OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

  • Characterize each of the patient's skin lesions or abnormalities OPQRST/OLD CARTS approach.
    • Location (unilateral, bilateral, upper or lower extremities)
    • Timing (onset, duration, course)
    • Character
    • Severity (scale of 1-10)
    • Radiation
    • Alleviating/aggravating factors including:
      • Pain worse with exertion like walking uphill?
      • How far can the patient walk without pain?
      • What effect does rest have on the pain?
      • Establish a baseline to compare activities preformed in the past
  • Associated symptoms:
    • Fatigue
    • Numbness
    • Changes in skin colour
      • Pallor
      • Hyperpigmentation
    • Temperature of skin
      • Cold
      • Warm
    • Hair loss, i.e. anterior tibial surface
    • Ulcers or gangrenous lesions
      • From trauma?
      • Have they spread over time?
      • Signs of infection
    • Slow or absent wound healing on lower extremities
    • Aching/pain that limits exertion
    • Intermittent claudication
      • Pain with ambulation, relieved with rest
    • Impotence
    • Post-prandial gastrointestinal pain with recent weight loss
      • Ischemia of celiac or superior/inferior mesenteric arteries
    • Chest pain
      • Is it exertional, pleuritic, or positional in nature?
    • Shortness of breath
      • Is it exertional, pleuritic, or positional in nature?

Past Medical History (PMHx)

  • Diabetes
  • Hypertension
    • Cardiovascular disease
    • Congestive Heart Failure
    • Coronary Artery Disease
      • Previous infarcts and dates
  • Stroke
  • Peripheral Vascular Disease
  • Dyslipidemia
  • Virchow's Triad
    • Immobilization (bed rest, long car rides or plane trips)
    • Previous endothelial injury
    • Hypercoagulable states (Factor V Leiden, prothrombin mutations)
  • Pregnancy
  • Cancer

Family History (FHx)

  • Hypercoagulable states
  • Myocardial infarctions and age at which they occurred
  • Cancers
  • First degree relative with abdominal aortic aneurysm (AAA)

Social History (SocHx)

  • Smoking (pack-years), alcohol, illicit drug use
  • Stressors
  • Occupation
  • Work and home environments
  • Diet and exercise
  • Travel history

Medications

Gather complete list, but specifically ask about:

  • Aspirin
  • Anticoagulants
  • Antihypertensives
  • Nitro patch or spray
  • Clopidogrel (Plavix)
  • Beta-Blockers
  • Calcium channel blockers (dihydropuridines and non-dihydropuridines)
  • Digoxin
  • Statins
  • Oral contraceptive pills
  • Hormone replacement therapy

Allergies

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

Substance Use History (SubHx)

Specifically ask about:

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 L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.
  2. Bitar R, Jugovic P, McAdam, L. Fundamental Clinical Situations: A Practical OSCE Study Guide 4th Edition. Toronto, ON, Canada: Elsevier Canada; 2004.
  3. Filate, W, Leung, R, Ng, D, Sinyor, M. Essentials of Clinical Examination Handbook 5th Edition. Toronto, ON, Canada: The Medical Society Faculty of Medicine University of Toronto; 2005.
  4. McGee S. Evidence-Based Physical Diagnosis. Philadelphia, PA: Saunders, 2001.