Medical History Taking
Definition and documentation of the Chief Concern
What are presenting symptom(s) or reason for visit including duration in patient's words using quotes?
Short, fine, inconspicuous, and relatively unpigmented hair
What is Vellus Hair?
Aging vision
What is Presbyopia?
BC>AC
What is conductive hearing loss?
Needle insertion for tension pneumothorax
Where is 2nd intercostal space?
Categories in comprehensive PMH (hint: 10)
What are: Childhood illnesses, Adult illnesses, Surgical, Reproductive Health, Psychiatric/Mental Health, Health maintenance, Allergies & Medications, Family History, Social History?
Solid elevation of the skin >1 cm in diameter that usually extends into the deeper skin layers
What is a nodule?
Vision at which referral to ophthalmologist is warranted
What is 20/40?
Cancer until proven otherwise
What is Virchow's Node (supraclavicular lymphadenopathy)?
Most likely location for aspiration pneumonia
Where is RML and RLL (Right main bronchus is wider, shorter and more vertical)?
Define OLDCARTS
What are the components of HPI:
Onset, Location, Duration, Character, Alleviating/Aggravating Factors, Radiation, Timing, Severity/Setting?
Elements to describe skin lesions and rashes (hint: 8)
What are: number, size, color, shape, texture, primary lesion, location, and configuration?
Rotates eye down and toward the nose
What is superior oblique?
Enlargement of bone and soft tissues due to excess growth hormone
What is Acromegaly?
Four potential causes of unilateral chest lag
What is asbestosis, silicosis or phrenic nerve injury or trauma?
Who & What of Family History
Who are: 1st degree relatives - parents, maternal and paternal grandparents, siblings, children, grandchildren and includes age and health, or age and cause of death?
Bright or ruby red lesions that are typically round, flat or sometimes raised found on the trunk or extremities
What are cherry angiomas?
The 3 cranial nerves that innervate the extraocular muscles
What are the abducens (CN VI), the trochlear (CN IV), and the oculomotor (CN III)?
A lesion of this results in asymmetric protrusion of tongue
What is CN XII = hypoglossal nerve?
2 potential pathologies leading to very loud, lower pitched percussion notes with longer duration
What is pneumothorax or COPD (hyperresonant note)?
5 Ps+
What are: Partners, Practices, Protection from STIs, Past history of STIs, Pregnancy intention & Plus: trauma, violence, sexual satisfaction, sexual health concerns/problems, and support for sexual orientation and gender identity (SOGI)?
Comma or corkscrew hairs on dermoscopy
What is tinea capitis?
Unilateral vision loss associated with headache and jaw claudication/pain
What is Giant Cell Arteritis?
White specks that resemble grains of salt on a red background on buccal mucosa near the first and second molars
What are Koplik Spots (early sign of measles)?
Periods of deep breathing alternating with periods of apnea
What is Cheyne–Stokes Breathing?