limitation, weakness, numbness or tingling, fever, chills, trauma (mechanism of injury), occupation activities, sports, repetitive movements frequency: intermittent vs. constant, have you ever had this pain before? palliative factors: is there anything that makes it better? (rest, activity, meds, heat, cold) provocative factors: is there anything that makes it worse? (rest, activity, etc.) pain history checklist socrates: site onset character radiation alleviating factors/ associated symptoms timing (duration, frequency) exacerbating factors severity alternatively, signs and symptoms with the 's' plotradio past history location onset/offset type/character (of pain) radiation aggravating/alleviating factors duration intensity other associated symptoms abdominal swelling causes 9 f's: fat feces fluid flatus fetus full-sized tumors full bladder fibroids false pregnancy head trauma: rapid neuro exam 12 p's psychological (mental) status pupils: size, symmetry, reaction paired ocular movements papilloedema pressure (bp, increased icp) pulse and rate paralysis, paresis pyramidal signs pin prick sensory response pee (incontinent) patellar reflex ptosis ocular bobbing vs. dipping "breakfast is fast, dinner is slow, both go down": bobbing is fast dipping is slow in both, the initial movement is down. pupillary dilation (persistent): causes 3am: 3rd nerve palsy anti-muscarinic eye drops (e.g. to facilitate fundoscopy) myotonic pupil clinical examination: initial inspection of patient from end of bed abc: appearance (sob, pain, etc.) behaviour connections (drips, inhalers, etc. connected to patient) differential diagnosis checklist "a vitamin c" acquired vascular inflammatory (infectious and non-infectious) trauma/ toxins autoimmune metabolic idiopathic neoplastic congenital primitive reflexes "absent reflexes should get paediatrics professors mad" absent: asymmetrical tonic neck reflex reflexes: rooting reflex should: suck reflex get: grasp reflex paediatrics: placing reflex professors: parachute reflex mad: moro reflex family history (fh) bald chasm: blood pressure (high) arthritis lung disease diabetes cancer heart disease alcoholism stroke mental health disorders (depression, etc.) four point physical assessment of a disease "i'm a people person" inspection auscultation percussion palpation medical history: disease checklist mj threads: myocardial infarction jaundice tuberculosis hypertension rheumatic fever/ rheumatoid arthritis epilepsy asthma diabetes strokes past medical history (pmh) vamp this: vices (tobacco, alcohol, other drugs, sexual risks) allergies medications preexisting medical conditions trauma history of hospitalizations immunizations surgeries smash fm: social history medical history allergies surgical history hospitalizations family history medications patient examination organization soap: subjective: what the patient says. objective: what the examiner observes. assessment: what the examiner thinks is going on. plan: what they intend to do about it patient profile (pp) ladders: living situation/ lifestyle anxiety depression daily activities (describe a typical day) environmental risks / exposure relationships support system / stress physical exam for 'lumps and bumps' "6 students and 3 teachers go for campfire": site, size, shape, surface, skin, scar tenderness, temperature, transillumination consistency attachment mobility pulsation fluctuation irreducibility regional lymph nodes edge short stature causes retard height: rickets endocrine (cretinism, hypopituitarism, cushing's) turner syndrome achondroplasia respiratory(suppurative lung disease) down syndrome hereditary environmental (postirradiation, postinfectious) iugr gi (malabsorption) heart (congenital heart disease) tilted backbone (scoliosis) sign vs. symptom s&s: sign: i (the examiner) can detect attributes/reactions without patient description symptom: patient only can sense attributes/feelings social history fed tacos: food exercise drugs tobacco alcohol caffeine occupation sexual activity surgical sieve for diagnostic categories investigations: iatrogenic neoplastic vascular endocrine structural / mechanical traumatic inflammatory genetic / congenital autoimmune toxic infective old age / degenerative nutritional spontaneous / idiopathic surgical sieve for diagnostic categories (alternate) past midnight: psychological autoimmune spontaneous/idiopathic toxic metabolic inflammatory degenerative neoplastic infection genetic hematological traumatic vitamin cdef: vascular infective/inflammatory traumatic autoimmune metabolic iatrogenic/idiopathic neoplastic congenital degenerative/developmental endocrine/environmental functional breast history checklist lmnop: lump mammary changes nipple changes other symptoms patient risk factors delivering bad news spikes: setting up perception invitation knowledge emotions strategy and summary nephrology dialysis: acute indications aeiou acidosis (refractory to treatment) electrolyte abnormalities (refractory to treatment, e.g. hyperkalemia) ingestions (e.g. methanol, ethylene glycol, lithium, salicylates) overload (volume overload refractory to iv diuresis) uremia (presenting with pericarditis, bleeding, encephalopathy) neurology chorea: common causes st. vitus's dance: sydenhams vascular increased rbc's (polycythemia) toxins: co, mg, hg uremia sle senile chorea drugs apla syndrome neurodegenerative conditions: hd, neuroacanthocytosis, drpla conception related: pregnancy, ocp's endocrine: hyperthyroidism, hypo-, hyperglycemia congenital myopathy: features dreams: dominantly inherited, mostly reflexes decreased enzymes normal apathetic floppy baby milestones delayed skeletal abnormalities dementia: reversible dementia causes dementia: drugs/depression elderly multi-infarct/medication environmental nutritional toxins ischemia alcohol friedreich ataxia trinucleotide repeat "ataxic gaait" guanine adenine adenine stroke risk factors heads: hypertension/ hyperlipidemia elderly atrial fib diabetes mellitus/ drugs (cocaine) smoking/sex (male) horner syndrome horny pamela: ptosis anhydrosis miosis enophthalmos loss of ciliary-spinal reflex anisocoria cerebellar signs danish: dysdiadochokinesia / dysmetria ataxia nystagmus (horizontal) intention tremor slurred speech hypotonia causes of pinpoint pupils pinpoint pupils are caused by opioids and pontine pathology diagnostic criteria of neurofibromatosis type 1 café spot: café au lait spots axillary + inguinal freckling fibromas eye: lisch nodules sphenoid dysplasia positive family history optic tumour (glioma) features of normal pressure hydrocephalus wet, wobbly, wacky: wet = urinary incontinence wobbly = ataxic gait wacky = dementia pathology main article: list of pathology mnemonics pharmacology gynaecomastia causing drugs some drugs create awesome knockers spironolactone digitalis cimetidine alcohol ketoconazole psychiatry conduct disorder vs. antisocial personality disorder conduct disorder is seen in children. antisocial personality disorder is seen in adults. depression: symptoms and signs (dsm-iv criteria) awesome: affect flat weight change (loss or gain) energy, loss of sad feelings/ suicide thoughts or plans or attempts/ sexual inhibition/ sleep change (loss or excess) / social withdrawal others (guilt, loss of pleasure, hopeless) memory loss emotional blunting depression unhappiness: understandable (such as bereavement, major stresses) neurotic (high anxiety personalities, negative parental upbringing, hypochondriasis) agitation (usually organic causes such as dementia) pseudodementia pain importuniing (whingeing, complaining) nihilistic endogenous secondary (i.e. cancer at the head of the pancreas, bronchogenic cancer) syndromal delirium dimes & 3ps: drugs (or withdrawal) infection (pus = pneumonia, uti, skin) metabolic (e.g. na, ca, tsh) environmental structural pain pee poo i watch death infections – pus, cns withdrawal – alcohol, sedatives, barbiturates acute metabolic changes – ph, hypo/hyper na, ca, acute liver or renal failure trauma – brain injury, subdural hematoma cns – post-ictal, stroke, tumour, brain mets hypoxia – chf, anemia deficiencies – thiamine, niacin, b12 (e.g. chronic g and t alcoholics) endocrinopathies – hypo-/hyper-cortisol, hypoglycemia acute vascular – hypertensive encephalopathy, septic hypotension toxins and drugs – especially anti-cholinergics, opioids, benzodiazepines heavy metals pinch me pain infection nutrition constipation hydration medication electrolytes erikson's developmental stages "the sad tale of erikson motors": the stages in order by age group: mr. trust and mstrust had an auto they were ashamed of. she took the initiative to find the guilty party. she found the industry was inferior. they were making cars with dents and rolling fuses . mr. n.t. macy isolated the problem, general tvt absorbed the cost. in the end, they found the tires were just gritty and the should have used de- spare! mental state examination aseptic: appearance speech emotion (objective/subjective) perceptions thoughts insight cognition mania: cardinal symptoms dig fast: distractibility indiscretion (dsm-iv's "excessive involvement in pleasurable activities") grandiosity flight of ideas activity increase sleep deficit (decreased need for sleep) talkativeness (pressured speech) mania: diagnostic criteria must have 3 of maniac: mouth (pressure of speech)/ moodl activity increased naughty (disinhibition) insomnia attention (distractibility) confidence (grandiose ideas) parasomnias: time of onset sleep terrors and sleepwalking occur during slow-wave sleep (stages 3 & 4).nightmare occurs during rem sleep (and is remembered). psychiatric review of symptoms "depressed patients seem anxious, so call psychiatrists": depression and other mood disorders (major depression, bipolar disorder, dysthymia) personality disorders (primarily borderline personality disorder) substance abuse disorders anxiety disorders (panic disorder with agoraphobia, obsessive-compulsive disorder) somatization disorder, eating disorders (these two disorders are combined because both involve disorders of bodily perception) cognitive disorders (dementia, delirium) psychotic disorders (schizophrenia, delusional disorder and psychosis accompanying depression, substance abuse or dementia) schizophrenia: negative features 4 a's: ambivalence affective incongruence associative loosening autism substance dependence: features (dsm iv) withdraw it: 3 of 7 within 12-month period: withdrawal interest or important activities given up or reduced tolerance harm to physical and psychosocial known but continue to use desire to cut down, control intended time, amount exceeded time spent too much radiology chest radiograph: checklist to examine "pamela found our rotation particularly exciting; very highly commended mainly 'cus she arouses": patient details film details objects (e.g. lines, electrodes) rotation penetration expansion vessels hila costophrenic angles mediastinum cardiothoracic ratio soft tissues and bones air (diaphragm, pneumothorax, subcut. emphysema) chest x-ray interpretation preliminary is abcdef: ap or pa body position confirm name date exposure films for comparison analysis is abcdef: airways (hilar adenopathy or enlargement) breast shadows / bones (rib fractures, lytic bone lesions) cardiac silhoutte (cardiac enlargement) / costophrenic angles (pleural effusions) diaphragm (evidence of free air) / digestive tract edges (apices for fibrosis, pneumothorax, pleural thickening or plaques) / extrathoracic tissues fields (evidence of alveolar filling) / failure (alveolar air space disease with prominent vascularity with or without pleural effusions) chest x-ray: cavitating lesions differential "if you see holes on chest x-ray, they are weird": wegener's granulomatosis (now known as granulomatosis with polyangiitis) embolic (pulmonary, septic) infection (anaerobes, pneumocystis, tb) rheumatoid (necrobiotic nodules) developmental cysts (sequestration) histiocytosis oncological lymphangioleiomyomatosis environmental, occupational sarcoid alternatively: l=left atrial myxoma elbow ossification centers, in sequence critoe: capitellum radial head internal epicondyle trochlea olecranon external epicondyle head ct scan: evaluation checklist "blood can be very bad": blood cistern brain ventricles bone neck sagittal x-ray: examination checklist abcd: anterior: look for swelling bones: examine each bone for fractures cartilage: look for slipped discs dark spots: ensure not abnormally big, or could mean excess blood osteoarthritis: x-ray signs loss: loss of joint space osteopyhtes subcondral sclerosis subchondral cysts t2 vs. t1 mri scan "ww 2" (world war ii): water is white in a t2 scan. conversely, a t1 scan shows fat as being whiter. upper lobe shadowing: causes breasts: beryllium radiation extrinsic allergic alveolitis ankylosing spondylitis sarcoidosis tb siliconiosis respiratory airway assessment lemon look evaluate mallampati occlusion neck mobility pippa position inspection palpation percussion auscultation asthma management asthma adrenergic agonists steroids theophylline hydration masked oxygen anticholinergics copd assessment test (cat) cat items: chest sea to aid memory, think of the chest (or lungs) floating in a sea of yellow sputum, which is commonly seen in copd. cough home-leaving confidence exercise tolerance (uphill/ 1 flight of stairs) sputum (phlegm/ mucus) tightness of chest sleep energy level adl at home croup symptoms 3 s's: stridor subglottic swelling seal-bark cough causes of upper zone pulmonary fibrosis a tea shop abpa tb extrinsic allergic alveolitis ankylosing spondylitis sarcoidosis histiocytosis occupational (silicosis, berylliosis) pneumoconiosis (coal-worker's) features of a life-threatening asthma attack a chest arrhythmia/altered conscious level cyanosis, paco2 normal hypotension, hypoxia (pao2<8kpa, spo2 <92%) exhaustion silent chest threatening pef < 33% best or predicted (in those >5yrs old) pulmonary edema: treatment lmnop: lasix morphine nitro oxygen position/positive pressure ventilation miscellaneous the following may or may not fit properly into one of the above categories. they are being stored in this section either temporarily or permanently. categorize them if needed. cholinergic crisis sludge and the killer b's: salivation lacrimation urination diaphoresis, diarrhea gastrointestinal cramping emesis bradycardia bronchospasm bronchorrhea also known as dumbbells diarrhea urination miosis bradycardia bronchospasm emesis lacrimation loss of muscle strength salivation/sweating cheyne-stokes breathing cheyne-stokes breathing sounds like "chain smokes" drugs causing gynaecomastia: disco digitalis isoniazid spironolactone cimetidine / ketoconazole oestrogen drugs for bradycardia and hypotension isoproterenol dopamine epinephrine atropine sulfate diaphragm innervation c3, 4, 5 keeps the diaphragm alive intubation preparation 7 p's preparation preoxygenation pretreatment paralysis with induction positioning placement of tube postintubation management pentad of ttp fat rn: fever anemia thrombocytopenia renal neuro changes systemic lupus erythematosus: diagnostic symptoms soap brain md serositis oral ulcers arthritis photosensitivity, pulmonary fibrosis blood cells renal, raynaud's ana immunologic (anti-sm, anti-dsdna) neuropsych malar rash discoid rash however, not in order of diagnostic importance.