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MEDICAL STUDENT POCKET GUIDE HISTORY AND PHYSICAL EXAMINATION

ID/PRESENTING COMPLAINT:
Name, Age, Gender, and the patient's primary reason for seeking hospital care (in their own words). Specify duration (or hospital stay number), state of health or important active medical problems. If pertinent, include race, culture, language, occupation, where they're from. include cancer, hypertension, heart disease, diabetes, or illness similar to patient's problem.

SOCIAL HISTORY:
- Cultural Background - Education - Occupation - Living Situation - Stresses - Finances - Hobbies - Religion/Spirituality

HISTORY OF PRESENTING ILLNESS:


Summarise the patient's narrative organised chronologically and by problem if there is more than one main problem. Include all significant information to rule in or out the diseases you are considering (differential diagnosis). Characterise each concern/condition: - Site - Severity - Quality - Time Course - Context Aggrevating/Alleviating Factors - Associated features - Effect on lifestyle - Attribution (what the patient thinks)

FUNCTIONAL STATUS:
Activities of daily living, bathing, ambulating, toileting, eating, dressing, shopping, cooking, transportation, phone, laundry, housekeeping. Ability to manage.

BEHAVIOURS:
- Sexual History, Contraception, STIs, sexual function/dysfunction, menses/menarche/menopause, pregnancies - Tobacco - Alcohol - Illicit Drugs Exercise - Diet - Caffeine - Travel Immunisations - Transfusions - Health Screening - Health maintenance behaviours

DIFFERENTIAL DIAGNOSES:
With pertinent positive and negative ROS for the diagnosis in your differential (think through relevant system).

REVIEW OF SYSTEMS:
General: Fever, sweats, weight, appetite change,
exercise tolerance, energy level

PAST MEDICAL/MEDICATION HISTORY:


Use two columns, in first column list prior diagnoses and surgeries, for each diagnosis include: Date of Onset, Investigations, Complications/Progression, Current Management. In the second column, list medications which relate to conditions, then other medications, over the counter ones, complementary/herbals, supplements, traditional medications. Also note allergies, meds, food, animals, note the specific reaction.

Skin: Rash, Pruritus, Changing Moles, Lumps,


Lesions

ENT: Headache, trauma; Vision, glasses, diplopia,


inflammation, pain; Hearing, tinnitus, vertigo, ear pain; Epistaxis, sinusitis, rhinitis; Dental care, dentures, oral sores, sore throat.

Breast: lumps, discharge, pain, swelling. Respiratory: Dyspnoea, pleuritic pain, cough,
sputum, wheezing, asthma, haemoptysis, snoring, apnoea, TB exposure

CV: Chest pain, angina, dyspnoea on exertion,


paroxysmal nocturnal dyspnoea, orthopnoea, peripheral oedema, known palpitations, claudication, leg cramps, hypertension

FAMILY HISTORY
Medical problems, ages, and causes of death for parents, grandparents, siblings; conditions to ask

GIT: odynophagia, dysphagia, heartburn, nausea,


vomiting, haematemesis, jaundice, abdominal pain, malaena, diarrhoea, constipation, change in bowel habits or stool colour, haemorrhoids.

GU: dysuria, nocturia, haematuria, frequency,


urgency, hesitancy, incontinence, vaginal/urethral discharge, sores, dyspareunia, testicular pain, swelling

Extremities: symmetry, deformity, nodules,


clubbing, perfusion (color, temperature, capillary refill)

Musculoskeletal: joint or back pain, swelling,


stiffness, deformity, muscle aches

Musculoskeletal: Spine, mobility/tenderness, Joints,


Range of movement, effusions, erythema, tenderness, synovial thickening, muscle tenderness

Neuro: dizziness, involuntary movements, syncope,


loss of coordination, weakness, paralysis, memory changes, speech, seizures, parasthesia

Neuro: Cranial nerves, motor, sensory (pos/pain/LT),


reflexes, cerebellar/coordination, speech clarity/rate, gait, tremor

Psych: depression, sadness, sleep disturbance,


appetite, anhedonia, suicidal or homicidal ideation, libido, anxiety, eating disorders, hallucinations, delusions, behavioural changes

Psych: Level of consciousness (Glasgow) orientation,


speech clarity/rate, thought process, affect/mood, emotional congruence, insight, judgement, MMSE

Haem: Anaemia, easy bruising, bleeding, history of


DVT

INVESTIAGATIONS:
Pathology, Radiology, Nuclear Med, ECGs, etc.

Endo: polyuria/dipsia, heat/cold intolerance

EXAMINATION:
General: Habitus, appearance Vitals: BP, RR, TC, SaO2, Weight (BMI) Skin: Colour, rashes, lesions, nails ENT: Scalp, trauma, pupils/reaction, sclera,
conjunctivae, tympanic membranes, dentition, mucosa (nose and oropharynx)

ASSESSMENT AND PLAN


Example: In summary, ______ is a __ year-old male/female, with a past medical history of _[prior diagnoses]_, now presenting with _#_ days/months/years of _[current main symptom/s]_. _[Problem 1]_ has the following _[DDx]_ and this is why _____ is likely/unlikely. List 5 management strategies for each problem.

Neck: Thyroid, rigidity. Carotids (pulses, bruits),


neck veins (JVP, AJR)

Lymph nodes: Size, consistency, mobility,


tenderness, cervical supraclavicular, axillary

Breasts: Appearance, asymmetry, tenderness,


masses, nipple discharge

Pulmonary: Inspection, Symmetry, tracheal


deviation, respiratory pattern, accessory muscle use, Palpation: fremitus; Percussion: dullness; Auscultation: crackles, rubs, wheezes, egophony, vocal fremitus.

CV: Inspection/palpation: apex beat, lifts, heaves,


peripheral pulses; Auscultation: rate, rhythm, S1, S2, murmurs, rub, gallops

Abdo: Inspection: distention, scars, veins, striae;


Auscultation: bowel sounds, bruits; Palpation: tenderness, guarding, rebound, masses, organomegaly, ascites, aneurysm; Percussion: organs, tympany, shifting dullness.

Genital: discharge, hernia, Rectal: tone, masses,


faecal occult blood test; Male: hydrocele, varicosele, testicular mass/tenderness, circumcision, lesions, prostate size, consistency, nodules, tenderness; Female: vulva, perineum, vaginal mucosa, cervix, cervical motion tenderness, uterine size/position, adnexal tenderness/mass

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