History&physical

From Anvita Health Wiki

Contents 1 More Specific Terms 2 Introduction 3 More General Terms 4 Additional Terms

More Specific Terms

• physical examination

Introduction

• Chief complaint:

• History of present illness:
• What brings you here... Anything else?
• Attributes of a symptom:

• location, including radiation
• quality
• quantity or severity
• timing

• when did/does it start?
• how long has it last?
• how often does it occur?

• setting in which it occurs

• environmental factors
• personal activities
• emotional reactions
• other contributing circumstances

• exacerbating or alleviating factors
• associated manifestations

• Past medical history:
• Past :
• Allergies:
• Medications:
• Social history: lives *, occupation *, tobacco *, EtOH *, IVDA *
• Family history:
• Review of systems:

• General:

• fever/ chills, night sweats, fatigue, malaise, weight change, sleep disturbance, anorexia, depression

• Infectious:

• Tuberculosis, AIDS, sexually-transmitted diseases

• Metabolic:

• diabetes, thyroid disease

• Eyes:

• blurring of vision, visual field loss, irritation

• Ears:

• deafness, tinnitus, vertigo, earache

• Nose:

• rhinitis, sinusitis, epistaxis

• Throat:

• sore throat, tonsillitis, hoarseness

• Neck:

• swelling, goiter, lymphadenopathy, stiffness

• Cardiopulmonary:

• heart disease, myocardial infarction, congestive heart failure, chest pain, palpitations, edema, hypertension, dyspnea, PND, cough, hemoptysis

• Gastrointestinal:

• nausea/vomiting, diarrhea, constipation, hemetemesis, BRBPR, melena, peptic ulcer disease, GERD, dysphagia, bloating pain

• Urinary:

• dysuria, hematuria, nocturia, frequency, kidney stones, infections, urinary incontinence

• Genital (female):

• menstrual irregularity, vaginal discharge, dysparunia

• Genital (male): impotence, penile discharge, testicular pain
• Musculoskeletal:

• myalgia, arthralgia, arthritis

• Skin:

• rash, pruritis, bruising, open sores

• Neurologic:

• headaches, stroke, seizures, loss of consciousness, ataxia, tremors, gait disturbance, paresthesias, numbness

• Physical examination:
• Vitals: Temp: *, HR: *, RR: *, BP: **/**
• General:
• HEENT: NC/AT, pupils, extraocular muscles, conjunctiva, sclera, oropharynx, dentition, tongue ( CN12), gag, ears, hearing (Weber & Rinne test), sinuses, masseter, temporal arteries
• Neck: supple, adenopathy?, trachea, JVD, thyromegaly?
• Back: spine, CVA tenderness
• Lungs: percussion, expansion, auscultation ( bronchophony, egophony)
• CVS: RR, m/r/g ( heart sounds), carotid bruits, PMI
• Abdomen: BS, tenderness, distention?, hepatosplenomegaly?, pulse?
• Extremities: edema, clubbing, cyanosis, fingers & nails
• Skin: moist/dry, tenting?, lesions, erythema, tattoos
• Pulses: radial, dorsalis pedis, posterior tibial, femoral
• Lymphatics: axillary, inguinal
• Neuro:
• Alert, oriented X 3, MMSE if appropriate
• CN II-XII (should have already been checked)
• DTR: biceps: flexion at elbow (C5, C6) triceps: extension at elbow (C6, C7) brachioradialis: flexion & supination of forearm (C5, C6) patellar: extension at knee (L2, L3, L4) ankle: plantar flexion at ankle (S1)
• Plantar flexion ( Babinski)
• check for clonus
• check for tremor
• motor:

• flexion at the elbow (C5, C6, biceps)
• extension at the elbow (C6, C7, C8, triceps)
• abduction at the shoulders ( deltoids)
• shrugging of shoulders, turning of head ( CN XI)
• extension at wrist (C6, C7, C8, radial nerve)
• handgrip (C7, C8, T1)
• finger abduction (C8, T1 & ulnar nerve)
• opposition of thumb (C8, T1 & median nerve)
• gait (if possible)

• rise from a sitting position without arm support
• heal to toe or tandem walk
• walk on toes: tests plantar flexion
• walk on heals: tests dorsiflexion

• if gait not testable:

• flexion at the hip (L2, L3, L4, iliopsoas)
• adduction at the hips (L2, L3, L4, adductors)
• abduction at the hips (L4, L5, S1, gluteus medius & minimus)
• extension at the hips (S1, gluteus maximus)
• extension at the knee (L2, L3, L4, quadriceps)
• flexion at the knee (L4, L5, S1, S2, hamstrings)
• dorsiflexion at the ankle (L4, L5)
• plantar flexion at the ankle (S1)

• finger to nose: tests for dysmetria ( cerebellar)
• heal to shin, repeat with eyes closed to check position sense
• rapid alterating movements: tests for dysdiadochokinesis ( cerebellar)

• sensory: position sense, vibratory sensation

• Romberg
• pronator drift
• stereognosis
• 2 point discrimination: 5 mm on finger pads

More General Terms

• clinical procedure

Additional Terms

• physician evaluation at nursing home admission

history & physical (H&P)