ophthalmologists(Optic) Occasionally(Occumotor) Troubleshoot(Trochlear) Tricky(Trigeminal) Abcessed(Abducens) Facial(Facial) Acne(Accoustic/Vestibulocochlear) Giving(Glossopheryngeal) Very(Vagus) Special(Spinal Accessory) Hydrocortisone(Hypoglossal)
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Olfactory Nerve Test
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smell
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Optic Nerve Test
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visual acuity, fields, funduscopic exam
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Oculomotor, Trochlear, Abducens Nerve Test
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extraocular movements, pupil response
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Trigeminal Nerve Test
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facial sensation, corneal reflex, grit teeth
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Facial Nerve Test
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facial symmetry, show teeth, raise eyebrows
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Acoustic(Vestubulocochlear) Nerve Test
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gross hearing, Weber/Rinne
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Glossopharyngeal Nerve Test
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gag reflex, voice tone, volume, hoarseness
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Vagus Nerve Test
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gag reflex, uvula deviation
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Spinal Accessory Test
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shoulder shrug, strengh, neck rotation
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Hypoglossal Test
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tongue protrusion, symmetry
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CN I name?
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Olfactory CN#?
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CN II name?
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Optic CN#?
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CN III name?
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Oculomotor CN#?
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CN IV name?
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Trochlear CN#?
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CN V name?
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Trigeminal CN#?
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CN VI name?
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Abducens CN#?
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CN VII name?
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Facial CN#?
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CN VIII name?
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Acoustic (Vestibulocochlear) CN#?
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CN IX name?
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Glossopharyngeal CN#?
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CN X name?
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Vagus CN#?
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CN XI name?
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Spinal Accessory CN#?
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CN XII name?
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Hypoglossal CN#?
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Sensory Exam
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Romberg test, two-point discrimination, vibration, propioception, pain, touch, temperature
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Motor Exam
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muscle strength, movement, tone, atrophy, flexion/extension, involuntary movements
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Cerebellar Exam
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finger-to-nose, run heel-knee to shin, gait, rapid alternating movements, stance
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Reflex Exam
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deep tendon reflexes, Babinski, clonus
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PHYSICAL EXAM
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Vital SIgns, General, Skin, Head, Hair, Eyes, Ears, Nose, Mouth & Throat, Neck & Shoulders, Back, Chest and Lungs, Breasts, Heart, Abdomen, Extremities & Joints, Peripheral Pulses, Genitalia Male/Female, Rectum and Neurologic Exam
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PATIENT HISTORY
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Identifying data, Source of referral, Source of history, Reliability, Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMHx), Health Maintenance, Family History (FHx), Social History (SHx) and Review of Systems (ROS).
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Chief Complaint (CC)
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Patient problem and duration
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History of Present Illness (HPI)
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Old(Onset), Cars(Character), Look(Location), Rad(Radiation), During(Duration), Frequent(Frequency), Fast(Factors that increase/decrease), Effective(Effect on patient), Accelerations(Associated symptoms), Passing(Past/prior siImilar symptoms), Traffic(Treatment)
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Past Medical History (PMHx) 5 Subtopics
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Childhood/adult illnesses, Hospitalizaciones/injuries/surgeries, Drug/allergies, Current and recent medications, Allergies
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Childhood/adult illnesses
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measles/mumps/chicken pox/rheumatic fever/ cardiovascular disease/HTN/Hyperlipidemia/ CA/TB/DM/STD/thyroid disease/arthrits/asthma/sleep apnea/ addictions/epilepsy/depression/anxiety/recurring diseases/other
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Hospitalizationes/injuries/surgeries
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Year/diagnosis/treatment/outcome
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Drug allergy
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Sensitivity/reaction
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Current and recent medications
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OTC-herbs-vitamins
Name/dosage/frequency/duration |
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Allergies
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Hay fever/environmental/foods
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Health Maintenance 3 subtopics
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Immunizations status, Screening tests, Occupational and environmental exposures
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Immunization status
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dT/dTaP/influenza/pnuemovax/
hepatitis A/B/MMR/HPV/zoster/ other |
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Screening tests
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PAP/mammogram/colon CA/cholesterol/HIV/prostate/ genetic/other
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Occupation and environmental exposures
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Seat belt use/helmets/firearms/smoke and CO detectors
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Family History (FHx) 1 subtopic
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Parents-age/Siblings-children-age-gender
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Parents-age/Siblings-children-age-gender
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cardiovascular disease/HTN/hyperlipidemia/CA/TB/DM/ STD/thyroid disease/arthrits/asthma/sleep apnea/ addictions/epilepsy/depression/anxiety/recurring diseases/other
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Social History (SHx) 3 subtopics
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Education-occupation-recreation, Diet and habits, Home situation and significant others
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Diet and habits
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Alchohol/tobacco/caffeine/drug use/injection drug use
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Review of Systems (ROS)
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General, Skin, Eyes, Ears, Nose, Mouth/Throat, Neck, Breasts, Cardiopulmonary, Gastrointestinal, Genitourinary, Sexual habits, Musculoskeletal, Endocrine, Neuropyschiatric, Hematologic
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General (ROS)
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Weight or appetite change/fatigue/dizziness
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Skin (ROS)
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Pruritus/rash/change
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Eyes (ROS)
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Vision change/corrective lenses/diplopia/blurring/last exam
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Ears (ROS)
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Hearing loss/tinnitus/ear pain
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Nose (ROS)
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Epistaxis/sinus problems
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Mouth/Throat (ROS)
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Hoarseness/dental problems/dentures/last dental exam
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Neck (ROS)
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Pain/swelling
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Breasts (ROS)
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Pain/mass/swelling/discharge/
breast self exam |
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Cardiopulmonary (ROS)
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Chest pain/palpatations/murmur/
claudication/syncope/cough/ hemoptysis/wheezing/dyspnea/ orthopnea/PND/ edema/exercise tolerance change |
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Gastrointestinal (ROS)
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Abdominal pain/heartburn/nausea/vomiting/hematemesis/ dysphagia/bowel habit change/diarrhea/constipation/ incontinence/melena/hematochezia/rectal pain/hemorrhoids/hernia
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Genitourinary (ROS)
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Dysuria/frequency/urgency/hesitancy/
discharge/nocturia/hematuria/ incontinence/contraception and conception planning... (then male/female ?'s) |
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Genitourinary (male) (ROS)
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Decreased stream/testicular pain/self exam/sexual dysfunction
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Genitourinary (female) (ROS)
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GP/GTPAL/LMP/LNMP/sexual dysfunction/dyspareunia
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Sexual habits (ROS)
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Men/women/both
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Musculoskeletal (ROS)
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Joint pain/swelling/stiffness/back pain
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Endocrine (ROS)
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Temperature intolerance/weight/menstrual changes/ skin/hair/voice change/polydipsia/polyuria
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Neuropsychiatric (ROS)
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Head ache/sensory change/tremor/weakness/eating disorders/sexual-physical-emotional abuse/depression/ anxiety/ever sought treatment
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Hemotologic (ROS)
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DVT/easy bruising/bleeding gums/increased vaginal bleeding/transfusions
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