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https://t.me/med1917

There are several mnemonic

devices to help remember the

seven attributes of a symptom.

OLDCARTS

Onset

Location

Duration

Character

Aggravating/Associated

Symptoms

Relieving

Timing

Severity

FARCOLDER

Frequency

Associated

Radiation

Character

Onset

Location

Duration

Exacerbating

Relieving

Remember your communication

checklist

• Introduction

• Elicit spectrum of concerns

• Pacing of interview

• Open- vs. closed-ended

question

• Nonverbal facilitation skills

• Patient perspectives

• Impact of illness on patient

• Transitional statements

1 History and Communication

• Setting the stage for an interview

• Creating a shared agenda with patients

• Eliciting a chief concern and other active

problems

• History of Present Illness

• Onset and chronology

• Location and radiation

• Duration and course

• Character and quality/quantity

• Associated symptoms

• Aggravating/Relieving

• Transforming factors

• Severity (1-10 Scale)

• Medical/surgical history

• Medications/allergies/vaccines

• Family history

• Social history

• Tobacco, ethanol, drugs (TED)

• Occupation, diet, exercise, sexuality,

sexual practices

• Other pertinent items (insurance,

family dynamics, psychosocial

stressors, social support, etc.)

• Personalized notes to remember the

individual

https://t.me/med1917

Usually asked in order from

broad to narrow (from

constitutional and skin to

individual systems) and from

head to toe.

2 Review of Systems

• The questions on the review of systems

(ROS) might vary according to individual

style.

• Get your list in your “muscle memory”

and ask it the same way each time to

make sure that nothing is missed with a

complete ROS.

• There are times when your ROS is more

problem focused, but be cautious about

missing pertinent information that you

might not have thought of.

• When doing your write-up or oral

presentation, if an item obtained in the

ROS is pertinent to the HPI, then move it

to that section.

• When putting it all together for your

write-up or oral presentation, move the

information to the pertinent section no

matter when you obtain the information

during your interview.

• You will ﬁnd a sample ROS list on the

following page.

https://t.me/med1917

Orthopnea (dyspnea lying

down)

Constitutional

• Appetite

• Weight gain or loss

• Fever/chills/sweats

• Energy level/fatigue

• Difﬁculty sleeping

Skin

• Rashes

• Lesions

• Change in texture

• Easy bruising or bleeding

HEENT

• Change in vision or blurry vision/itchy

eyes

• Changes in hearing, ringing, or pain in

ears

• Nasal congestion, rhinorrhea

• Epistaxis

• Sinus-type headaches

• Sore throats

• Snoring/witnessed apnea

Cardiac

• Chest pain/pressure

• Palpitations

• Edema

• Dyspnea

• on exertion (DOE)

• at rest

• lying down (orthopnea)

• that wakes you up at night (PND)

Develop your style. Get it

memorized. Use common

sense.

Apnea (stopped breathing)

PND

• Paroxysmal

• Nocturnal

• Dyspnea

Shortness of breath that wakes

patient up at night

HEENT

• Head

• Eyes

• Ears

• Nose

• Throat

https://t.me/med1917

Pulmonary

• SOB

• Cough

• Nonproductive/productive, color,

hemoptysis

• Chest congestion

• Wheezing

Gastrointestinal

• Abdominal pain

• Heartburn

• Nausea/vomiting

• Diarrhea/constipation

• Bright red blood

• Black tarry stools

• Change in bowel habits

Genitourinary (GU)

• Burning/pain

• Urgency

• Frequency

• Nocturia

• Discharge/sores/rashes

Musculoskeletal

• Joint pain

• Swelling

• Muscle aches

Neurologic

• Numbness/tingling

• Muscle strength/weakness

• Balance/vertigo

• Tremors

• Memory issues

• Headaches

• Depression/mood changes

SOB: Dyspnea, or shortness of

breath

Male GU

• Change in urinary stream

• Difﬁculty obtaining/

maintaining erection

Female GU

• Stress urinary incontinence

• Spontaneous urinary

incontinence

• Menstrual history

• Regularity

• Flow

Vertigo: Sensation of

imbalance or spinning

https://t.me/med1917

3 Core Physical Exam

Basic Core Exam

The following core exam is taught because

it represents what most physicians would

perform on all patients, regardless of their

reason for an ambulatory primary care visit.

Always Perform:

• Wash hands

• Vitals signs

• General appearance

• Heart auscultation

• Four places, on skin for two cardiac

cycles

• Lung auscultation

• Posterior lung ﬁelds (six places,

on skin)

• Anterior lung ﬁelds (two places,

on skin)

Low Threshold, Consider Including:

• Basic abdominal exam

• Inspection

• Auscultation (one place)

• Palpation of the abdomen (four

quadrants)

• Extremity

• Distal pulses

• Edema

Modiﬁcations of this core are

based on chief concern and

history. Add additional parts to

the exam as needed in a

hypothesis-driven manner.

Must direct patient to breathe

in and out through mouth once

at beginning and listen to each

place for an entire inspiration

and expiration.

Please note that by convention

the examiner should be

positioned on the patient’s

right side.

https://t.me/med1917

4 HEENT

Nose

Sinuses

Palpate the skin over the maxillary and

frontal sinuses

Ear

Tympanic Membrane

Jaw and Temporomandibular Joint (TMJ)

• Inspect

• Palpate

Mouth, Lips, Teeth, Tongue, and Cheek

• Inspect

• Outer lips

• Inner lips: gums

• Condition of teeth

• Bite line

• Palpate

• Tongue for induration

• Cheek for lesions

• Floor of mouth

Bridge

Tip

Anterior nares

(nostril)

Philtrum

Ala of nose

Vestibule

Helix

Antihelix

Lobule

of auricle

Tragus

Antitragus

Lateral process

of malleus

Posterior

mallear fold

Pars flaccida

mallear fold

Pars tensa

Handle

of malleus

Umbo

Cone of light

Point tip of otoscope away

from septum due to sensitivity

Use an otoscope to

examine:

• Septum

• Turbinates

Remember to look for glossitis

for anemia screening

Remember that the cone of

light points toward the

patient’s nose

Vermillion border: Border

between outer lips and skin

Remember to check the

Stensen duct for masses

Push patient’s cheeks together

to prevent bites when inserting

your ﬁngers into patient’s

mouth

https://t.me/med1917

5 Neck

Pharynx

• Inspect

• Hard palate (pale)

• Soft palate (pink)

• Anterior/posterior pillars

• Uvula

• Tonsils

Thyroid Examination

• Inspect

• Palpate

Cervical Lymph Nodes

• Inspect pharynx

• Tonsils

• Waldeyer ring

Palpate Neck

triangle

Posterior

triangle

1. Preauricular

2. Posterior auricular

3. Occipital

4. Tonsillar

5. Submandibular

6. Submental

7. Superﬁcial cervical

8. Deep cervical chain

9. Posterior cervical

10. Supraclavicular

Palpate Axillary Lymph

Nodes

• Pectoral

• Lateral

• Subscapular

• Infraclavicular

https://t.me/med1917

6 Eyes

External Eye Exam

• Inspect

• Eyelids―SIMPLE

• Cornea for clarity

• PERRLA

• Visual ﬁelds

• Extraocular motions (EOM)

• Visual acuity―Snellen chart

Lacrimal gland

Pupil

Iris

Lacrimal sac

Lateral canthus

Sclera

Limbus

Medial canthus

Punctum

Internal Eye Exam

• Red reﬂex―present/obscured

• Optic disc―atrophy, swelling, cupping,

angiogenesis

• Blood vessels―hemorrhages, artery/

vein occlusion, narrowing, or

microaneurysms

• Ocular fundus

Fovea

centrali

Macula

Vein

Artery

Optic

disc

Physiologi

cup

SIMPLE

• Symmetry

• Inﬂammation

• Masses

• Position

• Lashes

• Edema

PERRLA

• Pupils

• Equal

• Round

• React to

• Light

• Accommodate

Remember to look for

conjunctival pallor for anemia

screening

Remember the right hand rule:

your right hand, your right eye,

and the patient’s right eye;

vice versa for the left

Optic disc should be well

deﬁned and sharp. Disc border

blurred with increased

intracranial pressure

https://t.me/med1917

Anemia Focused Exam

• Overall pallor

• Conjunctival pallor

• Nail beds

• Palms and palmar creases

7 Skin

Skin Lesions Algorithm

Distribution

• Generalized or local

Conﬁguration

• Linear

• Clustered

• Annular (ring)

• Arciform (arclike)

• Dermatomal

Color

• Red, pink, pearly, brown, black,

variegated

Primary Lesions

• Macule, patch, papule, plaque, nodule,

cyst, scale, vesicle, bulla, pustule,

burrowing, telangiectasia, petechia,

ecchymosis

Secondary Lesions

• Crust

• Licheniﬁcation

• Excoriation

• Atrophy

• Fissure

• Erosion

• Ulcer

Epidermis

Dermis

Subcutaneous tissue

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