Headache

Key History

Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep?);

presence of associated neurologic symptoms, nausea, jaw claudication; recent trauma, dental surgery, sinusitis symptoms; exacerbating (stress, fatigue, menses, exercise) and alleviating factors (rest, medicines); past history of headache; family history of migraines.

Key Physical Exam

Vital signs; inspection and palpation of entire head; ENT inspection; complete neurologic exam, including funduscopic exam.

Confusion and memory loss

Key History

Must include history from family members/caregivers. Detailed time course of cognitive deficits, associated symptoms (constitutional, incontinence, ataxia, hypothyroid symptoms, depression); screen for delirium (waxing/waning level of alertness); ADL/IADL status, falls, medications (and recent medication changes); history of stroke or other atherosclerotic vascular disease, syphilis, HIV risk factors, alcohol use, or vitamin B12 deficiency; family history of Alzheimer"„¢s disease.

Key Physical Exam

Vital signs; complete neurologic exam, including mini-mental status exam and gait; general physical exam, including ENT, heart, lungs, abdomen, and extremities.

Dizziness

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Key History

Lightheadedness vs. vertigo, ± auditory symptoms (hearing loss, tinnitus), duration of episodes, context (occurs with positioning, following head trauma), other associated symptoms (visual disturbance, URI,nausea); neck pain or injury; medications; history of atherosclerotic vascular disease.

Key Physical Exam

Vital signs; complete neurologic exam, including Romberg test, nystagmus, tilt test (e.g., Dix-Hallpikemaneuver), gait, hearing, and Weber and Rinne tests; head and neck exam; cardiovascular exam.

LOC

Key History

Presence or absence of preceding symptoms (nausea, diaphoresis, palpitation, pallor, lightheadedness),context (exertional, postural, traumatic; stressful, painful, or claustrophobic experience; dehydration); associated tongue biting, incontinence, tonic-clonic movements, prolonged confusion; dyspnea or pulmonary embolism risk factors; history of heart disease or arrhythmia; alcohol and drug use.

Key Physical Exam

Vital signs, including orthostatics; complete neurologic exam; carotid and cardiac exam; lung exam.

Numbness and weakness

Key History

Distribution (unilateral, bilateral, proximal, distal), duration, ± progressive, pain (especially headache,neck or back pain); constitutional symptoms, other neurologic symptoms; history of diabetes, alcoholism, atherosclerotic vascular disease.

Key Physical Exam

Vital signs; neurologic and musculoskeletal exams; relevant vascular exam.

Fatigue and Sleepiness

Key History

Duration; sleep hygiene, snoring, waking up choking/gasping, witnessed apnea; overexertion; stress, depression,or other emotional problems; diet; weight changes; other constitutional symptoms; symptoms of thyroid disease; history of bleeding or anemia; medications; alcohol and drug use.Key Physical Exam Vital signs; head and neck exam (conjunctival pallor, oropharynx/palate, lymphadenopathy, thyroid exam); heart, lung, abdominal, and neurologic exams; consider rectal exam and occult blood testing.

Sore throat

Key History

Duration, fever, other ENT symptoms (ear pain, URI), odynophagia, swollen glands, ± cough, rash; sick contacts, HIV risk factors.

Key Physical Exam

Vital signs; ENT exam, including oral thrush, tonsillar exudate, and lymphadenopathy; lung, abdominal,and skin exams.

Cough and SOB

Key History

Acute vs. chronic; presence/description of sputum, associated symptoms (constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn, other), exacerbating and alleviating factors; exposures; smoking history; history of lung disease; allergies; medicines (especially ACE inhibitors).

Key Physical Exam

Vital signs ± pulse oximetry; exam of nasal mucosa, oropharynx, heart, lungs, lymph nodes, and extremities (clubbing, cyanosis, edema).

Chest Pain

Key History

Location, quality, severity, radiation, duration, context (exertional, postprandial, positional, cocaine use,trauma), associated symptoms (sweating, nausea, dyspnea, palpitation, sense of doom), exacerbating and alleviating factors (especially medicines); prior history of similar symptoms; known heart or lung disease or history of diagnostic testing; cardiac risk factors (hypertension, hyperlipidemia, smoking, family history of early MI); pulmonary embolism risk factors (history of DVT, coagulopathy, malignancy, recent immobilization).

Key Physical Exam

Vital signs ± BP in both arms; complete cardiovascular exam (JVD, PMI, chest wall tenderness, heart sounds, pulses, edema); lung and abdominal exams.

Palipitations

Key History

Gradual vs. acute onset/offset, context (exertion, caffeine, anxiety), associated symptoms (lightheadedness, chest pain, dyspnea); hyperthyroid symptoms; history of bleeding or anemia; history of heart disease.

Key Physical Exam

Vital signs; endocrine/thyroid exam, including exophthalmos, lid retraction, lid lag, gland size, bruit, and tremor; complete cardiovascular exam.

Weight loss

Key History

Amount, duration, ± intentional; diet history, body image, anxiety or depression; other constitutional symptoms; palpitation, tremor, diarrhea, family history of thyroid disease; HIV risk factors; alcohol and drug use; medications; history of cancer.

Key Physical Exam

Vital signs; complete physical.

Weight gain

Key History

Amount, duration, timing (relation to medication changes, smoking cessation, depression); diet history; hypothyroid symptoms (fatigue, constipation, skin/hair/nail changes); menstrual irregularity; past medical history; alcohol and drug use.

Key Physical Exam

Vital signs; complete exam, including signs of Cushing"„¢s syndrome (hypertension, central obesity, moon face, buffalo hump, supraclavicular fat pads, purple abdominal striae).

Dysphagia

Key History

Solids vs. both solids and liquids, ± progressive, constitutional symptoms (especially weight loss), drooling, regurgitation, odynophagia, GERD symptoms; medications; HIV risk factors, history of smoking, history of Raynaud"„¢s phenomenon.

Key Physical Exam

Vital signs; head and neck exam; heart, lung, and abdominal exams; skin exam (for signs of scleroderma/CREST).

Nausea and vomiting

Key History

Acuity of onset, ± abdominal pain, relation to meals, sick contacts, possible food poisoning, possible pregnancy; neurologic symptoms (headache, stiff neck, vertigo, focal numbness or weakness), other associated symptoms (GI, chest pain), exacerbating and alleviating factors; medications.

Key Physical Exam

Vital signs; ENT; consider funduscopic exam (increased intracranial pressure); complete abdominal exam; consider heart, lung, and rectal exams.

Abdominal pain

Key History

Location, quality, intensity, duration, radiation, timing (relation to meals), associated symptoms (constitutional,GI, cardiac, pulmonary, renal, pelvic, other), exacerbating and alleviating factors; prior history of similar symptoms; history of abdominal surgeries, gallstones, renal stones, atherosclerotic vascular disease;medications; alcohol and drug use; domestic violence.

Key Physical Exam

Vital signs; heart and lung exams; abdominal exam, including guarding, rebound, Murphy"„¢s sign, and CVA palpation; rectal exam; pelvic exam (women).

Constipation and diarrhoea

Key History

Frequency and volume of stools, duration of change in bowel habits, associated symptoms (constitutional,abdominal pain, bloating, sense of incomplete evacuation, melena or hematochezia); thyroid disease symptoms; diet (especially fiber and fluid intake); medications (including recent antibiotics); sick contacts, travel, camping, HIV risk factors; history of abdominal surgeries, diabetes, pancreatitis; alcohol and drug use; family history of colon cancer.

Key Physical Exam

Vital signs; relevant thyroid/endocrine exam; abdominal and rectal exams; ± female pelvic exam.

Upper GIT

Key History

Amount, duration, context (after severe vomiting, alcohol ingestion, nosebleed), associated symptoms (constitutional, nausea, abdominal pain, dyspepsia); medications (especially warfarin, NSAIDs); history of peptic ulcer disease, liver disease, abdominal aortic aneurysm repair, easy bleeding.

Key Physical Exam

Vital signs, including orthostatics; ENT, heart, lung, abdominal, and rectal exams.

BLOOD IN THE STOOL

Key History

Melena vs. bright blood; amount, duration, associated symptoms (constitutional, abdominal or rectal pain, tenesmus, constipation/diarrhea); trauma; prior history of similar symptoms; prior colonoscopy; medications (especially warfarin); history of easy bleeding or atherosclerotic vascular disease.

Key Physical Exam

Vital signs ± orthostatics; abdominal and rectal exams.

HAEMATURIA

Key History

Amount, duration, ± clots, associated symptoms (constitutional, renal colic, dysuria, irritative voiding symptoms); medications; history of vigorous exercise, trauma, smoking, stones, cancer, or easy bleeding.

Key Physical Exam

Vital signs; lymph nodes; abdominal exam; genitourinary and rectal exams; extremities.

OTHER URINARY SYMPTOMS

Key History

Duration, obstructive symptoms (hesitancy, diminished stream, sense of incomplete bladder emptying, straining, postvoid dribbling), irritative symptoms (urgency, frequency, nocturia), constitutional symptoms; bone pain; medications; history of UTIs, urethral stricture, or urinary tract instrumentation; stones, diabetes, alcoholism.

Key Physical Exam

Vital signs; abdominal exam (including suprapubic percussion to assess for a distended bladder); genital and rectal exams; focused neurologic exam.

ERECTILE DYSFUNCTION

Key History

Duration, severity, ± nocturnal erections, libido, stress or depression, trauma, associated incontinence; medications (and recent changes); past medical history (hypertension, diabetes, high cholesterol, known atherosclerotic vascular disease, prior prostate surgery); smoking, alcohol and drug use.

Key Physical Exam

Vital signs; cardiovascular exam; genital and rectal exams.

AMENORRHOEA

Key History

Primary vs. secondary, duration, possible pregnancy, associated symptoms (headache, decreased peripheral vision, galactorrhea, hirsutism, virilization, hot flushes, vaginal dryness, symptoms of thyroid disease); history of anorexia nervosa, excessive dieting, vigorous exercise, pregnancies, D&Cs, uterine infections; drug use; medications.

Key Physical Exam

Vital signs; breast exam; complete pelvic exam.

VAGINAL DISCHARGE

Key History

Pre- vs. postmenopausal, duration, amount; menstrual history and relation to last menstrual period; associated discharge, pelvic or abdominal pain, or urinary symptoms; trauma; medications (especially warfarin,contraceptives); history of easy bleeding or bruising; history of abnormal Pap smears.

Key Physical Exam

Vital signs; abdominal exam; complete pelvic exam.

DYSPARENIA

Key History

Duration, timing, associated symptoms (vaginal discharge, rash, painful menses, GI symptoms, hot flushes), adequacy of lubrication; libido; sexual history; history of sexual trauma or domestic violence; history of endometriosis, PID, or prior abdominal/pelvic surgeries.

Key Physical Exam

Vital signs; abdominal exam; complete pelvic exam.

ABUSE

Key History

Establish confidentiality; directly question about physical, sexual, or emotional abuse and about fear, safety, backup plan; history of frequent accidents/injuries, mental illness, drug use; firearms in the home.

Key Physical Exam

Vital signs; complete exam ± pelvic.

JOINT AND LIMB PAIN

Key History

Location, quality, intensity, duration, pattern (small vs. large joints, number involved; swelling, redness, warmth), associated symptoms (constitutional, red eye, oral or genital ulceration, diarrhea, dysuria, rash,focal numbness/weakness), exacerbating and alleviating factors; trauma (including vigorous exercise); medications; DVT risk factors; alcohol and drug use; family history of rheumatic disease.

Key Physical Exam

Vital signs; HEENT and musculoskeletal exams; relevant neurovascular exam.

LOW BACK PAIN

Key History

Location, quality, intensity, radiation, context (moving furniture, bending/twisting, trauma), timing (disturbs sleep), associated symptoms (especially constitutional, incontinence), exacerbating and alleviating factors; history of cancer, recurrent UTIs, diabetes, renal stones, IV drug use, smoking.

Key Physical Exam

Vital signs; neurologic exam (especially L4-S1 nerve roots); back palpation and range of motion (although rarely of diagnostic utility); hip exam (can refer pain to the back); consider rectal exam.

CHILD WITH FEVER

(No child will be present; only the mother will be present to tell the story.)

Key History

Severity, duration, associated localizing symptoms, appetite, rash, sick contacts, day care, immunizations, past history.

Key Physical Exam

Vital signs; HEENT, neck, heart, lung, abdominal, and skin exams.

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