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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
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| key diagnosis wgt loss | cancer incl colon, hyperthyroid, anxiety/depression/ED, GI, HIV, TB
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| key w/u wgt loss | TFT, stool for malabsorb/heme/infxs, U tox, HIV, TB PPD?
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| key HPI wgt gain | diet changes, smoking cessation, hypothyroid (fatigue, constipation, cold intolerance), menstrual irregul, anxiety/depression, Rx/meds (esp steroids)
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| key diagnosis wgt gain | smoking cessation, hypothyr, Cushing, PCOS, DM, atypical depression
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| key w/u wgt gain | TFT, 24hr free cortisol and dexameth suppression test
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| 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
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| 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)
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| key w/u dysphagia | Ba swallow, EGD w biopsy, mannometry, labs for CREST/scleroderma, infxs/HIV
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| key HPI N/V | diarrhea/flu sympt/F, sick contacts, HA/stiff neck/neuro sympt, CP (MI), food poison, ?pregnancy
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| key diagnosis N/V | infxs incl gastroenteritis, incrsd ICP/meningitis, MI, food poison, pregnancy
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| key w/u N/V | UPT, **fundo exam, infxs w/u
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| 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)
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| key diagnosis CP | MI/angina, pericarditis (incl recent URI), costochondritis, PE, GERD, PNA
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| 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)
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| 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
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| key diagnoses palpitations | hypogly, hyperthyroid, anemia, arrhythmia, MI
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| key w/u palpitations | TFT, CBC, EKG/Holter, BMP and glu, Urine metanephrine or VMA (pheo)
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| 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)
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| 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
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| 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
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| 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
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| key diagnoses constipation/diarrhea | thyroid, colon cancer, diverticulitis/diverticulosis, IBS, Celiac/Lactose intolerance, ulcerative colits/Crohns, gastroenteritis, endometriosis, hepA if traveled to Mexico
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| 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
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| key HPI upper GI bleeding | EtOH/wretching, PUD/GERD/gastritis, NSAID/ASA, liver dz, nosebleed, anticoag
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| key diagnoses upper GI bleeding | PUD, Mallory Weiss, varices, nosebleed
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| key w/u upper GI bleeding | EGD, coag tests, LFT/hep, CBC (anemia)
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| 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)
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| key diagnoses hematochezia | infxs, diverticulosis, colon cancer, IBD (esp ulcerative colitis)/IBS, mesenteric ischaemia, anal fissue, hemorrhoids, angiodysplasia; also upper GI bldg
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| key w/u hematochezia | CBC, CEA for colon cancer, coag
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| 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
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| key diagnoses hematuria | kidney stones, glomerulonephritis (nephrotic/nephritic), UTI, bladder cancer, polycystic kid dz, coag disorder, ?STD
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| key w/u hematuria | UA, Ucx, KUB/CT/IVP for kidney stones, Urine protein, BUN/Cr, chol/hypoalbumin (nephrotic), coags
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| key HPI urinary sympt | urgency/freq/decrsd stream/dribbling, dysuria, bone/back pain, wgt loss, neural (loss sensation, wknss), discharge (STD)
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| key diagnoses urinary sympt | neurogenic (DM neuropathy), BPH, prostate cancer (esp wgt loss or bone pain),
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| 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)
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| key HPI erectile dysfxn | stress/depression, nocturnal erections, DM, incontinence, Meds (esp anti HTN like BB, spironolactone, methyldopa), HTN, PVD
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| key diagnoses erectile dysfxn | psychogenic, neurogenic, atherogenic, Rx SE, HTN, low testosterone
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| key w/u erectile dysfxn | testosterone, HbA1C/glu, UA
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| 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)
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| 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
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| 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)
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| 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
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| key diagnoses HA | migraine, tension HA, cluster HA, tumor, temporal arteritis, trigeminnal neuralgia, partial sz, pseudotumor cerebri, meningitis
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| key w/u HA | temporal artery bx, EEG, LP w opening P, ESR, CT/MRI brain (tumor, bleed)
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| key HPI confusion/memory | thyroid sympt, meds, depression, daily tasks (apraxia), incontinence, tremor, CAD/PVD (multi infarct dementia), STD/syph, falls/trauma
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| 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
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| key w/u confusion/memory | B12, TFTs, VDRL/RPR, CT/MRI brain, glu (hypogly), LP w opening pressure, EEG (CJD)
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| key HPI depression | recent life stress, change in sleep and appetite, social fxn, suicide ideation, hypothyroid symptoms, EtOH/Rx use, meds
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| key diagnoses depression | normal bereavement, major depression, dysthmic d/o, bipolar, sustance/Meds induced, hypothyroid
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| key w/u depression | Utox, TSH, B12
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| 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
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| key diagnoses dizzy | Menieres, BPPV, labyrinthitis/vestibulitis, orthostatic hypotension (dehydration, Rx), CN8/Cb tumor
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| key w/u dizzy | Dix-Hallpike, audiogram to test hearing, orthostatic VS, MRI/CT brain
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| key HPI LOC | preceding sympt (lightheaded, N, sweating, pallor, palpitations), context (standing, emotional), dehydration, incontinence
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| key diagnoses LOC | hypogly, vasovagal, arrhythmia, dehydration/orthostatic hypotension, seizure
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| key w/u LOC | glu, EEG, EKG/Holter, orthostatic VS, Utox?
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| 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
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| key diagnoses numb/wknss | radiculopathy, DM/B12/EtOH peripheral neuropathy, stroke/TIA, G-B, MS, MG, polyomyositis/dermomyositis, thyroid dz
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| 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
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| 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)
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| key diagnoses fatigue/sleepy | depression, OSA, hypothyroid, rheum, cancer, anemia
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| key w/u fatigue/sleepy | sleep study, TFT, occult blood, CBC (anemia), lytes (incl Ca++)
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| key HPI sore throat | sick contacts, cough, HIV RF, dysphagia, rash (esp after ampicilin)
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| key diagnoses sore throat | mono, strep throat, viral, HIV,
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| key w/u sore throat | throat swab w Monospot and Strep test, HIV,
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| key HPI SOB | positional, s/p eating or at night, productive cough, triggers (allergies, exercise), ACEI, smoking, URI, NS, wgt loss, edema (CHF)
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| key diagnoses SOB | asthma, GERD, URI/PNA, lung cancer, COPD/chronic bronchitis, TB, CHF
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| key w/u SOB | CXR, PFTs w methacholine test, pH monitor, CT chest, TB
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| 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
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| key diagnoses vaginal bleeding | PCOS, anovulation, ectopic preg/spont abortion, fibroids, dysfxnl uterine bldg
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| key w/u vaginal bleeding | UPT, TFT, FSH, LH, prolactin, PT/PTT, endomet bx, progesterone challenge (anovulation, pelvic US
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| key w/u vaginal discharge | wet mount, G/C PCR, KOH prep, pH of fluid, cervical cx (+ pelvic exam)
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| 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)
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| 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
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| 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
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| key HPI LBP | radiation, sensory changes, wknss, impotence, incontinence, improve w rest, sitting v standing v leg raise, BPH sympt/prostate cancer, osteoporosis
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| key diagnoses LBP | radiculopathy, spinal stenosis, PVD/Leriche, met (ie prostate cancer), spinal fx (osteoporosis), slipped disk
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| key w/u LBP | MRI, U/S for ABI, transurethra prostate U/S
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| 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
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| key diagnoses child w fever | neonatal sepsis, otitis, URI, gastroenteritis, meningitis, viral exanthem, UTI
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| key w/u child w fever | LP esp if <6mo, pneumatic otoscopy, sepsis w/u, throat swab, stool
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| 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
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| key diagnoses child behavior changes | hearing/vision problems, autism, ADHD, oppositional or conduct disorder, adjustment disorder (recent changes), drug abuse, depression
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Created by:
ehstephns
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