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key HPI wgt loss diet changes, GI sympt (diarrhea/constip/blood in stool, N/V), hyperthyroid (palpitat, tremor, hot), anxiety/depression, body image, cancer history, infxs (ie TB), HIV risk factors, Rx/meds
key diagnosis wgt loss cancer incl colon, hyperthyroid, anxiety/depression/ED, GI, HIV, TB
key w/u wgt loss TFT, stool for malabsorb/heme/infxs, U tox, HIV, TB PPD?
key HPI wgt gain diet changes, smoking cessation, hypothyroid (fatigue, constipation, cold intolerance), menstrual irregul, anxiety/depression, Rx/meds (esp steroids)
key diagnosis wgt gain smoking cessation, hypothyr, Cushing, PCOS, DM, atypical depression
key w/u wgt gain TFT, 24hr free cortisol and dexameth suppression test
key HPI dysphagia solids v liquids, wgt loss (cancer), odynophagia, GERD sympt, HIV risk factors, h/o smoking & EtOH (cancer), h/o autoimmune/Reynauds, h/o swallowing pills or caustics
key diagnosis dysphagia scleroderma/CREST, esophageal cancer, achalasia (solids & liquids both), esophagitis (*incl GERD), motor problem (ie ALS), Plummer Vinson (c anemia), esophageal stricture (incl swallowing caustics)
key w/u dysphagia Ba swallow, EGD w biopsy, mannometry, labs for CREST/scleroderma, infxs/HIV
key HPI N/V diarrhea/flu sympt/F, sick contacts, HA/stiff neck/neuro sympt, CP (MI), food poison, ?pregnancy
key diagnosis N/V infxs incl gastroenteritis, incrsd ICP/meningitis, MI, food poison, pregnancy
key w/u N/V UPT, **fundo exam, infxs w/u
key HPI CP pain: radiation, positional, deep breathing, mvmt/palpation (musculoskel), +N/V/diaphoresis, +SOB (PE), relation exercise and eating/lying down (GERD), risk factors for PE (immobil, on plane, coagulo), recent URI (PNA, pericarditis)
key diagnosis CP MI/angina, pericarditis (incl recent URI), costochondritis, PE, GERD, PNA
key w/u CP CXR, ECG, Tn, CK-MB, Echo (pericarditis, asc ao), stress test, CT chest or V/Q and D-dimer (PE), EGD/pH monitor (GERD)
key HPI palpitations caffeine, anxiety (panic attack), w exertion, lightheadedness/syncope, CP, SOB, sweating (ie hypogly),hyperthyroid sympt (hot, trbl sleeping, hand shaking), anemia/bleeding, h/o heart disease
key diagnoses palpitations hypogly, hyperthyroid, anemia, arrhythmia, MI
key w/u palpitations TFT, CBC, EKG/Holter, BMP and glu, Urine metanephrine or VMA (pheo)
key HPI abd pain N/V/diarrhea/obstruction, food poison, relationship to eating, GERD sympt, urinary sympt/hematuria, clay colored stool/dark urine,respir sympt (PNA), CP, pelvic sympt/LMS, cancer (wgt loss), NSAID/ASA use (gastric ulcers), h/o abd surgeries (adhesions)
key diagnosis abd pain gastroenteritis, food poison, kidney stone/UTI/pyelonephritis, GERD/PUD/gastritis, gallstones/pancreatitis, appendicitis, hepatitis, PNA, MI, gynecol (endometriosis, PID, STD), cancer
key w/u abd pain RUQ U/S, amylase/lipase, UA/Ucx, XR/IVP/CT for renal stones, CXR (PNA), MI w/u, pH monitor
key HPI constipation/diarrhea blood? relationship to food (ie celiac, lactose intol, food poison), fiber in diet, relationship to stress (IBS), wgt loss (cancer), infxs (F, travel, camping, sick contacts), systemic (jts, ulcers ie Crohns), thyroid sympt
key diagnoses constipation/diarrhea thyroid, colon cancer, diverticulitis/diverticulosis, IBS, Celiac/Lactose intolerance, ulcerative colits/Crohns, gastroenteritis, endometriosis, hepA if traveled to Mexico
key w/u constipation/diarrhea colonoscopy, CEA for colon cancer, Ba enema if diverticulosis, CT w contrast diverticulitis, infxs w/u stool, stool malabsorbption, TFTs, H breath test for lactose intolerance, urinary 5HIAA for carcinoid, hep panel
key HPI upper GI bleeding EtOH/wretching, PUD/GERD/gastritis, NSAID/ASA, liver dz, nosebleed, anticoag
key diagnoses upper GI bleeding PUD, Mallory Weiss, varices, nosebleed
key w/u upper GI bleeding EGD, coag tests, LFT/hep, CBC (anemia)
key HPI hematochezia constipation/diarrhea, infxs, wgt loss, h/o diverticulosis, h/o PUD, PVD/CAD, pain, blood on tissue paper (hemorrhoids=pain OR bldg; anal fissure=pain+bldg and blood outside stool)
key diagnoses hematochezia infxs, diverticulosis, colon cancer, IBD (esp ulcerative colitis)/IBS, mesenteric ischaemia, anal fissue, hemorrhoids, angiodysplasia; also upper GI bldg
key w/u hematochezia CBC, CEA for colon cancer, coag
key HPI hematuria abd pain radiating twd groin, frequency/urgency/dysuria, recent infxn (glomeruloneph), edema (incl periorbital in morning), clots, vigorous exercise, smoking/working w dyes (RF for bladder cancer), FMH polycystic kid dz
key diagnoses hematuria kidney stones, glomerulonephritis (nephrotic/nephritic), UTI, bladder cancer, polycystic kid dz, coag disorder, ?STD
key w/u hematuria UA, Ucx, KUB/CT/IVP for kidney stones, Urine protein, BUN/Cr, chol/hypoalbumin (nephrotic), coags
key HPI urinary sympt urgency/freq/decrsd stream/dribbling, dysuria, bone/back pain, wgt loss, neural (loss sensation, wknss), discharge (STD)
key diagnoses urinary sympt neurogenic (DM neuropathy), BPH, prostate cancer (esp wgt loss or bone pain),
key w/u urinary sympt transrectal prostate U/S, prostate bx, PSA, UA/Ucx, (STD w/u: GMS and cx of discharge, PCR G/C)
key HPI erectile dysfxn stress/depression, nocturnal erections, DM, incontinence, Meds (esp anti HTN like BB, spironolactone, methyldopa), HTN, PVD
key diagnoses erectile dysfxn psychogenic, neurogenic, atherogenic, Rx SE, HTN, low testosterone
key w/u erectile dysfxn testosterone, HbA1C/glu, UA
key HPI amenorrhea h/o irreg menses, wgt changes, possible preg (contraception), s/s thyroid dz, menopause (hot flashes, vaginal dryness), galactorrhea, pituitary adenoma/prolactinoma (vision loss, HA), Rx (antipsych), difficult delivery (Sheehan), D&C (Asherman synd)
key diagnoses amenorrhea preg, thyroid, PCOS, anorexia, prolactinoma, Sheehans (infarct pituitary), premature ovarian failure, Asherman syndrome (scarring of endometrium s/p D&C), anxiety/stress
key w/u amenorrhea UPT, FSH, LH, TSH, testosteone/DHEAS, prolactin/CT or MRI brain, pelvic U/S (for PCOS)…progesterone challenge (wdrwl bleeding=anovulation, no wdrwl=inadeqaute estrogen)
key HPI HA unilat/bilat, photophobia/phonophobia, N/V, neuro sympt (visual changes, wknss, sensory loss, incontinence, memory), morning v end of day, stress, head trauma, sinusitis, F and neck stiffness, exposures for meningitis
key diagnoses HA migraine, tension HA, cluster HA, tumor, temporal arteritis, trigeminnal neuralgia, partial sz, pseudotumor cerebri, meningitis
key w/u HA temporal artery bx, EEG, LP w opening P, ESR, CT/MRI brain (tumor, bleed)
key HPI confusion/memory thyroid sympt, meds, depression, daily tasks (apraxia), incontinence, tremor, CAD/PVD (multi infarct dementia), STD/syph, falls/trauma
key diagnoses confusion/memory hypothyroid, low glu, high Ca++, depression, multi infract dementia, Alz D, Picks dz, CJD, neurosyph, nml P hydroceph (incontinence), diet (B12), chronic subdural
key w/u confusion/memory B12, TFTs, VDRL/RPR, CT/MRI brain, glu (hypogly), LP w opening pressure, EEG (CJD)
key HPI depression recent life stress, change in sleep and appetite, social fxn, suicide ideation, hypothyroid symptoms, EtOH/Rx use, meds
key diagnoses depression normal bereavement, major depression, dysthmic d/o, bipolar, sustance/Meds induced, hypothyroid
key w/u depression Utox, TSH, B12
key HPI dizzy lighthead v vertigo, hearing loss, duration, positional, N/V/diarrhea (dehydration/orthostatic), meds (clonidine, anti HTN), recent viral (labyrinthitis/vestibulitis), neuro findings (ataxia, visual changes, sensory/wknss), LOC head trauma
key diagnoses dizzy Menieres, BPPV, labyrinthitis/vestibulitis, orthostatic hypotension (dehydration, Rx), CN8/Cb tumor
key w/u dizzy Dix-Hallpike, audiogram to test hearing, orthostatic VS, MRI/CT brain
key HPI LOC preceding sympt (lightheaded, N, sweating, pallor, palpitations), context (standing, emotional), dehydration, incontinence
key diagnoses LOC hypogly, vasovagal, arrhythmia, dehydration/orthostatic hypotension, seizure
key w/u LOC glu, EEG, EKG/Holter, orthostatic VS, Utox?
key HPI numb/wknss distribution, onset/progression, other neuro signs, HA, pain, DM poorly controlled/other cxns, recent infxns, rash (dermatomyo), diet/EtOH, thyroid sympt
key diagnoses numb/wknss radiculopathy, DM/B12/EtOH peripheral neuropathy, stroke/TIA, G-B, MS, MG, polyomyositis/dermomyositis, thyroid dz
key w/u numb/wknss LP CSF (G-B and MS), MG: tensilon test, ACh R Abs, visual evoked potls, CT chest (thymoma), EMG/NCV, B12, carotid US/Echo/MRI brain (stroke/TIA), ESR/CK (polymyositis), TFTs
key HPI fatigue/sleepy snoring, hypothyroid sympt (wgt gain, cold intol, hair/nail changes), mscl wknss, joint pain, wgt loss (cancer), depression, DM/DI (drinking a lot)
key diagnoses fatigue/sleepy depression, OSA, hypothyroid, rheum, cancer, anemia
key w/u fatigue/sleepy sleep study, TFT, occult blood, CBC (anemia), lytes (incl Ca++)
key HPI sore throat sick contacts, cough, HIV RF, dysphagia, rash (esp after ampicilin)
key diagnoses sore throat mono, strep throat, viral, HIV,
key w/u sore throat throat swab w Monospot and Strep test, HIV,
key HPI SOB positional, s/p eating or at night, productive cough, triggers (allergies, exercise), ACEI, smoking, URI, NS, wgt loss, edema (CHF)
key diagnoses SOB asthma, GERD, URI/PNA, lung cancer, COPD/chronic bronchitis, TB, CHF
key w/u SOB CXR, PFTs w methacholine test, pH monitor, CT chest, TB
key HPI vaginal bleeding constipation, dyspareunia, hirsutism/wgt, possible preg, bw regular cycles (polyps, fibroids), heavy reg periods=fibroids, heavy periods since start=vWD, irreg=dysfxnl uterine bldg; s/p menopause think endometrial or cervical cancer--esp postcoital bldg
key diagnoses vaginal bleeding PCOS, anovulation, ectopic preg/spont abortion, fibroids, dysfxnl uterine bldg
key w/u vaginal bleeding UPT, TFT, FSH, LH, prolactin, PT/PTT, endomet bx, progesterone challenge (anovulation, pelvic US
key w/u vaginal discharge wet mount, G/C PCR, KOH prep, pH of fluid, cervical cx (+ pelvic exam)
key HPI joint/limbl pain small v large, swelling/pain, wknss/neuro/sensation, constitut sympt (F, wgt, URI/GI (Reiters), rash (dermatomyo, infxs), genital ulcers (Behcet), thyroid (wknss), throat (rheum F)), DVT RFs, depression/trbl sleep (fibromyalgia), typing (carpal tunnel)
key diagnoses joint/limbl pain RA, OA, SLE, Behcets, dermatomyo/polymyo, Reiters/IBD, infxs (parvo, rubella, Lyme, HepB), polymyalgia rheum, DVT, radiculopathy, fibromyalgia, domestic violence, carpal tunnel, gout/ps gout/septic joint, rheum F
key w/u joint/limb pain XR, MRI, CK, ESR, Rheum F, ANA, anti dsDNA and Smith (SLE), anti His (Rx Lupus) and other serology, tap joint, if DVT do LE U/S
key HPI LBP radiation, sensory changes, wknss, impotence, incontinence, improve w rest, sitting v standing v leg raise, BPH sympt/prostate cancer, osteoporosis
key diagnoses LBP radiculopathy, spinal stenosis, PVD/Leriche, met (ie prostate cancer), spinal fx (osteoporosis), slipped disk
key w/u LBP MRI, U/S for ABI, transurethra prostate U/S
key HPI child w fever lethargy, feeding, GI sympt, URI sympt, pulling at ear, HA/stiff neck, behavioral changes (meningitis), rash, exposures (sick contacts, travel, bugs), immuniz status
key diagnoses child w fever neonatal sepsis, otitis, URI, gastroenteritis, meningitis, viral exanthem, UTI
key w/u child w fever LP esp if <6mo, pneumatic otoscopy, sepsis w/u, throat swab, stool
key HPI child behavior changes changes at home/school, being alone or new grp of friends, drop in school performance, social/language development, behavior in mltpl settings
key diagnoses child behavior changes hearing/vision problems, autism, ADHD, oppositional or conduct disorder, adjustment disorder (recent changes), drug abuse, depression
Created by: ehstephns



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