You are seeing Mrs. Rostov, a 61 year old woman, because she feels slow. Take a focused history, and perform a physical exam pertinent to her complaint.

History

• Clarifies patient’s recent symptoms of fatigue
• Onset and duration of symptoms
• Asks about sleep habits
• Cold intolerance
• Dry skin
• Weight gain
• Hair loss
• Abnormal vaginal bleeding
• Muscle cramping
• Exercise intolerance
• Constipation
• Mood changes
• Poor focus
• Smoking and alcohol history
• Personal history of thyroid disorders
• Radiation to Head and Neck
• Family history of thyroid disorders
• Family history of auto-immune disorders (Type I Diabetes, Celiac Disease, Addison’s Disease, Rheumatoid Arthritis)
• Current medications
• Effect on daily activities

Physical Examination

Vitals

• Comments on bradycardia
• Assesses for orthostatic changes in vitals
• States that temperature should be measured, and it may show hypothermia

Inspection

• Comments on hair changes (thin)
• Assesses for skin changes, including dryness, and pretibial myxedema
• Edema (face and lower extremities)
• Comments on nail changes (brittle nails)
• Hair loss
• Assesses swallowing
• Proximal muscle wasting

Thyroid Examination

• Inspects for enlarged thyroid
• Observes thyroid while swallowing
• Palpates both thyroid lobes
• Comments on size, texture, and nodularity
• Palpates anterior cervical nodes for abnormality

Neurological Examination

• Reflexes (may be hyporeflexive)
• Proximal muscle power (may be decreased)

You are seeing Mr. Sampson, a 71 year old man, for the first time in 3 years. He says he hasn’t had his blood pressure checked recently and would like you to assess it today. He wanted to come sooner but says he couldn’t. Please take a focused history.

History

• Inquires about patient’s well being since last visit
• Establishes social context – patient lives alone with son
• Establishes sons’ social context (has recently lost his job, divorced)
• Inquires about independence regarding finance, health, transportation
• Inquires about aggression from son
• Establishes past history of injuries and abusive behavior by son
• Extent of medical attention sought/needed for past injuries
• Inquires if son was verbally abusive
• If son has used weapons to harm patient, or has access to weapons
• Substance abuse by the son and quantity (abuses alcohol weekly)
• Assesses patient’s access to health care/medication
• Asks if patient feels safe at home
• Whether friends/family are aware of the abuse
• Emergency plans to escape in the event of further abuse
• Asks if he has access to financial resources
• Asks if he would like help from a counselor
• Asks if he would like support from community resources
• Asks if he would like legal counseling
• Addresses patient’s concern about loss of independence and lack of power

You are seeing Mr. Le, an 83 year old man, because of recent sleep problems. He says he hasn’t had a full night’s sleep in over a week. He currently lives alone. Please take a focused history.

History

• Onset and duration of insomnia
• Amount of sleep per night
• Quality of sleep
• Activating medications
• Activities before sleep: coffee, alcohol, exercise, smoking
• Disturbances during sleep: night terror, orthopnea, nocturia, restless leg, obstructive sleep apnea
• Smoking and alcohol history
• Thought content during periods of insomnia
• Establishes social context (wife has recently been admitted to hospital for ‘failure to cope’)
• Effect on daily activities
• Day time somnolence
• Inquires about what patient believes the insomnia is due to
• Asks about guilt
• Asks about low mood
• Poor concentration
• Poor appetite
• Psychomotor retardation
• Asks about life stresses, e.g. care-giver stress
• Homicidal/suicidal ideation
• Psychotic symptoms
• Symptoms of anxiety
• Past history of depression
• Past history of psychiatric illness

You are seeing Mrs. Rajwal, a 69 year old woman, who feels concerned about her health. She heard that her sister was recently diagnosed with diabetes and wonders if she is at risk of developing the disease as well. Take a focused history, addressing Mrs. Thompson’s concern.

History

• Addresses patient’s concerns about diabetes
• Establishes patient’s ethnicity
• Polydipsia, polyuria
• Nocturia
• Fatigue
• Blurry Vision
• Parasthesias/numbness in peripheries
• Lower extremity ulceration or infection
• Skin darkening
• Weight history: gain/loss
• Asks about diet history
• Current medications/Allergies
• Personal history of gestational diabetes
• Personal history of myocardial infarction and stroke
• Personal history of renal disease
• Peripheral vascular disease (patient has intermittent claudication)
• Dyslipidemia
• Hypertension
• Smoking history (quantity in pack-years)
• Family history of Type II diabetes mellitus
• Family history of cardiac or cerebrovascular events