Clinical Patient Encounter section provides High Yield information needed in Medical School and Residency.
Patient Encounter for UMSLE 2 CS and COMLEX 2 PE
Neurologic
Headache
Headache Hx
1. Onset
2. Previous occurrence
3. gradual or sudden
4. describe
5. location
6. come and go or constant
7. Intensity
8. URI s/sx, fever, n/v, confusion, stiff neck, rash, photophobia
Headache PE
1. Skin (Rash)
2. Head
3. CNs
4. Neck (ROM, Kernings/Brudzinski)
5. Respiratory
6. Cardiac
7. Neuro (motor, reflexes, babinski)
Headache DDX
– Migraine (complicated)
– Tension headache
– Cluster headache
– Pseudotumor cerebri
– Trigeminal neuralgia
– CNS vasculitis – Temporal Arteritis
– Subarachnoid hemorrhage (SAH)
– Partial seizure
– Intracranial neoplasm
– Sinusitis
Headaches Work-up
– CBC with diff
– ESR
– CT—head
– MRI—brain/MRA—brain
– Lumbar Puncture (LP)
– XR-sinuses
Headache 2
Headache 2 Hx
1. Onset
2. Gradual/Sudden
3. How often
4. First occurrence (when)
5. Can you tell they are coming on
6. Triggers
7. Describe
8. Location/radiation/intensity
9. Nausea, numb/tingle/weak, depression/anxiety, fever/chills, toothaches, earaches, sinus congestion, trauma
Headache 2 PE
1. Head
2. Sinuses
3. EENT
4. Neck
5. Respiratory
6. Cardiac
7. Neuro (motor, reflexes)
Headaches 3 HX
1. Onset
2. Previous Occurrence
3. How often
4. What doing at onset
5. Sudden or gradual
6. Describe/Duration/Location/Radiation/Intensity
7. Recent cold, migraine hx, n/v, trauma, photo/phonophobia, numb/tingle, vision changes
Headaches 3 PE
1. Head (inspect/palpation)
2. Sinuses
3. Eyes (visual acuity, EOM, pupillary reflexes)
4. Nose
5. Ears
6. Mouth/throat
7. Neck
8. Respiratory
9. Cardiac
10. Neuro (motor, reflexes)
Headache 3 DDX
– Cluster headache*
– Migraine
– Tension headache
– Sinusitis
– Pseudotumor cerebri
– Trigeminal neuralgia
– Intracranial neoplasm
Headache 3 WORK-UP
– CBC with diff, ESR
– CT—head
– MRI—brain
– LP
Forgetfulness
Forgetfulness Hx
1. Onset
2. Progression
3. Example of forgetfulness
4. Affect on daily activities
5. Slurred speech/facial droop
6. Numb/tingle/weak
7. fever/chills, falls, anxiety, depression, sleep, appetite
Forgetfulness PE
1. Neuro (CN, motor, sensation, reflexes, cerebellar)
2. Neck (bruits)
3. Respiratory
4. Cardiac
5. MMS
Lightheadedness
Lightheadedness Hx
1. Onset
2. Previous Occurrence
3. How often
4. What are you doing at onset
5. Sudden or gradual
6. Describe
7. How long does it last
8. Falls
9. Weakness, fatigue, concentration, LOC, heart racing, blurred vision, SOB, change in stools, dark tarry stools
Lightheadedness PE
1. Skin
2. Neck
3. Cardiac
4. Respiratory
5. Abdominal
6. Vascular (peripheral pulses, cap refill)
7. Neuro (motor, sensory, reflexes, cerebellar, babinski, romberg)
8. Rectal
Weakness
Weakness Hx
1. Onset
2. Sudden or gradual
3. Previous Occurrence
4. Describe/How weak
5. Slurred speech/facial droop, numb/tingle, vision changes, palpitations or chest pain, SOB, falls
Weakness PE
1. Neuro (Orientation, CN, Motor, Sensory, Reflex)
2. Neck (Bruits)
3. Cardiac
4. Respiratory
Ears
Hearing Loss
Hearing Loss Hx
1. Onset
2. Previous Occurrence
3. Changes
4. Which ear
5. Example of what cannot be heard
6. Ringing, dizziness, pain, discharge, cold/runny nose/sore throat, fever/chills, trauma
Hearing Loss PE
1. Ear (otoscopic exam, Weber/Rinne)
2. Nose
3. Throat
4. Lymphatics
5. Respiratory
6. Cardiac
Respiratory
Runny Nose
Runny Nose Hx
1. When did it start
2. Previous Occurrence
3. Describe Discharge
4. Itchy, watery eyes; Headache, Nasal congestion, ear pain, fever, sore throat, cough
Runny Nose PE
1. Sinuses
2. Eyes
3. Ears
4. Nose
5. Throat
6. Lymphatics
7. Respiratory
8. Cardiac
Common Cold
Common Cold Hx
1. Onset
2. Sudden or gradual
3. Previous Occurrence
4. Previous Treatment
5. Describe “cold”
6. SOB, fever/chills, headache, sinus congestion/pressure, ear pain, cough, n/v
Common Cold PE
1. Skin (rash)
2. Sinuses (palpate, illuminate)
3. Eyes
4. Ears
5. Nose
6. Throat
7. Lymphatics
8. Respiratory
9. Cardiac
Cold 2
Cold 2 Hx
1. When
2. Progression
3. Previous occurrence
4. How often
5. Previous Dx/Tx
6. Sinus congestion/pressure, headache (location), nasal discharge (color), fever, ear pain, sore throat, postnasal drainage, cough
7. Allergies
Cold 2 PE
1. Sinuses
2. Eyes
3. Ears
4. Nose
5. Throat
6. Lymphatics
7. Respiratory
8. Cardiac
Cough
Cough Hx
1. Onset
2. Previous Occurrence
3. How often
4. What are you doing at onset
5. Describe
6. Productive cough
7. What does it look like
8. Pain/where, intensity
9. SOB, fatigue, wt loss, bone pain, fever, night sweats
Cough PE
1. Throat
2. Neck
3. Lymphatics
4. Respiratory
5. Cardiac
6. Abdominal
Cough 2 Hx
1. Onset
2. Previous occurrence
3. Describe cough/productive/color
4. Affect activity of daily life
5. Runny nose, sore throat, fever/chills, chest pain, wheezing, SOB/DOE, SOB when laying flat, wake up suddenly with SOB
Cough 2 PE
1. Skin (cyanosis)
2. HEENT (throat)
3. Neck (thyroid, bruit, JVD)
4. Cardiac
5. Respiratory
6. Extremities (edema)
Cough 3 Hx
1. Onset
2. Previous Occurrence
3. Sudden or gradual
4. Describe/Productive
5. SOB, fever/chills, chest pain (when), night sweats, SOB lying flat, swelling, wt loss
6. Recent travel
Cough 3 PE
1. HEENT (nasal/buccal mucosa)
2. Lymphatics
3. Respiratory (egophony, bronchophony, whispered pectoriloquy)
4. Cardiac
SOB (Shortness of Breath)
SOB Hx
1. SOB right now
2. When did it start
3. Doing anything at onset
4. Sudden or gradual
5. Previous occurrence
6. How long does it last
7. Affect daily activities
8. Wheezing, cough, sputum, chest pain, fevers/chills
SOB PE
1. Skin (inspection of skin/nails)
2. HEENT (nasal otoscopic exam)
3. Respiratory
4. Cardiac
SOB 2 Hx
1. Onset
2. Doing anything when it started
3. Previous occurrence
4. Describe cough/sputum/color
5. Affect daily activities
6. SOB, chest pain, fever/chills, muscle aches, sore throat
SOB 2 PE
1. HEENT
2. Lymphatics
3. Respiratory (inspect, auscultate, tactile fremitus, percuss, egophony/bronchophony/whispered pectoriloquy)
4. Cardiac
Cardiovascular
Chest Pain
Chest Pain Hx
1. Onset
2. Sudden/gradual
3. How long did it last (this time and in past prn)
4. Previous Occurrence
5. Progression/change
6. Location/Radiation
7. Sweating, n/v, SOB, dyspepsia, cough
Chest Pain PE
1. Neck (JVD, bruit)
2. Cardiac
3. Respiratory
4. Abdominal
Chest Pain 2
Chest Pain 2 Hx
1. Onset
2. What doing
3. Previous occurrence
4. Describe/Location/Radiation/intensity
5. Sudden or gradual
6. Continuous or come and go
7. Lightheadedness, n/v, SOB, abdominal pain, Arm/leg pain, slurred speech/facial droop, numb/tingle/weak
Chest Pain 2 PE
1. Neck (JVD)
2. Cardiac
3. Respiratory
4. Extremities (pulses, pallor)
5. Neuro (CN, strength, sensory)
Palpitations
Palpitations Hx
1. Onset
2. What doing when onset
3. Previous occurrence
4. Sudden or gradual
5. Continuous or come and go
6. How fast is rate
7. Stress/anxiety, nervousness, chest pain, SOB, fever/chills, n/v/d/c, wt change, hungry/thirsty, cause yourself to vomit, heat/cold intolerance, urinary frequency, FDLMP (normal), any change to periods, sexually active
Palpitations PE
1. Skin (hair loss, excoriations of finders)
2. HEENT (dental erosions, exophthalmia)
3. Neck (bruit, thyroid)
4. Cardiac
5. Respiratory
6. Abdominal
Funny Heart Beats Hx
1. Onset
2. Previous Occurrence
3. How often
4. Doing anything at onset
5. Sudden or gradual
6. Describe
7. How long does it last
8. Lightheadedness, dizziness, SOB, Chest Pain, Stress/Anxiety
Funny Heart Beats PE
1. Neck (Bruits, thyroid)
2. Cardiac
3. Respiratory
Leg Pain
Leg Pain Hx
1. When
2. Changed/Progression
3. Previous Occurrence
4. Trauma
5. Where/radiation/intensity
6. Swelling/redness/warmth, numb/tingle, fever/chills, SOB, chest pain
Leg Pain PE
1. Neck (bruit)
2. Cardiac
3. Respiratory
4. Abdomen
5. Extremity (HIPR, pulses, Homans’)
Leg Pain 2
Leg Pain 2 Hx
1. Onset
2. Previous Occurrence
3. How often
4. Doing anything at onset
5. How far can you walk before onset
6. Sudden or Gradual
7. Describe/Location/Radiation/Intensity
8. Leg hair loss, Numb/tingle/weak, chest pain, SOB
Leg Pain 2 PE
1. Neck (bruit)
2. Cardiac
3. Respiratory
4. Abdomen
5. Extremity (inspect, pulses x4)
Lower Leg Pain
Lower Leg Pain Hx
1. When
2. How/What doing at time
3. Previous occurrence
4. Prior Dx/Tx
5. Location/Radiation/Intensity
6. Bruising, swelling, weakness
Lower Leg Pain PE
1. MSK (HIPR)
2. Vascular (peripheral pulses)
3. Neuro (strength, gait)
Endocrine
Excessive Fatigue Hx
1. Onset
2. Changed
3. Describe what is happening
4. Fallen asleep driving
5. Snore, stope breathing, wake yourself up, sleep at night, problems concentrating, depression, anxiety/panic, heartburn
Excessive Fatigue PE
1. HEENT
2. Neck (masses/thyroid)
3. Cardiac
4. Respiratory
5. Abdomen
6. Neuro (orientation, motor, sensory, reflexes)
7. Extremities (inspection/edema)
Gastrointestinal
Abdominal Pain
Abdominal Pain Hx
1. Onset
2. Previous Occurrence
3. Changes
4. Location/Radiation
5. Description of pain
6. Come/go or constant
7. N/V, appetite, diarrhea/constipation, blood/mucus, fever/chills, burning w/ urination, blood in urine
Abdominal Pain PE
1. HEENT (icterus)
2. Respiratory
3. Cardiac
4. Abdominal
5. Rectal
Abdominal Pain 2
Abdominal Pain 2 Hx
1. Onset
2. What doing/When
3. Previous Occurrence
4. Sudden or gradual
5. Continuous or come and go
6. Describe/Location/Radiation/Intensity
7. Heartburn, n/v/d/c, Fever/chills, difficulty breathing, cough
Abdominal Pain 2 PE
1. Eyes (icterus)
2. Respiratory
3. Cardiac
4. Abdomen
5. Rectal
Abdominal Pain 3
Abdominal Pain 3 Hx
1. Onset
2. Previous Occurrence/Dx/Tx
3. When does it happen
4. Describe/Location/Radiation/Intensity
5. Heartburn, n/v/d/c, bloody/dark stools, fever/chills
Abdominal Pain 3 PE
1. HEENT (Eye conjunctiva)
2. Cardiac
3. Respiratory
4. Abdominal (rebound, rigidity, guarding, Murphy)
5. Rectal
Musculoskeletal
Neck Pain
Neck Pain Hx
1. When
2. Previous Occurrence
3. Describe
4. Location/Radiation/intensity
5. Trauma
6. Swelling, redness, bruising, ROM, numb/weak, fever/chills, photophobi
Neck Pain PE
1. Head
2. Neck
3. Lymphatics
4. Respiratory
5. Cardiac
Shoulder Pain
Shoulder Pain Hx
1. When
2. Previous occurrence
3. What doing when onset
4. Gradual/Sudden
5. Description
6. Radiation
7. Duration (come/go or continuous)
8. Fever/chills, other jt pain, weakness, numb/tingle, chest pain, SOB, cough
Shoulder Pain PE
1. Neck
2. Respiratory
3. Cardiac
4. MSK (HIPR, special tests)
5. Vascular
6. Neurologic (motor/sensory/reflexes)
Arm Pain
Arm Pain Hx
1. Onset
2. Doing at time
3. Previous occurrence/when
4. Prior Dx/Tx
5. Describe/location/radiation/intensity
6. Constant or come/go
7. Bruising/redness, swelling, numb/tingle
Arm Pain PE
1. MSK (HIPR, wrist flexion against resistance)
2. Respiratory
3. Cardiac
Arm Pain 2 Hx
1. Onset
2. How/what doing at time
3. Changed
4. Previous occurrence
5. Describe/Location/Radiation/Intensity
6. Bruising/Redness/Swelling, Numb/Tingle/Weak, ROM
Arm Pain 2 PE
1. Neck (ROM, palpation tenderness)
2. Respiratory
3. Cardiac
4. MSK (HIPR, drop arm)
5. Neuro (reflexes)
Wrist Swelling
Wrist swelling Hx
1. When
2. Previous occurrence
3. How often
4. Sudden or gradual
5. What are you doing when it happens
6. Describe
7. Morning stiffness, hands/wrist pain (describe, intensity), other joints, fatigue, depression, wt loss
Wrist swelling PE
1. Eyes
2. Neck
3. Respiratory
4. Cardiac
5. MSK (HIPR)
6. Neuro
Back Pain
Back Pain Hx
1. Onset (what were you doing)
2. When did it happen
3. Where/radiation
4. Describe pain
5. Swelling, bowel/bladder habit change, incontinence, numb/tingle/weak
Back Pain PE
1. Cardiac
2. Respiratory
3. MSK (HIPR, OMM)
4. Neuro (reflexes, strength)
5. Rectal
Back Pain 2
Back Pain 2 Hx
1. Onset
2. What doing at onset
3. Previous Occurrence
4. Sudden or gradual
5. Continuous or come/go
6. Describe/Location/Radiation/Intensity
7. Burning w/ urination, n/v, fever/chills
Back Pain 2 PE
1. Respiratory
2. Cardiac
3. Abdominal (rebound, rigidity, rovsings)
4. CVA tenderness
5. Genital/Rectal
Hump on Back
Hump on back Hx
1. When
2. Previous Occurrence
3. Pain
4. Location/Radiation/intensity
5. Numb/tingle/weak, bowel/bladder problems, SOB, recent growth
Hump on back PE
1. Cardiac
2. Respiratory
3. Skin (cafe au lait, axillary freckling, dimpling)
4. MSK (shoulder heights, forward bend test, leg length)
5. Neuro (motor, sensory, reflexes)
Knee Pain
1. Onset, how
2. When
3. Previous Occurrence
4. Previous dx/tx
5. Describe
6. Location/radiation/intensity
7. Bruising, swelling, ROM, click/lock, numb/tingle
Knee Pain PE
1. MSK (HIPR, special tests)
2. Neuro
3. Vascular
4. Gait
Foot Pain Hx
1. When
2. What were you doing at the time
3. Previous occurrence
4. Previous treatments
5. Where/Description/Intensity
6. Bruising, swelling, numb/tingle
Foot Pain PE
1. MSK (HISP, gait)
2. Neuro (sensory)
3. Vascular (pulses)
Foot Pain 2 Hx
1. Onset
2. Previous Occurrence
3. Previous Dx/Tx
4. Trauma/new activity
5. Describe/Location/Radiation/Intensity
6. Swelling, redness, increased heat, fever/chills, stress
Foot Pain 2 PE
1. MSK (HIPR)
2. Respiratory
3. Cardiac
Reproductive
Amenorrhea
Amenorrhea Hx
1. FDLMP
2. Missed period before
3. Periods changed before
4. Age of first period
5. Regular periods
6. Usual days between periods
7. How long do they last
8. Flow description
9. Sexually active/protection
10. Pregnancy history
11. Breast tenderness/enlargement/discharge, n/v, fatigue/cold intolerance/wt gain, abdominal pain, vision changes
Amenorrhea PE
1. Skin
2. HEENT (facial hair)
3. Neck (thyroid)
4. Respiratory
5. Cardiac
6. Abdomen
7. Genital/breast
Urinary
Dysuria
Dysuria Hx
1. Onset
2. Previous occurrence
3. Changes
4. Describe/Intensity
5. Difficulty start/stop urination, discharge, blood, frequency, nocturia, change in stream, fever/chills, abdominal pain/back pain
Dysuria PE
1. Cardiac
2. Respiratory
3. Abdomen
4. Genital/Rectal
UTI (Urinary Tract Infection)
UTI Hx
1. Onset
2. Previous occurrence
3. How often does it happen
4. Describe
5. Urinary frequency (how often, wake up at night)
6. Burning w/ urination, vaginal discharge, increased thirst/hunger, lightheaded/dizzy, wt change, fatigue, numb/tingle, vision changes
7. Sexual history/partner symptoms
UTI PE
1. Eyes (diabetic retinopathy)
2. Neck (thyromegaly)
3. Cardiac
4. Respiratory
5. Abdominal
6. Vascular (distal pulses)
7. Neuro (sensory, reflexes)
Hematuria
Hematuria Hx
1. Onset
2. Previous Occurrence/When
3. Describe urine
4. Trauma/overexercising, fever/chills, pain, wt change, penile discharge, dysuria, hesitancy, frequency, urgency
Hematuria PE
1. Respiratory
2. Cardiac
3. Abdominal
4. CVA tenderness
5. Genital/Rectal
Nocturia
Nocturia HX
1. Onset
2. Previous Occurrence
3. How many times a night
4. Thirst/hunger, wt change, fever, fatigue, burning w/ urination, pain, urgency, blood, malodor
5. Describe urine (cloudy)
6. vaginal discharge, back pain, sexually active
Nocturia PE
1. Cardiac
2. Respiratory
3. Abdominal
Integumentary
Burn
Burn Hx
1. When
2. Previous Occurrence
3. How did it happen
4. Bleeding, discharge, Pain
Burn PE
1. Skin (inspect, palpation, description)
2. Cardiac
3. Respiratory
Rash
Rash Hx
1. When
2. Previous Occurrence
3. Describe
4. Itch (intensity)
5. Recent illness
6. Fever, nasal discharge, ear pain, fatigue, n/v, cough
7. New exposures (chemicals, environmental, etc)
Rash PE
1. Skin
2. HEENT
3. Lymphatics
4. Respiratory
5. Cardiac
6. Abdominal
Preventative
High Cholesterol
Cholesterol Hx
1. When were you told it was high
2. Ever told before
3. What was the value
4. Chest pain, SOB, DOE
5. How far can you walk/climb stairs
6. Weakness/paresthesia, slurred speech/difficulty swallowing, pain in calves when walking
Cholesterol PE
1. Skin
2. Neck (bruit, thyromegaly)
3. Cardiac
4. Respiratory
5. Abdominal
6. Vascular
7. Extremities (edema)
Fertility Planning
Fertility Planning Hx
1. When do you plan to get pregnant
2. Previous pregnancies
3. FED TACOS
4. Health Insurance
5. Married, how long, how does spouse feel, have you told him
6. PMHx
7. First Menses, regular timing
8. FDLMP
9. Age when first had sex
10. number of partners
11. STIs
12. Last pelvic/breast exam and results
Fertility Planning PE
1. HEENT (PERRLA, thyromegaly)
2. Lymphatics
3. Respiratory
4. Cardiac
5. Abdomen
6. Breast/Genitalia
7. Extremities (pulses, edema, cyanosis)
Hypertension
Hypertension Hx
1. Onset
2. Who told you it was elevated
3. Previous treatment
4. Headaches, palpitations/sweating, weakness/polyuria, claudication, chest pain, DOE, vision changes, stress/anxiety
Hypertension PE
1. Neck (thyromegaly, bruit)
2. Eye (papilledema, hypertensive changes)
3. Cardiac
4. Respiratory
5. Abdominal
6. Vascular (peripheral pulses)
Possible Pregnancy
Possible Pregnancy Hx
1. Why do you think pregnant
2. FDLMP
3. Pregnancy hx
4. Vaginal/Csection, Term, Baby wt/complications
5. Non-term pregnancies
6. Married, plan to have baby
7. How are you feeling about it
8. How does husband feel
9. Breast tenderness/discharge, n/v, frequency of urination, vaginal discharge/lesions, STDs
Possible Pregnancy PE
1. Skin/Integument (Hair)
2. Eyes
3. Mouth (dentition)
4. Respiratory
5. Cardiac
6. Abdomen
7. Extremities (edema)
8. Breast/Genitalia
Quit Smoking Hx
1. When start smoking
2. Tried quitting before/when/how long
3. How did you quit before
4. What made you start smoking again
5. PPD
6. Cough (all the time or come/go), productive/color
7. Chest pain, SOB, activity, wt change, lightheadedness, numb/tingle/weak
Quit Smoking PE
1. HEENT (inspection)
2. Neck (masses/bruits)
3. Cardiac
4. Respiratory
5. Abdominal
6. Vascular (peripheral pulses)
Pediatrics
Baby Spitting Up
Baby spitting up Hx
1. Onset
2. Frequency
3. Any particular time
4. Describe
5. Dribble or shoot out of mouth
6. Wt loss, difficulty breathing, pain, irritability, cough, blue/dusky, spit up blood, constipation/diarrhea, fever
Baby spitting up PE
1. Skin
2. HEENT
3. Cardiac
4. Respiratory
5. Abdominal
USMLE and COMLEX Exams
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