The Patient Note/Cases

Page 1

-Fields present for hx, physical exam, ddx, and workup

-Before typing, review hx

-History:

CC

HPI

ROS: GEN, HEENT, CV, lungs, GI, GU, skin, neuro

Allergies

Medications

PMH

PSH

Birth hx:

Dietary hx:

Immunization hx:

Developmental hx:

FH

SH

Initial diagnostic workup

-Best to start with "forbidden physical exam maneuvers" if indicated

-No referrals, treatments, hospitalizations, or consults (not scored)

-Do not say "chem 7" or LFTs, but "Na, K" (or electrolytes) and "AST/ALT"

Headache:

-neurologic

symptoms: paresthesias, visual disturbances, weakness, numbness,

ataxia, photophobia, dizziness, auras, neck stiffness

-Nausea/vomiting,

jaw claudication, recent trauma, dental surgery, sinusitis problems,

exacerbating factors (stress, fatigue, menses, exercise, certain foods),

alleviating (rest, meds), familiy hx, constitutional sx (temporal

arteritis), caffeine consumption (withdrawal), OCPs (migraine)

Memory loss:

-associated

sx: constitutional, incontinence, ataxia, hypothyroid sx, depression,

waxing/waning (delirium), falls, meds/med changes, stroke hx, syphilis,

HIV risk factors, alcohol use, family hx of Alzheimer's, vit B 12,

gradual vs. stepwise

-perform mini mental status exam & general physical exam

-Wernicke on differential for CJD

Depression:

-Drug & alcohol use, prior episodes

-appearance, behavior, speech, mood, affect, thought process, thought content, cognition, insight, and judgement

DIG FAST

D = Distractibility and easy frustration

I = Irresponsibility and erratic uninhibited behavior

G = Grandiosity

F = Flight of ideas

A = Activity increased with weight loss and increased libido

S = Sleep is decreased

T = Talkativeness

Psychosis:

-Positive sx: delusions, hallucinations,

disorganized thinking, catatonia; negative sx: blunted affect, social

withdrawal, anhedonia, poverty of speech; cognitive: paranoia

Dizziness:

-Auditory

sx (hearing loss, tinnitus), hx of atherosclerotic vascular dz,

following head trauma, nausea, URI (vestibular neuronitis

-Dix-hallpike maneuver (head to side, extended 30 degrees, repeated on both sides), Weber & Rinne

-BPPV,

Meniere's, Vestibular Neuronitis (rapid onset of severe vertigo with

nausea, vomiting, and gait instability), acoustic neuroma

Syncope:

-Preceding

sx: nausea, diaphoresis, palpitation, pallor, lightheadedness,

exertional, postural, traumatic, stressful, dehydration,

incontinence/tongue biting, post-ictal, dyspnea (PE), arrhythmia,

htn/dm, alcohol/drugs

Numbness/weakness:

-Progression, pain (HA, neck, or back), constitutional, alcoholism, atherosclerotic vascular dz

Fatigue/sleepiness:

-Sleep

hygiene, snoring, waking up choking/gasping, overexertion, shift

changes, diet, weight cx, constitutional sx, thyroid dz, hx of anemia,

meds, alcohol/drug use

Night sweats:

-Recent URI sx, pleuritic

chest pain, itching, alcohol hx, sexual exposure, sick contacts,

exposure to high risk (homeless, prisoners), menstrual hx

-Hyperthyroidism

Insomnia:

-Other medical problems keeping the pt awake at night (arthritis, diabetes), nightmares

-Stress-induced insomnia

Sore throat:

-HIV risk factors

Cough/shortness of breath:

-sputum, postnasal drip, heartburn, wheezing, meds, allergies

-Bronchiectasis: cough/purulent sputum for months to years

Chest pain:

-Context:

exertional, postprandial, positional (leaning forward), cocaine,

trauma, PEs (recent surgery, h/o DVT, pregnancy/OCPs, malignancy, HR

>100, hemoptysis)

-Esophagitis, esophageal spasm, aortic dissection, pericarditis

Palpitations:

-Lightheadedness, chest pain, dyspnea, hyperthyroidism, anemia

Weight loss:

-Intentional

vs. unintentional, body image, anxiety/depression, palpitations, tremor

(anorexia), diarrhea, HIV risk factors, tobacco, alcohol/drugs

Weight gain:

-Menstrual irregularity, signs of Cushing's syndrome

Dysphagia:

-Solids, liquids, both, progression, drooling, HIV risk factors, smoking, Raynaud phenomenon

-Esophagitis (pill-induced: abx, aspirin, bisphosphonates), esophageal stricture, scleroderma

Nausea/vomiting:

-Pregnancy, food poisoning, abd pain, neuro (HA, stiff neck, focal numbness/weakness)

-Funduscopic exam

Abdominal pain

-Cardiac, pulmonary, renal, pelvic associated sx, domestic violence

-Pancreatic

cancer (wt loss, dark urine), PUD (epigastric, radiation to back),

Fitz-Hugh Curtis (RUQ pain referred to right shoulder), gastritis,

peptic ulcer perforation (severe acute pain epigastric-->generalized,

peritonitis, tachycardia, fever, hypovolemia), hernia, ddx mesenteric

ischemia (diverticulitis, pud)

-Ruptured ovarian cyst (brought on by

strenuous activity, vaginal bleeding, vss, mild/mod abd pain, Cullen's

sign [periumbilical ecchymoses assoc. w/ intraabdominal bleed]), vs

ovarian torsion (mod/sev abd pain n/v, fever, poss. bleeding--less

common) ddx diverticulitis (UC--tenesmus, Crohn's, abscess)

-Male appendicitis ddx (Crohn's dz, nephrolithiasis, volvulus/intestinal obstruction), IBS (celiac dz)

Constipation/diarrhea

-Hx

of abd surgeries, chronic pancreatitis, antibiotic use, traveler's

diarrhea ddx (giardiasis, amebiasis--bloody, mucoid stools, hepatitis A)

Upper GI bleedings

-AAA repair, easy bleeding/bruising, alcoholic (mallory-weiss tear, NOT boerhaave syndrome--no hematemesis)

Blood in stools

-orthostatic vs

-Anal fissure, hemorrhoids (painless w/ BM), ischemic bowel disease (elderly)

Hematuria

-Clots, trauma, vigorous, exercise, easy bleeding/bruising, bladder CA, RCC, PKD (precipitation by infection, exercise)

Other urinary sx:

-Hesitancy,

weak stream, incomplete bladder emptying, straining, post void

dribbling, irritative (urgency, frequency, nocturia), bone pain,

alcoholism

-Urodynamic evaluation

Erectile dysfunction:

-Nocturnal

erections, stress/depression, trauma, incontinence, meds/changes, HTN,

DM, hypercholesterolemia, atherosclerotic vascular dz, prior prostate

surgery, smoking, alcohol, drugs (antidepressants, spironolactone,

clonidine, thiazide diuretics, ketoconazole

Amenorrhea:

-PREGNANCY,

HA, decreased peripheral vision, galactorrhea, hypothyroidism,

hirsutism, vaginal dryness, anorexia, vigorous exercise, uterine

infections, hyperprolactinemia

Vaginal bleeding:

-Associated discharge, pelvic/abd pain, urinary sx, meds, easy bleeding/bruising, abnormal pap smears

-Endometrial

cancer, cervical cancer, endometrial hyperplasia, atrophic

endometrium/vaginitis, endometrial polyp (peri/early postmenopausal)

-1st trimester blleeding: ectopic pregnancy (increased risk w/ PID), spontaneous abortion, polyps, GTD

-2nd/3rd trimester bleeding: bloody show, placental abruption, vasa previa, uterine rupture

Vaginal discharge

-Odor, burning, pruritus, LMP, tampons, douches

Dyspareunia

-Vaginal discharge, rash, painful menses, GI sx, hot flashes, sexual hx, hx of sexual trauma/IPV

-Endometriosis (dysmenorrhea, dyspareunia, infertility, constipation/diarrhea), vaginismus

Abuse

-Establish

confidentiality, fear, safety back up plan, firearms in the home, hx of

multiple accidents/injuries, mental illness, drug use/abuse

Joint/limb pain

-Pattern

(small vs. large joints, red eye, genital ulceration, diarrhea,

dysuria, rash, focal numbness/weakness, FH of rheumatic dz

-Carpal

tunnel ddx (median nerve compression in forearm, C6-7 radiculopathy

c-spine), psoriatic arthritis, arthritis associated w/ IBD, pseudogout,

gout, tennis elbow (lateral epicondylitis)--pain on resisted wrist

dorsiflexion, elbow in full extension (Cozen's test), plantar fasciitis

(heel pain w/ initiation of walking, point tenderness with dorsiflexion)

Child w/ fever

-Appetite, rash, sick contacts, daycare, immunizations

-Neonatal sepsis, meningitis, pneumonia, UTI, otitis media

Child w/ GI symptoms

-Timing in relation to meals, abdominal surgeries, changes in weight

-Constipation: hirschprung's, anal stenosis, hypothyroidism, lead poisoning, intussusception

-Abd pain: intussusception, appendicitis, Meckel diverticulum (painless GI bleeding), colic (relief after belching, passing gas)

Child with red eye

-Eye discharge

-Seasonal allergies, keratitis (corneal inflammation)

Child with short stature

-Familial short stature, growth hormone deficiency, hypothyroidism, chronic renal insufficiency

Behavioral problems in childhood

-triggers, physical violence/use of weapons, school performance, changes in environment

-ADHD, oppositional defiant, conduct d/o, adjustment d/o, substance abuse