Patient: 38 yo Female

CC: Fatigue
Fatigue or sleepiness?
Fatigue:
- Alertness not problem
- Lack of energy
- Poor performance
- Worse with activity
- Sleep doesnt help
Sleep:
- Tendency to fall asleep
- Temporarily aroused by activity
What are the most common causes of fatigue?
What are the most dangerous causes of fatigue?
Vascular, inflammatory, autoimmune:
- Rheum/Autoimmune
o Lyme
o MS
o Hashimotos
Cancer?
- Have you lost weight?
- Appetite
- Family Hx of cancer

Can you describe your fatigue?

Fatigue or Sleepiness?
o A
Physiologic (lifestyle) or
Secondary (underlying clinical
condition?)
Subacute or Acute
Can you describe your fatigue?
When did you first notice it?
Progressive / Acute?
Can you recall if you had any
colds recently? Before the
fatigue?
How has your fatigue affected
your life? (Socially and at work)
Any undue stress in your life right
now?

Can you describe the color in

more detail? (Cloudy, clouts, teacolored?)

Have you noticed any other

changes in your urination?
o Frequency
o Urgency
o Volume
Have you noticed any other
changes recently?

How do you feel right now?

Have you had a cold, had a fever,
or been sick in anyway recently?
Any coughing or bowel
problems?
o How is your appetite?
o Have you lost any weight?
Do you have any other conditions
that I should know about?
Summarize

ROS:
-

PMH:

Have you felt overwhelmingly

tired recently?
Skin symptoms (rashes, dryness,
abnormal bruising, or bleeding?)
Have you ever had any issues
with your hearts, experienced
chest pain or any other
cardiovascular issues?
Sinus symptoms
Abdominal pain?
Issues with balance? Headaches,
sensory or motor abnormalities?
Have you ever had issues with
persistent infections?
Body aches? Swollen joints?
Trouble getting around?
Yellowing of skin or eyes?

Have you had any major illnesses

or hospitalizations?
Autoimmune Diseases?
Have you ever had kidney
stones?

Urinary tract infections?

Are you currently on any

medications?
Supplements, vitamins?
Female
o Menses (abnormal vaginal
bleeding?)
o Endometriosis
Allergies

Family Hx:
-

Do you know of any serious

illnesses in your family?
o History of heart disease
o Cancer? (Prostate, uterine
fibroids? Kidney? Bladder?)
o Kidney disease?
o Autoimmune disease?
o Kidney stones?

Social History:
-

What do you do for a living?

Do you smoke? (How much and

for how long?)
Do you drink? (How often?)
Recreational drugs? (Heroine?)
Are you able to exercise or be
physically active?
Food: Rhubarb, beets,
blackberries?
Have you done any traveling
recently?
Are you sexually active? Use
Protection? Ever had an STD?
Diet? (Well hydrated?)

Physical exam
1)
2)
3)
4)

Wash hands
Check blood pressure (this can be down away from the camera)
Pulse
Inspect the Conjunctiva of each eye (look up, look down) move the patient
towards the base of the examination table facing the camera
5) Inspect the Oral cavity
6) Inspect the Auditory canals and TMs with otoscope
7) Inspect the Nasal cavities
8) Inspect the Sinuses (maxillary and frontal)
9) Palpate all the nodes to the axilla
10)
Palpate the thyroid
11)
Adjust the gown and listen to the lungs, make sure this is done directly
on the skin (anterior, lateral, posterior, deep breaths, go R, L, R, L, R, L)
12)
Reposition the gown and measure the JVP at 30 to 45 degrees, A)
move the bed to the right position and pull out the leg rest, B) cut the light
with the auxiliary light still on C) tell the patient to turn his or her face to the
side, D) check to make sure less than three inches of JVP
13)
Turn lights back on and palpate the carotids one at a time (just
anterior to the SCM)
14)
Auscultate the carotid pulse bilaterally with the bell of the
stethoscope, tell the patient to hold his or her breath each time you check a
carotid
15)
Move the bed all the way down an auscultate the aortic, pulmonic,
tricuspid, and mitral valves, then do the same thing with the bell (listen on
the skin)
16)
PMI (put hand flat against the area under the left breast)
17)
Check the radial, posterior tibial, and dorsalis pedis pulses
18)
Inspect the lower extremity for any edema (look for pitting edema)
19)
Adjust the gown and move the legs to 45 degrees to soften up the
abdomen
20)
Auscultate for bowel sounds (do the house with the front door)
21)
Check for any scars, asymmetry, masses, or protuberances
22)
Palpate superficially the first time, then deeply the second time (look
at the patients face)
23)
Percuss the liver, measure its span (were looking for less than 8 cm)
24)
Palpate the livers edge (breathe in, breath out (out = go), breathe in,
breath out)
25)
Palpate the spleen (same concept, but flip onto right hip and put non
palpating hand on ribs to try to bounce the spleen back and forth on the left
side, pathologic)
26)
Palpate the abdominal aorta (do not measure its width), just to the left
of the umbilicus
27)
Visual ROM- look up, look down, turn your head side to side, all fingers
to thumb and out rapidly, flex and extend wrists, flex and extend elbow, hand
out in front and over head, cross arms behind back and lift
28)
On the bed flex the hip, then extend hip, internally and externally
rotate hip, also flex and extend the about the knee, and dorsi flex and plantar
flex the feet

29)
Inspect the dorsal and palmar surfaces of the hands and check the
foot, toes, and plantar surfaces of the feet
30)
Check the strength of the interosseus muscles then check grip
31)
Flex and extend the wrist, biceps, triceps, chicken wings for deltoids
(push up and down), hip flexors, adductors, abductors, knee flexion and
extension, foot dorsiflexion, plantar flexion, inversion and eversion (gas
pedal, raise toes towards the sky)
32)
Say we will now finish up with the neurologic exam
33)
Whats your name? Where are you? What time is it? What are we
doing right now?
34)
Whats this? A watch. What are these? Bands. What is this? The face
of the watch.
35)
Repeat this after me: no ifs, ands, or buts
36)
Remember a black cat, a red car, and a baseball. Repeat them back
to me. I will ask you at the end of the exam.
37)
Spell world backwards.
38)
Visual field test, visual acuity test, pen light to each eye to check
pupillary response (make sure its consensual) make sure far enough back to
not be an ass and come in from the side to avoid accommodation, check both
eyes on one side to make sure consensual reflex (II)
39)
Turn off the lights (check with ophthalmoscope) look at the eyes for a
red light reflex (dont forget to tell the patient to look at the wall behind you
and focus on one object) (II)
40)
Turn the lights back on and check extra-ocular movements with the
giant H, make sure to tell the patient to focus on the tip of your finger. (III, IV,
VI)
41)
Have the patient raise his or her eyebrows after the extra-ocular
movements (III)
42)
Check facial sensation by prick or soft touch in all three regions on
either side. The tell the patient to bite down and open mouth as wide as
possible (V)
43)
Smile, puff out the cheeks, close the eyes tightly (VI)
44)
Check for hearing in one ear, the other, then together (VIII)
45)
Say ahhhhhh (IX, X)
46)
Shrug your shoulders. Turn your head towards my hand and resist the
movement of my hand. (XI)
47)
Stick out your tongue and move it around (XII)
48)
After the cranial nerves do rapid alternating movements of finger to
nose
49)
Reflex testing: biceps, brachioradialis, triceps, patella, Achilles,
Babinski
50)
(STP VP = sensation, temperature, pain prick, vibration,
proprioception) Do touch vs. prick on all legs and arms as well as the face,
and then check for the temperature. Is this relatively warm or cold or
neutral?
51)
Check for vibration in a big toe on each side then the index finger on
each hand.
52)
Proprioception: your finger is up now, down now, with the eyes closed
check both the thumbs and the big toes. Repeat what is up and what is down
each time you grab an appendage.

53)
Check regular gait by having walk across the room, then have toe and
heel gates tested, check the heel to toe tandem gait, then check Rhomberg
(feet together and check for excessive sway or loss of balance, then do the
same things with the eyes closed)
54)
Touch your toes, come back up to upright position, lean to the left,
lean to the right
55)
I asked you to remember three objects at the start of the neurologic
exam Can you repeat those back to me?