OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint or reason for visit.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

Seizures

  • Seizure history
    • Age of onset
    • Frequency
    • Symptom pattern
    • Compliance with medication(s)
    • Precipitating factors
  • Preceding abnormal smells, thought processes, sensations
  • Loss of consciousness
  • Description of seizure if observed
  • Tonic-clonic activity
  • Incontinence of bladder or bowel
  • Post-ictal state
    • Drowsiness
    • Impaired memory
    • Headache
  • N.B. Seizures are often confused with syncope. Features most suggestive of seizures are tongue lacerations, abnormal posturing, and head turning during event.

Loss of Consciousness

  • History of fainting
  • Feeling faint versus “light-headed”
  • Flushing, nausea, warmth or tunnel vision
  • Syncope during exertion
  • Events preceding LOC
  • Description of event if observed
  • Tonic-clonic activity
  • Incontinence of bladder or bowel
  • Prodromal experience
  • Rate of recovery (syncope recovery should be no longer than few minutes)

Vertigo or dizziness

  • Lightheadedness
  • Perception that room is spinning (vertigo)
  • Associated nausea, double vision, difficulty speaking
  • Association with head movement or changes in position
  • New or change to medications
  • Difficulty with gait or balance
  • History of falls

Visual disturbance

  • Episodic or progressive
  • Diplopia (monocular or binocular)
  • Visual field loss
  • Photophobia
  • Eye pain

Headache

Ask about:

  • Onset and frequency
    • Early morning (increased intra-cranial pressure)
    • Changing pattern from acute to chronic headache or progressively severe headaches increase likelihood of tumour, abscess or other mass lesion(s)
  • Location
  • Time between onset and maximum severity
  • Red flags:
    • First or characteristically unlike previous headaches
    • Maximum severity at onset (thunderclap headache)
    • Neck stiffness or meningismus
    • New onset headache in pregnancy or postpartum
    • Age>50
    • Change in mental status, level of consciousness
    • Tender over temporal artery
    • Weight loss, fever, night sweats, fatigue
  • Associated symptoms:
    • Nausea
    • Vomiting
    • Fever
    • Tearing
    • Diaphoresis
    • Visual changes
    • Parasthesias
    • Dizziness
  • Balance disturbances
  • Tinnitus

Specific Types of Headaches

  • Tension headache
    • Occipital or temporal
    • Unilateral or bilateral
    • Non-pulsating criteria
    • Not aggravated by routine criteria
    • No nausea, no vomiting
    • Only one of phonophobia or photophobia
  • Cluster headache
    • Usually unilateral, periorbital
    • Occur daily, usually at night for several weeks
    • Often associated with ipsilateral autonomic symptoms: conjunctiva injection or lacrimation, nasal congestion rhinorrhea, eyelid edema, forehead diaphoresis, miosis or ptosis
    • Lasts 15 minutes to 3 hours
  • Migraine
    • Unilateral (sensitivity: 66%, specificity: 78%)
    • Nausea and/or vomiting (sensitivity: 82%, specificity 96%)
    • Episodes last 4-72 hours
    • Can be with our without aura
    • Aura: flickering of lights, spots or lines (scintillating scotomas-sensitivity 54%, specificity 74%), blurred vision, parasthesias - Completely reversible, lasts <60 minutes
    • Pulsating quality, photophobia, phonophobia
    • Aggravated by routine physical activity
  • Temporal/giant cell arteritis
    • Tenderness over temporal artery
    • Age>50 (99%)
    • Fever (50%)
    • New headache (60%)
    • Jaw claudication (50%)
    • Visual loss or blindness (15-20%)
    • Polymyalgia rheumatica (50%)
    • Fatigue
    • Anorexia
    • Weight loss
    • Nausea and/or vomiting

Weakness, difficulty moving, falls, paralysis

  • Generalized versus localized weakness
  • Sudden v gradual onset
  • Pattern of onset (ex. Distal to proximal)
  • One or both sides of the body affected
  • Worsen with repetitive motion and improve with rest

Abnormal movements, tremors or fasiculations

  • Trembling
  • Body movements that patient seems unable to control
  • Rigidity of movements
  • Difficulty initiating movements
  • Gait abnormalities
  • Action tremor
    • Postural, kinetic, intention
  • Rest tremor

Paraesthesia

  • Loss of sensation/numbness
  • Tingling/“pins and needles”
  • Distorted sensations in response to a stimulus (dysesthesias)
  • Hypesthesia: diminished ability to perceive a simple sensation (pain, temperature, touch, vibration)
  • Anesthesia: complete inability to perceive a simple sensation
  • Hypalgesia: decreased sensitivity to painful stimuli
  • Analgesia: complete insensitivity to painful stimuli
  • Hyperpathia, hypereshesia, allodynia all refer to increased sensitivity to sensory stimuli

Other

  • Use of analgesia
  • Difficulty hearing, tinnitus
  • Loss of taste or smell (anosmia)
  • Difficulty with gait, balance, and coordination
  • Dysphasia or speech impairment
  • Difficulty with sphincter control or sexual function
  • Difficulty with thinking or memory (cognitive or memory impairment)
  • Changes in sleep pattern
  • Depression

Past Medical History (PMHx)

Specifically ask about:

  • Previous episode
  • Headaches
  • Stroke, TIA
  • Cardiovascular disease
  • Seizures
  • Diabetes
  • Head trauma
  • Infectious disease
  • Cancers (Systemic symptoms)
  • Thyroid disease
  • Past surgical history

Family History (FmHx)

Specifically ask about:

  • Cardiovascular disease
  • Stroke, TIA
  • Cancers
  • Movement disorders
  • Diabetes
  • Myopathy

Social History (SocHx)

Specifically ask about:

  • Travel history
  • Exercise
  • Diet
  • Alternative healthcare practices
  • Work routine and occupational exposures

Substance Use History (SubHx)

Specifically ask about:

Medications

Gather complete list, including particularly relevant drugs such as:

  • Anticonvulsants (Valproic acid)
  • Antiparkinsonian drugs (L-dopa)
  • Skeletal muscle relaxants
  • Headache meds (Triptans)
  • Pain meds (GABApentin, opioids)
  • Psychiatric drugs

Allergies

Note allergies and ensure they concord with those listed in the EMR

Immunizations

Note immunization history as described in the immunization history section.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.

References

  1. Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Wolter Kluwer Health; 2009.
  2. Lincoln, Matthew, McSheffrey eds. Essentials of Clinical Examination Handbook. 6th ed. Toronto, ON: University of Toronto Medical Society: 2010.