Medical History and Physical Examination

This type of history includes all elements of health Hx and complete Px

Comprehensive

This type of medical history is usually done on new patients

Comprehensive

This type of medical history is tailored to the reason for the visit

Problem-oriented

This type of medical history is usually done for established patients

Problem-oriented

This type of medical history is usually done for urgent/sick visits

Problem-oriented

Which is subjective? Sign or symptom?

Symptom

Which cannot be measured? Sign or symptom?

Symptom

Which is objective? Sign or symptom?

Sign

Which is measurable and factual? Sign or symptom?

Sign

Which can be seen with VS, PEx, labs, tests? Sign or symptom?

Sign

What are the 7 main components of the medical history?

CC, HPI, PMH, PSH, FH, SH, ROS

This is a brief statement as to why the patient is seeking medical care

CC

This includes the medical complaint and duration

CC

This is written as a direct quote

CC

This is extremely important because it explains the CC

HPI

This component tells a story

HPI

What are the mnemonics for HPI?

LOCATES, AMP

In LOCATES, what does the L stand for?

Location

In LOCATES, what does the O stand for?

Other associated symptoms

In LOCATES, what does the C stand for?

Characteristics

In LOCATES, what does the A stand for?

Aggravating/alleviating symptoms

In LOCATES, what does the T stand for?

Timing

In LOCATES, what does the E stand for?

Environment

In LOCATES, what does the S stand for?

Severity

What is a good way to get a clear and concise Location?

Can you point to where it hurts with one finger

What are some questions you will ask with Location?

Local or Diffuse? Deep or superficial? Does it radiate?

When you are asking about Other Associated Symptoms, how to we need to document it?

Group pertinent positives together; group pertinent negatives together

What questions are important to ask when you are doing Aggravating/Alleviating Factors?

What have you tried? What makes it better? What makes it worse? Triggers?

What questions are important to ask when you are doing Timing?

Onset, frequency, intervals between events, duration (both total and episode)

What questions are important to ask when you are doing Environmental?

What were you doing when it happened? Where were you when it happened? Triggers? Anyone else ill? Outdoor activities? Bites? New hobbies? Exercise? Chemical exposure? International travel? Changes in routine?

What questions are important to ask when you are doing Severity?

On a scale of 1-10... What does a 10 look like for you? How does this affect your life?

What should be included in the PMH?

Childhood illnesses, adult illnesses, immunizations, hospitalizations, injuries/accidents, health maintenance.

In the PMH, what should be included with the Ob/Gyn/Sexual History?

Total # of pregnancies, # of living children, abortions, C sections, menstrual history, menopause, birth control use, sexual function/dysfunction, sexual orientation, STD risk factors.

In the PMH, what should be asked with the psychiatric history?

Diagnoses, hospitalizations, treatments, FH of mental illness, voluntary vs involuntary

What should be included in PSH?

Types of surgeries, dates, indications, complications

What should be included in the FH?

Outline/pedigree, Parents, siblings, children

What are the FH important diseases?

Anemia, asthma, Bleeding disorders, CA, CAD, Connective tissue disease, CVA/TIA, DM, EtOH Use, Glaucoma, Hereditary diseases, High cholesterol, HTN, Kidney disease, mental illness, thyroid disease, Tobacco use, Weight problems

What are the SH important questions to ask?

Tobacco use, EtOH use, Illicit drug use, Caffeine use, Occupation, Education level, Ethnic background, Marital status, Children, Retirement, Military service, Exercise level, Hobbies, Nutrition, Faith/Spiritual belief, Stress Level, Alternative health care, Domestic Violence, Helmet, Sunscreen, Gun safety, Smoke detector, seatbelts

If you are concerned about a patient's EtOH use, what should you administer?

CAGE Questionnaire

What are the ROS for general?

Fatigue, malaise, weakness, weight changes, preferred weight, fever, chills, sleep changes, hot flashes, night sweats, hot or cold intolerance, changes in facial hair, enlarged lymph nodes, pica, abnormal bleeding or bruising, anemia, blood transfusions, appetite, anhedonia, general state of health

What are the ROS for Skin?

Changes in skin, unusual moles or lesions, rashes, hives, dry skin, excessive sweating, itching, bruising, ecchymosis, striae, skin cancer, skin disorders, sunscreen

What are the ROS for nails?

Pitting, brittleness, discoloration, spooning, cupping

What are the ROS for hair?

Pattern changes, hair loss, dry scalp, lesions

What are the ROS for Head and Heck?

Headaches, concussions, syncope, LOC, head injury, enlarged lymph nodes, enlarged thyroid, thyroid problems, radiation, changes in facial hair, scalp pain, scalp lesions, neck pain, neck stiffness, dizziness, jaw pain, jaw locking/clicking, CVA/TIA

What are the ROS for eyes?

Changes in vision, blurriness, double vision, eye pain, redness, icterus, discharge, excessive tearing, eye injury, photophobia, eye infections, vision correction, glaucoma, cataracts, last eye doctor visit

What are the ROS for Ears and Nose?

Tenderness, pain, changes in hearing, hearing loss, tinnitus, dizziness, vertigo, ear discharge, ear injury, hearing aids, nasal bone fractures, difficulty breathing, stuffiness/aptency, epistaxis, nasal discharge, loss of smell, injury, sinusitis, allergic rhinitis

What are the ROS for the throat?

Sore throat, odynophagia, change in voice, hoarseness, dysphagia, thrush, tonsilitis, pharyngitis

What are the ROS for the mouth?

bleeding gums, gum pain, tongue burning, tooth pain, tooth abscessess, last dental visit, mouth sores, mouth ulcers, change in taste, dentures

What are the ROS for cardiovascular?

Chest pain, palpitations, heart murmur, HTN, syncope, dyspnea, orthopnea, PND, MI, DOE, varicose veins, lower leg edema, discoloration, pain in lower legs, loss of hair on legs, coldness of feet, leg ulcers, heart murmurs or defects, rheumatic fever, last ECG, prior stress tests, Heart disease

What are the ROS for respiratory?

Cough

Sputum production

Hemoptysis

Wheezing

Dyspnea

Tobacco use

Environmental Inhalants

Tuberculosis

Rib Pain

Exposure to TB

Asthma

COPD

Pneumonia

Last PPD

Last CXR

What are the ROS for the breast?

Nodules/ Lumps

Pain

Skin Changes

Lesions

Nipple discharge

Nipple Inversion

Galactorrhea

Fibrocystic breast disease

Breast cancer

Self breast exam

Last Mammogram

Date of 1st Mammo

What are the ROS for abdominal?

Appetite

Excessive hunger

Odynophagia

Dysphagia

Acid taste in mouth

Water brash

Indigestion

Heartburn

Burping / belching

Bloating

Abdominal pain

Nausea & Vomiting

Hematemesis

Frequency of bowel movements

Stool consistency

Change in bowel habits

Change in stool color

Constipation

Diarrhea

Flatulence

Hematochezia

Melena

Steatorrhea

Hemorrhoids

Abdominal swelling

Jaundice

Hepatitis

Liver disease

Gallbladder disease

Pancreatitis

Hernias

PUD/ GERD

Alcohol intake

Abdominal surgery

Colon polyps

Colon cancer

Last colonoscopy

Other cancers

What is the ROS for GI?

Difficulty urinating

Dysuria

Increased frequency

Urgency

Nocturia

Hematuria

Hesitancy

Retention

Weak stream

Dribbling

Incontinence

Urine color

Cola-colored urine

Urethral discharge

Flank pain

Genital lesions

Hernias

Renal disease

Urinary Tract Infection (UTI)

Renal Calculi

Sexual activity/ history

Libido / orgasms

STDs

Cancer

What are the ROS for male GI?

Testicular pain

Testicular masses / swelling

Undescended testes

Hemospermia

Erectile dysfunction

Anorgasmia

Fertility Issues

Prostatitis

Vasectomy

Prostate cancer

What are the ROS for female GI?

Menstrual- cycle, duration, flow

Last menses

Painful menses

Age at menarche

Last menses

Pelvic Pain

Pelvic mass

Vaginal discharge

Vaginal dryness

Abnormal bleeding

Dyspareunia

Anorgasmia

Fertility issues

# Pregnancies / # births

Pregnancy Complications

C sections

Abortions

Miscarriages

Diethylstilbestrol exposure

Last PAP / HPV

Menopause/ age

Menopausal Symptoms

Post Menopausal bleeding

What are the ROS for MSK?

Joint pain

Joint stiffness

Muscle pain

Weakness

ROM

Warmth

Erythema

Edema

Deformity

Limping

Muscle cramps

Night pain

Back pain

Injuries

Orthopedic surgeries

Arthritis

Gout

Cancer

Connective Tissue Disorders

What are the ROS for Nervous?

Headaches

Dizziness

Vertigo

Syncope

Numbness / Paralysis

Tingling / Paresthesias

Decreased sensation

Weakness

Coordination

Seizures

Tremors

Memory Loss

Head Trauma

Speech Disorders

Gait Disorders

Movement disorders

CVA or TIA

Cancer

What are the ROS for Psych?

Anxiety

Stress

Depression

Mood Changes

Suicidal ideations

Paranoia

Hallucinations

Nervousness

Disorientation

Irritability

Loss of control

Anger issues

Difficulty with relationships

Insomnia

Eating disorders

Substance abuse

Dx of mental disorders

What are the 4 components of the PEx?

Inspection, Palpation, Percussion, Auscultation

In the PEx, what general survey items are you looking for?

General state of health

Build / posture

Appearance / Grooming

Hygiene / Body odor

Awareness / Level of consciousness

Affect

Reactions

Speech

Motor Activity

For the PEx, what VS are you looking at?

Weight

Height

Pulse

Respirations

Temperature

Blood Pressure

For the PEx, what items are you looking for in the skin and nails?

Lesions

Rashes

Texture

Dryness

Nails

Hair

For the PEx, what items are you looking for in the head and neck?

Inspect:

Head, scalp, face

Neck

ROM

Alignment of trachea

Palpate:

Scalp

Lymph nodes

Trachea

Palpate thyroid

TMJ

For the PEx, what items are you looking for in the eyes?

Inspect: external eye

Visual acuity

Visual fields

Eye movements

Pupil alignment & size

Reaction to light

Inspect internal eye:

Funduscopic exam

For the PEx, what items are tou looking for in the ears?

Inspect external ear

Palpate external ear

Auditory Acuity

Conduction

Lateralization

Visualize canal & middle ear

For the PEx, what items are you looking for in the nose?

Inspect external nose

Palpate nose & sinuses

Visualize internal nose

sense of smell

patency

For the PEx, what items are you looking for in the mouth?

Inspect external features

Inspect inside mouth

Halitosis

Palpate

Tongue

Gums

Buccal mucosa

For the PEx, what items are you looking for in the pharynx?

Inspect pharynx

Alignment

Gag reflex

For the PEx, what items are you looking for in the heart?

Inspect:

Jugular pulsations

Palpate:

Apical pulsations

Peripheral pulses

PMI

Auscultate:

Heart sounds

For the PEx, what items are you looking for in the lungs?

Inspect:

comfort, color, position, speaking/ breathing pattern, chest wall movement, accessory muscle usage

Palpate:

Excursion

Tactile fremitus

Percuss:

Auscultate:

Lung sounds

Egophony

Whispered Pectoriloquy

For the PEx, what items are you looking for in the breasts?

Inspection:

Skin

Palpation:

Axillary Lymph Node

Breast tissue

For the PEx, what items are you looking for in the abdominal?

Inspection:

Ascites

Auscultation:

Bowel sounds

Palpation:

Light, then deep

Percussion:

Organomegaly

For the PEx, what items are you looking for in the male GI?

Inspect:

Penis & scrotum

Palpate:

Penis & scrotum

Test:

Hernias

Palpate:

Groin lymph nodes

Rectum & prostate

For the PEx, what items are you looking for in the female GI?

Inspect:

External genitalia

Vaginal canal & cervix

Palpate:

Canal, cervix, uterus & ovaries

Rectal / Rectovaginal

For the PEx, what items are you looking for in the MSK?

Inspection

Palpation

Test ROM:

Passive

Active

Resistive

Specific Orthopedic testing

Compare Right to Left sides

For the PEX, what items are you looking for in the nervous?

Mental status

Cranial Nerves

Motor Function - tone, strength, skill, coordination

Sensory - pain, temp, vibration, discrimination

Reflexes

Compare Right to Left sides

For the PEx, what items are you looking for in psych?

Affect

Response

Attitude