part 4 case history/exams

what acronym do we use for history

LOPPPPQRST

what does the L stand for in LOPPPPQRST

location

what does the O stand for in LOPPPPQRST

onset

what does the Ps stand for in LOPPPPQRST

paillative

provocative

priors

progression

what does the Q stand for in LOPPPPQRST

quality

what does the R stand for in LOPPPPQRST

radiation

what does S stand for in LOPPPPQRST

severity

what does the T stand for in LOPPPPQRST

timing

how do we ask about location

can you point to exactly where it hurts

how do we ask about onset

how did it start, what happened

how do we ask about paillative

what makes it better

how do we ask about provocative

what makes it worse

how do we ask about priors

has this ever happened before

how do we ask about progression

has it gotten better or worse since you first noticed this issue

how do we ask about quality

what does it feel like

how do we ask about radiating symptoms

does the pain travel anywhere

how do we ask about severity

on a scale of 1-10 10 being the worst what does it feel like today

how do we ask about timing

when do you feel it

what acronym helps us remember past medical history

SHITA

what does the S stand for in SHITA

past surgeries

what does the H stand for in SHITA

have you ever been hospitalized

what does the I stand for in SHITA

any recent infections or immunizations

what does the A stand for in SHITA

allergies

what do we need to ask about during family history

diabetes

cancer

heart disease

CC (if applicable)

what do we need to ask about the patients daily life

what do they do for work

what is the acronym for social history

SSS DDD E

what does the SSS stand for in SSS DDD E

smoking

sleeping

sexually active

what does the DDD stand for in SSS DDD E

drugs

drink

diet

what does the E stand for in SSS DDD E

exercise

what do we ask to conduct a ROS

are there any other s/s that you have noticed since your (CC) began?

what do we need to do after we take a whole history and conduct an ROS

repeat everything back

what are our vitals

temperature

blood pressure

pulse

respiratory rate

what is a normal value for temperature

98.6

what is a normal value for an adult pulse

60-100

what is the normal adult respiratory rate

14-18

what is the normal adult blood pressure value

90-120/60-80

what is considered hypertension

over 140/90

what is considered hypotension

under 90/60

what are conditions that can affect the skin

herpes zoster

psoriasis

systemic lupus erythmatosus

lymes disease

how will herpes zoster present

vesicel

elevated serous filled cavity .5 cm follows dermatome

how will psoriasis present

silvery scales on extensor surfaces

how will systemic lupus erythematous present

butterfly rash h

how will lymes disease present

bullseye rash

what are some conditions that can affect the eyes

ptosis

iritis/uveitis

papilledema

arteriosclerosis

hypertension

diabetes mellitus

what does bilateral ptosis indicate

myasthenia gravis

what does unilateral ptosis indicate

horners syndrome

what is horners syndrome

loss of cervical sympathetics, ptosis, miosis, and anhydrosis

when is iritis/uveitis observed

early staged of ankylosing spondylitis (AS)

what is papilledema an indication of if the eyes are affected

increased intracranial pressure

what is indicative of arteriosclerosis if the eyes are affected

AV nicking

silver wire arterioles

widened light reflex

what is indicative of hypertension if the eyes are affected

flame hemorrhages

cotton wool spots

narrow light reflex

what is indicative of diabetes mellitus if the eyes are affected

yellow, hard, waxy exudates

neovascularization

microaneurysms

absent red light reflex

what do we need to do for our physical examination (not orthos)

vitals

inspection

palpation