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1|Cardiovascular

45 Y/O male/chest pain for the last 3 days/ ER/ HX


Acute chest pain: 1-3 hours heart attack, unstable angina (NSEMI), aortic dissection, pneumothorax (last for minute to hour, otherwise he will die!) First attack of GERD, diffuse spasm, trauma to chest. 3 days chest pain: o continuous: 1. Heart: Pericarditis 2. Lung: PE (based on size presentation could be different. 3. Chest wall: herpes zoster trauma to chest (musculoskeletal). 4. (Gastric cancer #10 in your list.) o Intermittent

CC OCD PQRSTAA (and is it the first time?) Associated symptoms (with the transition) Cardiac By system or by differential diagnosis ( pulmonary, GI, pericarditis Risk Factors: cardiac (5), pericarditis (renal failure, recent heart attack, recent surgery, recent flu, malignancy, medication (TB),) pulmonary (recent travel, malignancy, CHF, ocp (for women)

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Knock, knock, knock Introduction: As I understand, you are here because you have been having severe chest pain for the last three days, can you tell me more about that from the moment it started? - How did it start? Gradually - What were you doing at that time? I cant remember. - Is it all the time or on and off? Its all the time. - Is it increasing or decreasing? Its increasing. - I can see you are in a lot of pain, bare with me for just a few minutes and then Ill give you some painkiller. - Is this the first time? Yes. - How do you feel it? Stabbing. - Does it shoot anywhere? No. - On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain? - Where you able to sleep last night? No. - It must have been difficult, Im glad you came here; hopefully we can figure out whats going on. - Is there anything that increasing or decreasing it like breathing or leaning forward? Did you try any medications?
- In addition to this, did you notice any other symptoms?

Constitutional symptoms: Any fever, chills, lumps and bumps, loss of


appetite, weight loss, history of cancer?

Cardiac: Any Nausea, vomiting, excessive sweating, loss of consciousness,


dizziness, heart racing?

Lung: Any cough, phlegm, shortness of breath, wheezing, chest tightness,


coughing blood, recent flu like syndrome fever, night sweat?

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GI: Any heart burn, difficulty swallowing, acid taste in your mouth history of
peptic ulcer?

DVT: Any recent trauma, redness and swelling in your legs, pain in calf, recent
travel, prolonged staying in a position? - Now Im going to ask about factors that might put you at risk: (Even though it looks like pericarditis, you still need to go for cardiac risk factors because you dont want to lose anything.) Cardiac: major (high blood sugar, high blood pressure, stress, diet, positive family history) Pericarditis: . -And also pass medical history, family history and social history.

A dream doesnt become a reality through magic; it takes sweat, determination and hard work COLIN POWELL

4|Cardiovascular

45 Y/O male/ chest pain for the last 6 weeks/ ER/ HX/ 5 min

Intermittent chest pain: 1. 2. 3. 4. Cardiac: stable Angina, unstable Angina Pulmonary: __ GI: GERD, DES (diffuse oesophageal spasm Panic attack: (patient can remember exactly how many episodes he had)

KKK -As I understand you are here because you had chest pain for the last 6 weeks. Can you tell me more about it? P: Yes, Ive been having the pain for the last 6 weeks. It increased gradually, Im concerned about it. -I see, what is your concern? P: I started to have it at night. -How about now, do you feel any pain right now? (Whenever patient says Im concerned or worried, you should say I can see you are concerned, what is your concern? Do you need any information? Are you interested in general information, or do you need any specific information?) -How did it start? Gradually. -What were you doing? P: I was playing golf. (Playing golf has two important points. One would be because of the physical activity hes doing; that might cause or aggravate chest pain, and the other would be bending during golf that might cause GERD.) -Is it increasing or decreasing? -Is this the first time you have these symptoms? -From that time until now, is the pain all the time or is it on and off? P: Its on and off. -How often do you have it?

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-How many attacks have you had in the last week? (Frequency), how many in the beginning? -Are these attacks, similar to the earlier ones? -Are they more severe than before? How many blocks can you walk now? How many could you walk then? (What about having meal?) -Can you show me where exactly the pain is? How does it feel like? Squeezing. -Does it shoot anywhere? My jaw. -How about your shoulder, hand, and back? - On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain? -Is it in a particular time of the day? How about night? -Is it related to activities, heavy meals, stress, breathing, cold air, change in position? -Is there anything that increases or decreases your pain?

Constitutional Sx: Any fever, chills, lumps and bumps, loss of appetite,
weight loss, history of cancer?

Cardiac: Any Nausea, vomiting, excessive sweating, loss of consciousness,


dizziness, heart racing?

Lung: Any cough, phlegm, shortness of breath, wheezing, chest tightness,


coughing blood, recent flu like syndrome fever, night sweat?

GI: Any heart burn, difficulty swallowing, acid taste in your mouth history of
peptic ulcer?

CHF symptom: leg swelling, S.O.B, how many pillow do you put under your
head

Panic attack symptoms: excessive fear? sense of losing control, death or


being crazy.

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Risk Factors:
-Because it is the first time I see you, I would like to ask some questions to see if there is any conditions that might explain your symptoms. -Any history of high blood sugar, high blood pressure, high cholesterol, stress, and positive family history for heart disease? -When is it diagnosed? Is it controlled? -Do you smoke? How much and for how long? -Have you ever considered quitting? (You have to be nonjudgmental.) -I would like you to know smoking is harmful to your body, if you would like to, we can arrange a meeting to help you quit. (And also past medical history, family history and social history).

One important key to success is self-confidence.an important key to self-confidence is preparation . ARTHUR ASHE

7|Cardiovascular

42y/o chest pain for the last 6 weeks/HX and counselling/clinic


Introduction -As I understand you are here because you have been having chest pain for the last 6 weeks, during the next few minutes, Ill take history, do some physical exams and hopefully toward the end of our session, well reach our working plan. -During the exam I might take some notes, is that okay with you? Do you have any questions at this start? -When did your pain start? P:It started 6 weeks ago and its improving and Im very concerned. -What is your concern? P: My dad died from heart disease in age 45. -It is a very reasonable concern, Im glad you came here. Hopefully we can figure it out together and deal with it. -How did it start and how long did it last? P:It started suddenly and lasted for a few hours. -Is it increasing or decreasing? P: Its almost the same as the beginning. - From that time until now, is the pain all the time or is it on and off? P: Its on and off. - How long do they last? How about beginning? -How often do you have it? -How does it feel? __ (patient refuse to answer this question) -Does it shoot anywhere? - On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain? P: Sometimes 5, sometimes10.

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-Does it decrease or increase with exercises or changing positions? -How did it affect your life, how did it affect you financially? You can refer the patient to social worker. -Is there anything that makes it better or worse?

Cardiac: Any Nausea, vomiting, excessive sweating, loss of consciousness, dizziness, heart racing? Lung: Any cough, phlegm, shortness of breath, wheezing, chest tightness, coughing blood, recent flu like syndrome fever, night sweat? GI: Any heart burn, difficulty swallowing, acid taste in your mouth history of peptic ulcer? Is there something new? Risk Factors: Cardiac: (5), CHF, GERD (repeated cough, change in voice, tight clothing position, diet triggers; like alcohol, chocolate, fat, obesity pregnancy and strogen. PMH, FHX, SHX.

Counselling:
-I know you are here because you are concerned because of heart disease, this is quite reasonable to be worried about, as I told you. Based on what we have done so far, the chance of having heart disease is low but because of smoking, positive family history, and diet, we still need to rule it out completely by doing some blood work, electrical tracing of your heart. Even -If they are normal, we still cant send you for more confirmatory assessments, such as exercise test to be sure (EST), on the other hand, most likely your pain can be explained by a common condition called GERD. Have you ever heard of it? It stands for: Gastroesphageal Reflux Disease (always in concealing you should give the patient the name of the condition, then simply explain pathophysiology and mechanism of the disease. Then talk about how to treat it and side effects of the treatment, and then mention about alternative option and complication of not treating.) -When you eat food, it goes down through your feeding tube, or food pipe. In the lower part of your oesophagus is stomach which contains acid. There is a valve like structure between these two which prevent going acid up from stomach to oesophagus. In GERD, this acid leaks up and causes pain. What we
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are trying to do is preventing that from happening. It is a common condition that can be treated by modification of the risk factors. -Is it reasonable? Wait control is important; I can refer you to a dietician. You need three meals and three snacks and also try to avoid having meals late before sleep and avoid these specific foods like alcohol, chocolate, avoid tight clothing and .. It is also a good idea to raise the head of your bed about 6 inches (10 cm). Quitting in smoking is also important because you have been having symptoms while sleeping; it is a good idea to start some medication for you (proton pumps inhibitor). You have to take it for one month and we will see how it affects you. There is also some articles and brochures available here.

Open your arms to change, but dont go of your values

DALAI LAMA

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28 Y/O chest pain for the last 6 weeks ER/ HX+ counselling

Differential diagnosis: cardiac, GI, pulmonary, panic attack Introduction As I understand . P:Yes Dr. I have been having chest pain for the last 6 week. OCD, PQRSTAA How did it start? Suddenly What were you doing in that time? nothing How many attack did you have? Three Dose it shoot anywhere? Are they the same or not? How does it feel? Not specific On the scale from 1-10.? 5-7, variable. Any increasing or decreasing factors? Not really P:I am very concerned about that. Im afraid from having another attack

Associated symptom: Cardiac: nausea+, vomiting, sweating+, dizziness+, heart racing+, loss of
consciousness.

Lung: SOB+, cough, whizzing, chest tightness. GI: difficulty swallowing+ (sense of lump in chest), heart burn. Neurologic: shakiness+, numbness, weakness, light headedness+, sense of
losing control or going crazy+. -Do you feel that things around you are not real? -Can you see yourself from outside from the attack? -Sometimes whenever people have similar chest pain may lose control or feel that theyre going crazy or dying. Have you experienced it?

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-Is there anything that brings these attacks? -Are you under stress? What kind of stress? How do you cope with it?

Co-morbidity: GAD, OCD, PTSD, Phobia


-Are you such a person that is worried a lot? -Any fear from being in high places, or certain objects, or animals, or speaking in public (specific phobia)? -Do you have repetitive intrusive thought that you feel you are not able to get rid of them (OCD)? -Have you ever experienced in which personal and emotional safety and wellbeing is in danger? -Any thinking, nightmares, flash backs about that? -At that time, did you have tense period of sever fear for which you lose your control?

MOAPSS: (mood, organic, anxiety, psychosis, selfcare,suicide)


Ask PMH in organic: any long term dis, MVP, hyperthyroidism, drugs like cocaine.

Counselling:
Based on what you have told me, your chest pain is most likely related to a medical condition called panic attack. Its a common condition related to stress.

Explanation: Imagine you are crossing a street and there is a car approaching
you fast. How would you feel? At that time, you would feel afraid and your heart would go fast and your blood pressure would increase and you would be more alert and it is very important because it helps you to deal with a danger situation and this is related to a hormone called Norepinephrine. Sometimes the same reaction might happen without any trigger and obvious risk which is panic attack. More than half of people will improve. We have different treatment options; I can refer you to a psychiatrist

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We have 2 kinds of medications, first we start with benzodiazepine for the first 2 weeks. At the same time, we start other types of medication called SSRIs for 6 months. They are safe but because of some side effects, like abdominal discomfort, nausea dizziness, we increase it gradually. (In some patients improvement of energy might be faster than improvement of mood and it is important for those who have suicidal thought .in this situation they are told to contact their physician) (Beside we need to do PE and some lab test like TSH,.)

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71Y/O female/Abdominal pain for the last 4 weeks


Abdominal pain Related to meal: mesenteric ischemia ,Ischemic colitis, gastric cancer, pancreatic failure(bulky stool, shooting to back),GERD, cholecystitis Introduction As I understand Patient is concern about having stomach cancer because his wife has died from stomach cancer. When was that? How do you feel about that? It is good you came here, now we can find what is the cause of your pain. Usually stomach cancer is not similar to flu; we dont get it by infection. Its related to food and the other risk factors but because you have been together for years, you have exposed to the same environment and some underlying risk factors. OCD PQRSTAA(increasing gradually-on and off-dull wage pain-no shooting) Is it related to anything? Any specific time in the day? Any nausea, vomiting pain after meal, change in bowel movement? Did you lose weight? Constitutional symptom

Risk factors:
for ischemic colitis: DM,HTN,FHX of heart disease (what kind? when? Are you under regular follow up? when was your last f/u visit? any intervention? Any treatment? any trigger? (And For peptic ulcer and gastric cancer)

Wrap up: I know you are here because you have concern about abdominal
pain, however cardiac symptoms are concerning for me. I am going to do PE and some blood works and ECG to find any underlying heart disease and also Ill do surgical and cardiac consultation.

Control your own destiny or someone else will.


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JACK WELCH

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45y/o male /leg pain for the last10week/clinic/HX


Intermittent claudication: 1. Neurologic (increase pain when going down hills.) 2. Vascular (related to time, and increase going uphill.) OCD PQRST AA Local symptoms Risk Factors: 1. Cardiac 2. Neurologic, spinal PMH, FH, SH As I understand you are here . -Is the pain in one side or both? -Did you seek any medical attention? -What makes you to choose to come today? My pain started last night. -What were you doing at that time? -How often do you have it? -How long does it last each time? -What does bring the pain up? Is it related to any activities? -How many blocks can you walk? (How many now? What about before?) -What do you do when you have pain? -Do you have pain at rest? How about if you dangled your feet? -Have you ever wake up with this pain? (Alarming) PQRST AA -How does it feel? Crabs. -Do you have pain in your toes, foot, thigh, buttocks? (Lerish syndromeid )

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-Did you notice you have you have more pain when you walk uphill or downhill? Does it make any difference? -Is it related to time or related to the way you seat? Local symptoms: In addition to your pain, do you have any numbness, tingling, weakness, burning sensation? -Any color change, ulcer, hair loss, thickening of your nails, coldness? Back pain, back trauma Constitutional symptoms: ... Risk Factors: DM, HTN, high cholesterol, heart disease, smoking, medication (b-blocker), HX of peripheral vascular disease

-Sometimes some patients who have this pain, might note change in sexual desire or any difficulty with erection. What about you? (If you have still time, check symptoms of heart and mesenteric ischemia) -How did it affect your life? -Im glad you came here today, we will do further steps to be sure.(ultrasound) Ill give you a medical note for your work to modify your job.

In order for you to succeed, your desire for success should be greater Than your fear of failure. BILL COSBY

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67 Y/O/fall 20 minutes ago/ER/10 min/HX & concealing

Introduction Every time the patient had loss of consciousness you plan for event. Event (fall): - Before -During - After

Causes:

Medication (poly pharmacy) Recent hypovolemia (decrease in take, recent bleeding, vomiting Diarrhea

PMH, FHx, Social history

4 setting in which you ask the patient how do you feel right now? 1) After the fall (did you hurt yourself? Does it still hurt? Im going to take a look after I finish my interview.) 2) The patient who couldnt pass urine (Bear with me just for a few minutes, I will bring a surgeon to put a catheter for you.) 3) Hypoglycaemia and Arrhythmia (you are fine, Im looking after you) 4) The patient who attempt suicide.

-As I understand, you are here because you had fell 20 minutes ago. Before I proceed, Id like to ask you about how you feel right now. -Did you hurt yourself? -Can you tell me more about what happened?

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-Did you lose your consciousness? Yes, I was having a nap, when I woke up, I fell down on the floor. -Where you alone? No, I was with my wife. -Did she accompany you? -Did she describe what happened to you? -If you dont mind, after we finish, Im going to clarify some point. -Before you fell down, did you feel any dizziness or light-headedness? Any sense of spinning things around you? -Did you fall down immediately, or were you able to take some steps? -Before you fell down, did you feel hungry, heart racing, shakiness, sweating? (Hypoglycaemia) -Any chest pain or heart racing? (ischemia- arrhythmia) -Any weakness, numbness, difficulty finding words, change or loss of vision? (CVA) -Any flashes, light, strange feeling? (Seizure) -How long were you unconscious? -How did you regain consciousness? On your own or after intervention? (Hypoglycaemia) -While you were unconscious, did your wife mention, if you were shaking or jerking moment? (One part, or all over the body? Did you bite your tongue, rolled up your eyes? Did you hurt yourself? Was there any loss in bladder, or bowel control? Where you breathing? Did you turn blue (seriousness)? After you gained your consciousness did you feel things around you are not familiar? (confusion) -Im going to ask more questions to see what would be the cause of your fall. -Do you take any medication? Do you have the list? Metformin, B- blocker, hydrochlorothiazide, Lipitor, ASA, B Complex, B12, benzodiazepine, Amitriptyline. Ask about them one by one in Q2 exam and any recent change in medication in CE1 exam. Metformin: When did you diagnose by DM?

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How controlled where you? When was the last time you saw your doctor? Do you measure your blood sugar? Are you taking water pills? How long and why? Any new change in dose? Why do you take b-blocker? For how long? Why are you taking ASA? By prescription or on your own? Have you had recent bleeding? You are taking two sleeping pills. Are they per scripted by the same doctor or a different doctor? Any recent change in dose? What about amitriptyline? Are you depressed? How long are you taking it? Do you think about hurting yourself or the others? Patient: I didnt feel so good, so my doctor increased the dose of Amitriptyline. Did you have any diarrhoea bleeding, vomiting, ? Constitutional symptoms, PMH, FHX, social HX. ( PE, was done orthostatic hypotension) Based on what you told me, most likely the reason of your fall is a condition called orthostatic or postural hypotension. Have you ever heard about that? Whenever we change our position from lying to sitting, or sitting to standing, the blood tends to pool in our legs. Usually, our body reacts to it by narrowing blood vessels to maintain blood pressure. Sometimes because of age, medication , diabetes or combination of the body fail to react appropriately so the blood pressure drops and fails to reache to brain. This condition may happen again so whenever you want to change your position, do it slowly or sit on the edge of the bed, also I would like to contact your psychiatrist in order to see if he wants to change the medication or adjust the dosage. Also ECG?

Life just does not hand you things. You have to get out there and make things happen. EMERIL LAGASSE
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Heart racing
Case: male patient 37 years old, having palpitation for the last six weeks. Hx and counselling Consequences of Atrial fibrillation: embolism, sudden death, heart failure Cause: age, coronary arty disease, valvular heart disease, heart failure, hyperthyroidism in old patients, alcohol (holiday heart), lone AF ( only one time in 24 hours), COPD, medication ( digoxin), cocaine, any factor gives tachycardia in right setting ( anaemia, ephedrine, chocolate, coffee, antihistamine, decrease volume, beta agonist), any factor give enlargement of the heart Differential diagnosis: pheochromocytoma, hyperthyroidism, panic attack Ask Sudden death in the family: 1. Hypertrophic cardiomyopathy 2. QT prolongation Once the AF became continuous (48 H) the possibility of clot formation became high so we should ask to screen neurological problems: do you have difficulty finding words? Any weakness, numbness in your body?

KKKKKKKKKKK

Dr: Good afternoon, Mr. Douglas, Im Dr. Miller one of the physician working in the clinic today. As i understand you are here because you have palpitation for the last six weeks, could you tell me more about it? P: it is not improving and Im getting concern about it. Dr: what kind of concern? P: I have never had it before, Im not sure is it serous or not. (Whenever patient uses medical term we should clarify to make sure we are in the same line) Dr: before I proceed Id like to know, when you say palpitation what do you mean?

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(The patient might say my heart skipping beats or going fast, or my heart is bouncing in my chest) P: my heart goes fast Dr: how did it start? P: I started suddenly Dr: what were you doing? How long did it last at that time? From that time till now, is it all the time or on and off? P: in the last 3 weeks it started became continuous and at the beginning it was attacks. Dr: before that how often did you have it? What was the duration of these attacks? What was the duration of the longest attack? Did you have any attack longer than 48 hours? Dr: even during the night? How did it affect your sleep? (Because it is more than 24 hours we empathize with the patient) Dr. Can you tap it for me? Dr: it sounds irregular to me. Dr: is it the first time or did it happen before? P: no, it didnt happen before. Dr: with that did you notice any chest pain, chest tightness, any dizziness, light headedness, or loss of consciousness, sweating, nausea vomiting (cardiac symptoms) (Because it is long and irregular and day and night it is not panic it attack.) Dr: Did you notice anything increase it? Anything decrease it? Anything brings it? Do you believe it related to coffee, chocolate, energy drinks, alcohol? Do you smoke (for extrasystoly) have you ever try recreational drugs (cocaine can cause arrhythmia)? (If the patient says I fell Im dying and it is scary we can say as empathy: sometimes people feel like that with heart racing and I know that it is very scary) Transition: Im going to ask you more questions to see what could be the cause.

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Dr: Do you have history of heart disease? Any history of thyroid disease? If you are in a place that everybody feels fine, do you feel hot? Do you have any weight loss and any shakiness? Do you have moist skin? Anybody told you are pale? Any bleeding recently? Have you ever been diagnosed with romatic fever? (if no) as a child did you have repeated attacks of sore throat? (if no) do you remember injection of penicillin or any antibiotic on regular basis? P: yes, but I had allergy and they stopped it. Dr: any repeated attacks of headache with the heart racing and excessive sweating? (pheo) Dr: any diarrhoea? Flushing? (characinoid) Any family history of sudden death at young age? Do you take medication? Have you ever been seen by a psychiatrics? In the last few weeks did you notice any difficulty finding words, weakness, numbness in your body? Transition: as this is the first time I see you, any long term disease? Any high blood pressure? High blood sugar? Hospitalization. How do you support yourself? Stress? In the Ph.Ex dont forget to tilt for mitral stenosis, use bell. Ph.Ex: general exam, vitals, touch thyroid, cardiac exam, if have time neurological system.

Dizziness:
1. Panic attack 2. In older person deal with it as syncope, is it repeated or one time a. repeated: is it related to cough, urination, or emotional stress, vasovagal b. once: is it related to change in position ( exclude everything related to event), medication, cardiac, neurologic, spinning

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1|Ph.Ex

General Physical Exam lessons:


Cardiovascular exam: Introduction, Vitals, inspection (general and specific), then palpation, then auscultation with 2 accentuating manoeuvres: sitting up and holding breath and in&out, bending forward. Then you go for peripheral related exams like JVP exam, finger nails. Respiratory system: Introduction, Vitals, Inspection, palpation and feeling, tapping or percussion for resonance and dullness, auscultation and special tests (say 99, vocal and tactile fremitus, ego phony and whispered pectoroliqouy) GI system: inspection, AUSCULTATION, percussion, superficial and deep palpation, some special tests like Mcburny and Row sings sign, DRE and pelvic exam. MSK system: Introduction, Vitals, Inspection (SEADS: swelling, erythema, atrophy, deformity, scars), and palpation (TTC: tenderness, temperature, crepitus) Range of movement: active, passive and against resistance. In neck, back and hand do neurovascular. Shoulder mostly mechanical and knee mostly stability. Ankylosing spondylitis mostly mechanical. One joint above one below. Neurologic exam: Introduction, Vitals, Inspection and orientation, Cranial nerves, upper and lower extremities, Coordination and gait and dysdiadocokinesia, end up with cortical sensation. Muscular exam: inspection, bulk, tone, power, reflexes and sensory. 5 feet: 150cm, 6 feet: 180, 5`6: 165, 220:100kg Do SEADS for all joints.

2|Ph.Ex

HAND TREMOR EXAM:


Hello, Good afternoon, Mr. Andros, I am Dr. Miller, one of the physicians working in this clinic today. As I understand you are here, because you have shakiness in your right hand. I have been asked to do a Physical examination, if you had any questions, Please do not hesitate to ask me. If you want to do the V/S at the moment, it is fine, otherwise skip over it. Do not forget to ask about orthostatic hypotension (Parkinson disease). 1. Ask the patient to count from 10 to 1. The tremor did not disappear (even increased) which is consistent with Parkinson and rules out anxiety. 2. There is no fine tremors (rule out hyperthyroidism), 3. No flapping tremor(R/O liver and other internal organ failure). 4. Touch your nose and my finger repeatedly with arm change(R/O intentional tremor in cerebellar diseases). 5. Essential tremor is all the time and disappears with B-blockers or a shot of whisky and is familial. In inspection the patient has tremor in his right hand and right arm and the patient does not have tremor in the left arm and if there is any pill rolling or head nodding, mention it. There is cog wheeling in the right arm and wrist and elbow, there is fine rigidity, I cannot assist any spasticity because the patient is rigid. There is no rigidity, spasticity, cog wheeling on the left side. Now ask the patient to stand up, the patient has difficulty in initiating movement, having stooped posture, festinating gait, ask him to turn in blocks. Pull the patient to the back (in Parkinson they continue to fall down and cannot control themselves). Come and sit: check for mask face, decreased eye blinking and drooling, monotonous speech, articulation (normal or abnormal) micrographia and check for dysdiadokokynesia.
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ACUTE BACK PAIN EXAM:


Hello, good afternoon, Mr. Douglas, I am Dr. Miller, one of the physicians working in this clinic today, As I understand you are here because of the back pain for the last three days, and I have been asked to do a physical exam and ask some questions about it. During my exam if you had any pain or discomfort, or any other concerns to stop, please do not hesitate to inform me. Do you prefer to be lying down or to be standing? How did it start? How was the pain? Standing.

3 days ago I was lifting an object heavier than usual. Stabbing. No. I had to stop.

Were you able to continue?

From that time is it all the time or on and off? Increasing or decreasing? At certain time of the day? Can you point or show me where your pain is? How does it feel? A sharp pain in my back. Yes, to my leg.

Does it shoot to anywhere? Both or one?

No, to the right one.

Which one bothers you more, your back or your leg? How is the severity of the pain if you want to grade it from 1 to 10? 7. That was very difficult I could not even sleep. Did you take any painkiller? Good you are here, hope we would be able to deal with that and help you. Anything that increase your pain? How about lying down, stretching your back, bending or moving? Is it the first time you have such a problem? In addition to your back pain, do you have any numbness, tingling? Any difficulty with your balance, any falls? Difficulty with passing urine or loss of control? Bowel movement? Any numbness in the buttocks? Any fever, night sweat, chills? Loss of appetite? Weight loss? Any trauma to your back? Smoke drink, drugs?
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Long term diseases? Surgery? Burning sensation with urine? How did this affect you? How do you support yourself financially? Now I start the P/E, can you tell me the vitals please? Turn the patient to the way examiner can see. May I untie your gown? Normal cervical and thoracic curvature. No scoliosis, scars, atrophy. Feel your back, normal temperature. I am going to press now. I reach lumbar area, if you have any pain please inform me. Do some movements for me please. Try to bend as much as you can. Can you touch your toe with your fingers? Bend right and left. Can you cross your arms? Walk towards the wall (hold your arms around him in order not to fall). Walk on your heels. He can. And on your toes, he will not be able to do it There is normal L5 and impairment of S1. (Heel#L5, Toe#S1) Please lie down. Do you need my help? I am going to raise your leg, which might cause some pain, please inform me. (SLR test) Then I go to the sensory, I am going to touch different parts of your toes: Little toe: S1, Big toe (first web): L5, middle malleolous: L4, knee: L3, Mid Thigh: L2. Then check the powers. Next step: Just relax. I want to check your reflexes, first the Knee, then the Achilles, you mention but do not do the Babinsky. To examiner: I would like to do DRE. End up with the pulses.

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CHRONIC BACK PAIN:


Hello, Good afternoon, Mr. Anderson, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here due to the back pain since the last six months. I have been asked to do the physical exam. During my exam at any time if you had any pain discomfort or questions, please do not hesitate to ask me, also I will report my findings to the examiner, is that OK with you? Can you tell me the Vitals, please? The patient is sitting comfortably with no signs of distress. Would you please stand up? If I wanted to do the history first or doing the physical exam of the Ankylosing spondylitis, I would have started with my inspection (may I untie your gown?). Do you need my help? From the side NL cervical and thoracic and lumbar curvature, no obvious scoliosis from the back view. No signs of scar, swelling, deformity or oedema, also no obvious muscle contraction. I warm my hands. I am going to feel your back. NL temperature. I am pressing on the spine. Always identify C7 spinous process, then thoracic spine and lumbar area. Feel paravertebral muscles. Since it is chronic back pain, do Sacroiliac joints. Id like you to do some movements for me: 1. Can you touch your toes with your fingers without bending your knees? (Limited flexion) 2. Can you arch your back? Can you bend to the right and left laterals? 3. Can you slide your arm along your side? 4. Can you cross your arms?

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I am going to do a special test called Shobers test: I am going to draw some lines on your back, which are washable: Line 1: at the level of Sacroiliac joint and line: 2, 10 cm above it. Try to touch your toes. The distance of 10 cm should increase to 15 cm or more. Stand in front of the wall and touch the wall with back of your head, shoulders, hips and heels. Then please walk. NL gait is seen. Walk on your toes: NL S1, Walk on your heels: NL L5. I want to look at your eyes; there is no redness, pallor or yellowish discoloration of sclera. Ankle reflex is NL S1. Open your mouth, no ulcers. I am going to take a look at your hands No pitting changes in the nails. No clubbing, no psoriatic changes or skin rash. Would you please lie down? Cover him. Do SLR. Do Patricks test. Listen to his heart for murmur or regurgitation. Then mention digital rectal exam. If time is left, mention power and sensory, too. Do the chest expansion test.

7|Ph.Ex

Neck pain exam (short introduction):


Hello, good afternoon, Mr. Douglas, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here because of the neck pain for the last two weeks, and I have been asked to do a physical exam. During my exam if you had any pain or discomfort, or any other concerns to stop, please do not hesitate to inform me. Taking the vitals. Based on the vitals, the patient is stable and I am going to proceed (report any abnormality in the vitals). (If they dont provide you the vitals you have to do them. If they dont give you even 1 of them you have to ask for it). The patient is sitting comfortable without any signs of distress. Go to the back of the patient. I want to have a look at your neck. May I untie your gown? Normal cervical and thoracic curvature from the side. No scars, or deformity, muscular atrophy or swelling or erythema. Warm the hands. I am going to feel: 1. Temp. Is Nl. 2. Feel the vertebrae, spinous processes till the middle of the thoracic spines? 3. Feel Para vertebral muscles. 4. Feel and exam Trapezius and Sternocleidomastoid muscle. 5. Then feel the mastoid process. 6. Then check for the lymph nodes. I want to feel the back, if you had any pain, please inform me. Cervical spines are not tender. Id like you to do a swallow for me. No enlargement in the thyroid gland. Go to the front. I want you to do some movements for me. Please touch your chest with your chin. Can you look to the ceiling? Can you turn your head to the right? To the left. Any pain?
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Can you touch your shoulder with your ear on the right? How about on the left? Can you cough for me? Any pain? Then valsalva manoeuvre, can you press against my hand? Any pain? Neck pain is not associated with any muscle spasm. Part of my exam is to look at your upper extremities. Please roll up your sleeves. Deltoid, biceps and triceps are normal and symmetrical. Forearm, thenar and hypothenar muscles of NL bulk. Check the tones in Stroke Pt. Start to move the hands. No cog wheeling at the wrist, elbow and there is no lead pipe rigidity. And there is no clasp knife spasticity (there is a click and then relax in stroke like Chaghoo-zaamendaar) (velocity dependent). (Tremor is on top of cog wheeling, but not with lead pipe) Can you touch your shoulders with your hands? (Support his arms with your hands). Do the sensory (peace of cotton and closure of both eyes) and exam the reflexes (biceps and brachioradialis: 5, 6- Triceps: 7, 8) then do the power (if you do biceps, triceps and deltoid its more than enough). I like to stretch your arm on the painful side, and then Turn your head to the opposite side, electric shock shows irritation of the nerve (It is equal to SLR in the legs). Check all the powers in hands, wrists, fingers and forearms and arms. Ask the patient to stand. Can you walk some steps for me? Check the gait. Say that you want to do the clonus. Then check the cranial nerves (just verbalize).

9|Ph.Ex

UNCONSCIOUS PATIENT, STROKE, P/E:


Knock, knock, knock, Do the introduction to Rule out the locked in syndrome also to confirm the unconsciousness of the patient. Hello, Mr. Douglas, Mr. Douglas, I am Dr. Miller one of the physicians working in the ER today. Can you open your eyes? Can you hear me? The Pt. is not responding.

I want to open your eyes and shine the light in your eyes? Report the pupils now (dilated or constricted or round) If you hear me move your eyes up and down. Ask for Vitals: 1. Look for bradycardia and HTN or Cushing triad. 2. Look at the pattern of respiration and report it. 3. Feel the body and pay attention to the temperature. Check the GCS (3-15). In intubated Pt. 10+T If no response then ask for intubation. Check the cranial nerves while unconscious: 1. CN2 with Ophthalmoscopy to see retinal haemorrhage, 2. CN3,4and 6 the eyes are deviated or not and the movement of the eyes and their symmetry. 3. CN2, 3 for papillary reaction, 4. CN5and7 corneal reflex. 5. CN9&10 gag reflex. 6. CN7 with facial expression also drooling and nasolabial folds. Then we go for upper extremity for inspection, check tone and reflexes, then the same for lower extremities report any spasticity or rigidity, dragging of leg is Nl.
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Then do the reflexes and Babinsky. Look at the examiner and ask if neck x-ray is clear Then I have to do meningeal signs: kerning in knee, brudzinsky in the neck and neck stiffness unless in trauma. Are there any brain stem reflexes. Then you have to mention oculocephalic tests and cephalocaloric test (just verbalize it). GCS: not in primary survey. In primary survey ABPU: alert... pain, unresponsiveness Verbal: talking normally: 5, short inappropriate sentences:4, inappropriate words:3, incomprehensible sounds:2, nothing:1. Motor: can you move your arm: 6. Press on sternum and localizing: 5, if withdraw: 4, flexion: 3or decorticate, extension: 2or decerebrate, none: 1.

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CRANIAL NERVE EXAMINATION:


12 pairs of cranial nerves: 1. CN1. (Kallman syndrome) : Just to be done in Quebec exams. Coffee and ammonia (Rule out malingering). 2. Start with the Optic nerve. It has 5 steps. In 2 of them you shine the light inside the eyes for fundoscopy and pupillary reaction. 3 of them the patient looks for visual fields, colour vision and visual acuity. 3. Then go for CN 3, 4 and 6 by extra ocular movements. (Pupillary reaction is 2&3.) 4. Then you go for 5thCN.The CN5 has sensory and motor components. For motor: clench your teeth and corneal reflex. 5. CN7 is mostly motor. 6. The CN8 is hearing, do Rhinne and Weber in Manitoba and Newfoundland exams. 7. The CNs 9th and 10th have 5 steps. 8. The CN11 has 2 steps (sternocleidomastoid and shrugging the shoulders). 9. Stick your tongue in CN12 exam. Knock, knock, knock (short introduction) Hello, good afternoon, Mr. Douglas, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here because of having head ache, and I have been asked to do the cranial nerve exam in the next 5 minutes. During my exam if you had any pain or discomfort, or any other concerns to stop, please do not hesitate to inform me. Taking the vitals I am going to skip over the first cranial nerve.

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I am going to do the 2nd N. Exam: 1. Is it your best vision or you need eye glasses? Cover one eye with one hand and read the chart, middle line then jump down, and vice versa with the other eye do the same. 2. Ask about the colour both sides and in between. 3. Check the visual field. 4. I am going to shine the light into your eyes. Check for direct and indirect (consensual) reflexes (swing test). Afferent is 2, efferent is 3. Both pupils are round, symmetric and reactive to light, not dilated, not constricted. 5. I want to do fundoscopic exam. Why? I am looking for disc oedema and 2-3 signs of HTN (flame shape hemorrhage, AV nicking, exudates, cupper wire) and 2-3 signs of D.M. (hard exudates and neovascularisation). I am going to exam 3rd, 4th and 6th N.: (Corneal reflex is 5&7). 1. By Inspection both eyes are symmetrical, no deviation, no nystagmus, no head tilting, no ptosis. (Head tilting in cases of 4th N. palsy that the patient wants to put his gaze at the same level, so adjust their head to see straight, like Alexander who had syphilis neuropathy and head tilting)(Ptosis is for 3rd. N.). 2. Look at the tip of this pen and follow it with your eyes. At any time you had double vision, inform me, please. (H shape) Now we go the 5th N. (Trigeminal N.): Pay attention to temporal wasting, and clench your teeth (for masseters muscle). Check the sensory with piece of cotton with closed eyes in 3 sites vertically and bilaterally. Now we go to the 7th. N.: 1. By inspection face is symmetrical, Nl. Nasolabial folds, no drooling, and no deviation in the angle of mouth. 2. Now Id like you to copy me and do some movements for me, can you raise your eyebrows, wrinkle your front or forehead, can you close your eyes and dont let
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me open it. Can you puff out your cheeks, can you show me your teeth and smile, can you whistle 3. To the examiner: Id like to do corneal reflex. CN8: Go to the back of the patient, Whisper house and horse and ask the patient to repeat them after you and do the wiggling fingers closing to ears, bilaterally. Now we go to 9 and 10. Give me a swallow, please. No hoarseness, NL voice, say AA, soft palate is symmetrical and uvula is central To the examiner: Id like to do gag reflex. Now the 11th N.: 1. Please shrug your shoulder while I press down, Nl. Trapezius muscle. 2. Id like to turn your head to the right side against my hand and to the left side the same Nl. Sternocleidomastoid muscle. Now we reached the 12th N., Hypoglossal N.: 1. Would you please open your mouth, there is no fasciculation, there is no tongue atrophy. 2. Would you please stick out your tongue, tongue is central, no deviation, turn it to the right and left, normal movement. 3. Press your tongue against your cheeks. Tongue deviation is to the same side as the lesion. For face and uvula is opposite.

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Shoulder exam:
Hello, Good afternoon, Mr. Walter, I am Dr. Miller one of the physicians working in this clinic today, as I understand you are here because you have pain in your shoulder for the last 2 weeks. I have been asked to do the physical exam. During my exam if you had any pain or discomfort, please do not hesitate to inform me. Also if you had any questions please do not hesitate to ask me. Also I will report my findings to the examiner, Is that OK with you? Can you give me the Vitals, please? V/S is stable; the patient is sitting comfortably with no signs of distress. I want to look at your shoulder; may I untie your gown? In my inspection, both shoulders are symmetrical; both clavicle and scapula bones are at the same level, Normal muscle bulk bilaterally, no signs of scars, erythema, atrophy, deformity or swelling. Normal cervical curvature. (Warm your hands)I want to feel your shoulder now. Temperature is Normal. I am going to press. Sternal notch is not tender, both sternoclavicular joints and both clavicles are not tender, acromioclavicular joints and acromions both are nontender. I am going to continue my exam on your left shoulder. Spine of Scapula is not tender also middle aspect and tip of scapula are not tender. When I am pressing on your spine in the neck do you have any pain? No sign of bursitis. Id like you to relax. Move the shoulder up and down, no pain or tenderness in rotator cuff area. Glenohumeral joint is not tender. Check the sulcus sign to check Glenohumeral laxity. Check for cripitation in circular movement of the shoulder.

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Would you please put your gown back and stand up and face me, do you need my help? Id like you to do some movements, can you move your arm forward, push back, (flexion and external rot.) (Extension and internal rotation) and can you cross your arms like this? Move to the side like this? Over your head and hold it? No drop arm (check external and internal rotation, abduction and adduction) can you touch your chest with your chin? Can you look to the ceiling? Can you turn your head to the right and left? Shoulder pain is not related to any neck lesion. There is no painful arch and there is no dropped arch, no signs of bicipital tendinitis, Normal power and sensation at the shoulders.

ROTATOR CUFF INJURY:


Partial or complete tear, Impingement or Tendinitis. In complete tear, you cannot initiate movement and you have dropped arm. In partial tear he can initiate, but it is painful. So he puts his arm in supination to ease the movement and have further range. He will have dropped arm, but due to pain. Scarf test is done here. Apprehensions test (Handball players) or shoulder relocation test to show shoulder joint instability and anterior dislocation. Yergasons test for bicipital tendinitis in flexion and supination.

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KNEE PAIN:
QEII patient in this case is usually young. Hello, Good afternoon, Jack, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here due to the knee pain for the last week. I have been asked to do the physical exam. During my exam at any time if you had any pain discomfort or questions, please do not hesitate to ask me, also I will report my findings to the examiner, is that OK with you? Can you tell me the Vitals, please? By general Inspection, The patient is sitting comfortably with no signs of distress. Would you please stand up? Do you need my help? Can you put your gown a little bit up? Both knees are symmetrical. NL joint alignment. No genu valgus or varus. Would you please walk to the wall? NL gait, no limping. No bulging in the popliteal fossa, no limping, NL gait. Turn and lie down. I am going to drape you; by inspection both quadriceps muscles have the same bulk, no scar, atrophy, oedema, erythema or swelling. Warm hands. I am going to feel your knee. Temperature is NL in both patellae and colder than the other parts of knee joint. If patellae and knee have the same temp, it means inflammation, doesnt need to be warmer. Both knees are symmetrical with no local fever. Supra patellar pouch. Press and swing the patella to R/O chondromalacia. Then go to the large tendons and end up with tibial tuberosity(R/O Osgood-Schlatter). Lateral and medial collateral ligaments and press to the back.

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Bend your knee and feel up, down, middle. Feel lateral and medial tibial condyle. Check medial and lateral meniscus. Check crepitus and effusion. Patellar tapping and bulging sign or milking test. Range of movements: bend your knees, check flexion and extension. Check Power, push against my hand. Exam stability of knee. Anterior and posterior cruciate ligament by anterior posterior drawer tests the same test is Laschmans test but in 15 degrees, medial and lateral collateral ligaments by varus and valgus stress test in 15 degree. Other knee exam and check the pulses. Tendon of quadriceps is attached to tibial tuberosity.

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HIP PAIN EXAM:


Hello, Good afternoon, Mr. Douglas, I am Dr. Miller, Im one of the physicians working in this clinic today, as I understand you are here due to the right hip pain for the last 3 days and I have been asked to do physical exam. During my exam at any time if you had any pain discomfort or questions or you wanted me to stop, please do not hesitate to ask me, also I will report my findings to the examiner, is that OK with you? Can you tell me the Vitals? Temp.: 40 and the patient is febrile The Pt. is sitting

comfortably and not in distress. Would you please stand up? Do you need help? If he cannot, exam him in lying down position with turning to the left side. Id like to have full inspection, can I have full exposure? (If no: mention that hips and symphysis are deep seated joints and we cannot get a lot of information by inspection or palpation, however I am looking for any obvious swelling, erythema, tenderness or deformity. Lumbar curvature is NL. Gluteal folds are at the same level and both hips are symmetrical. I am going to feel the local temperature. I am going to press over the hips. Feel sacroiliac joint, posterior iliac spine, iliac crest and superior iliac spine. Would you please walk towards the wall? NL gait, no limping. Do Trendelenburg test? (To see the weakness of Gluteus Medius) Can you stretch your right leg towards the back, while you are holding the edge of the bed? I hold you from the back for support. Would you please lie down? Drape him.
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Id like to have full inspection and feel the inguinal ligaments, head of the femur and greater Trochanter also Symphysis Pubis. Check the R.O.M. and bend your knee as much as you can. Then you do internal, external rotation, flexion and extension, adduction and abduction. 2 special tests: Patricks test and Thomas test. Up to 1 inch difference is accepted for the difference between the lengths of legs. Check the power. Press against my hands, up, down, in and out. Patricks (Fabers) test: would you please bend your knee and put it above the other knee. I press on the knee to R/O sacroiliitis. If you bring the bent leg to touch the bed, it will check piriformis syndrome. (Please check these 2 tests on YouTube, too) The people with Osteoarthritis cannot have full extension. Hold one knee and stretch the other knee is Thomas test. If the stretching leg is elevated from the bed shows ileopsoas tightness.

Ankle exam:
For ankle exam mention no open fracture, obvious swelling and bruises in trauma cases and SEADS in medical cases. In the case of pure physical exam, you can have long introduction. In cases of both history and physical exam, introduction would be shorter. Suppose that examiner is blind, so you have to verbalize as much as you can. They want to see how you react to stress or in difficult conditition. Really care about to find the Drape for the patient, even on the floor. First cover then put up the gown. Warm your hands (usually my hands are cold and I am going to warm them). Then warm your stethoscope with your coat. Always warn the patient before any movement. Can you show me where you have pain? Sympathize and do empathy. Tell him whatever you want to do on him, and ask him to do them.

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Cases:
Cardiovascular cases: 1- 65 y/o with essential hypertension for the last 30 years, do P/E. 2- 35y/o with high blood pressure, do focused cardiovascular exam. 3-25y/y recently diagnosed with high blood pressure, do relevant P/E. 4-60y/o with cuff muscle pain, take history and do P/E. 5- Take history and do P/E for a patient with palpitation in 35y/o patient 6-Patient with cardiac Murmur 7- 70 y/o man having surgery 3 days ago, not passing urine for 4 hours, next 10 minutes do physical exam.( volume state exam) 8- Pt. had a surgery 3 days ago, now having shortness of breath for the last 2-3 hours, next 5 minutes do P/E. 9-Pt. had a car accident, or fracture or surgery 24 hours ago, now comes with S.O.B. (think of fat emboli or pulm. Emboli or athelectasis) do P/E for the next 5 minutes. 10-Pt. with S.O.B. for the last 3 hours after surgery 3 days ago in the next 10 minutes do focused P/E. 11-Pt. having history of Heart failure for the last 10 years. 3 days ago he has developed S.O.B. In the next 10 minutes do P/E? Respiratory cases: 1-Pt. has cough for the last 3 days. In the next 5 minutes do P/E? 2-55y/o Pt. has a history of breast cancer 5 years ago with mastectomy, received chemotherapy and radiation, now she is having cough or S.O.B. for the last 3 days, do a focused P/E. (primary fibrosis) 3-67y/o Pt. coughing blood, take history and do P/E in 10 minutes.

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GI system: A. Abdominal Pain: 1-24y/o female with lower abdominal pain for the last 24 hours, do P/E in 5 minutes. 2-35y/o woman came to the ER for severe abdominal pain for the last 2 hours, do P/E. 3-22y/o girl with the history of crohns disease for the last 5 years came with abdominal pain for the last 24 hours, do P/E in 5 minutes. 4- 30 y/o male with abdominal pain for the last 24 hours, do P/E in 5 minutes. B. GI bleeding: 1-61 y/o, well known alcoholic patient came to the ER with vomiting blood in next 5 minutes do P/E. (liver failure). 2-25 y/o Female Pt. with nasal bleeding, systematic and ENT exam. (Search for bruises and petechia)
Neurological cases:

1-HIV patient with head ache since the last week, do cranial nerve exam in 5 minutes 2-Pt has difficulty in his vision, 40y/o, in next 10 minutes take history and do P/E 3-Pt with crooked face (Bells palsy) do relevant P/E. 4- In Newfoundland Pt. is coming with hearing loss. 5- Pt. with weakness in the right or left hand, look for power, tone and reflexes 6-Pt. with diabetic foot do neurovascular exam. (If 5 minutes: no Monofilament test, if 10 minutes they want it) 7- Unconscious patient, do neurological assessment 8-Pt. with back pain, do P/E MSK system: 1- Do all the joints, except elbow 2- Shoulder exam 3- neck exam 4- hand laceration and carpal tunnel syndrome 5-hip exam 6-knee trauma and c heck anterior and posterior cruciate ligament, medial and lateral collateral ligament and medial and lateral meniscus
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7- Osteoarthritis of the knee based on the age 8- Ankle sprain P/E or counselling, be careful to R/O fracture and ligament tear 9- Pt. who had acute back pain regardless of the age 10- 67y/o man with acute on chronic back pain for the last 6 months, 3 days ago started with severe back pain since 24 hours ago (Think of metastatic fractures, Prostatic malignancy or breast cancer or osteoporosis in old age) 11- Chronic back pain: If young think about Ankylosing spondylitis, if old think about spinal stenosis or osteoarthritis or facet joint Then we will go to the joints and related cases one by one which are all mentioned above.

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1|Gastrointestinal

Mr Walter coming to clinic because of difficulty in swallowing for last 6 weeks, next 5 min take history
(In 5 min cases you dont need to give diagnosis) DDx: oesophageal cancer, scleroderma, strictures, web, rings and diffuse spasm. First see if it is intermittent or progressive. A) If intermittent ask if its for solid/ fluid or both. 1. Solid and liquid spasm. 2. Solid ring or web. B) If progressive ask if its for solid/ fluid or both. 1. Did it stuck both or fluid first? Achalasia or scleroderma, 2. Started with solid food, think of cancer (mechanical factor). Stroke/MS in brainstem affects coordination (whenever I eat foot, it comes out from my nose).

Approach: first clarify (what do you mean?), second analyse (where? Intermittent vs.
Continues, solid vs. both) and then go to associated symptom, risk factors and R/O other possibilities (in young patient think of HIV), PMHx, FHx and finally Social Hx. KKK, Hello, good after noon Mr Douglas! I am doctor Miller, one physicians working in the clinic, nice to meet you. D: As I understand you are here because you have difficulty swallowing for last 6 wks, can you tell me more about it? P: Yes doctor for the last 6 wks I have difficulty swallowing, its not improving. When you say difficulty swallowing, what do you mean? P: Doctor whenever I eat, it is difficult! Food stuck. Can you show me where do you feel it stuck? Did it start suddenly or gradually? Gradually Do you remember what you did at that time? I was in a stake house......

2|Gastrointestinal

From that time till now, is it all the time or on-off? All the time Getting all the time. Solid or fluid? Solid food (meat) Were you able to flush it down? When you drink, did it help? Yes or no!!!! Is the first time or happened to you before? I am going to ask some questions to see if you have any symptoms related to that? Do you have any chest pain? Tightness? Do you vomit? Do you bring up undigested food? Any cough/ repeated chest infection/ change in your voice? Any abdominal pain/ distension/ change in bowel movement (constipation/diarrhea). Did you notice any blood in your stool or vomit blood?

Constitution symptom: fever, night sweat, weight loss, lumps and bumps.
How much weight loss over how long? Any nausea vomiting, abdominal pain, tiredness (he is repeating)

Go for metastasis: do you have any yellow discoloration, itchiness, pale stool and
dark urine? Any back pain? Risk factors: do you have any history of GERD? 1) If yes when was that? How long was it? Did you seek medical attention? Did you ever have any studies done? Did they ever put any camera or light in to your chest? Did they ever tell you that you have a condition called Barrette esoghagitis? 2) If no ask for the symptoms; heart burn, acidic taste in your mouth, use a lot of pillows for sleeping? Do you have history of smoke? Drink alcohol? Any family history of esophageal cancer? P: Yes my dad died of esophageal cancer. When and in which age? Any history of swallowing acid or alkaline? Chest surgery (not sure), chest radiation?

DDx: Any history of skin tightness? If you are exposed to cold or hot weather, do you
feel that change in the color of your hand?

3|Gastrointestinal

PMHx: Hx of stroke, weakness, numbness, difficulty finding word, DM, any


medication? +/- HIV?

Social Hx: How do you support yourself financially? How did it affect your life?
How do you cope with it? (empathy should be put in appropriate places).

35 y/o male patient having fever for the last 6 weeks (history)
*Think of HIV, Hepatitis, malignancies and spleenectomy. * Start with introduction then analyzing fever then go for constitutional symptoms and DDx (head to toe). Pay enough attention to liver; symptoms and risk factors. End up with PMHx, FHx and Social Hx. KKK, Hello Mr Hutson......... As I understand, you are here because you have fever for the last 6 wks, can you tell me more about it? Yes doc. ........... How did it start? Suddenly or gradually? At that time did you have any flu/illness? Did you seek any medical attention before? NO What motivated you to seek medical attention today? Maybe he say I started to have skin rash.... Increasing or decreasing? All the time or on-off? Did you measure it? How often do you measure it? How do you measure it? What was the highest measurement? Any variation or special pattern? Did you try and medication? Anything decrease/increase it? Is it the first time you have this or have had it before?

Constitutional symptoms.....
I am going to ask you more questions to see if you have any other symptoms: Start with CNS; do you have any headache, nausea, vomiting, bothered by the light, neck pain, neck stiffness? Any pain in your ears, discharge in your ears? Runny nose? Any pain in your face? Sore throat? Difficulty swallowing? Any tooth problem?
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4|Gastrointestinal

Any heart racing (IE)? Chest pain? SOB? Cough, phlegm, wheezing, chest tightness, contact with TB patients, have you ever been screened for TB (skin test)? Abdominal pain? Distension? Diarrhea? Change in bowel movement? Any flank pain, burning sensation, more go to the washroom, change in your urine? Any joint pain, joint swelling, Skin rash, ulcers in your body or mouth, red eye? Have you ever you or any of your family member been diagnosed by conditions called autoimmune disease? Like RA, SLE... Any history of liver disease, have you been screened for liver disease/HIV? Have you been vaccinated for hepatitis? Do you have any yellow discoloration, dark urine, pale stools, itchiness, increase in size of your abdomen(pants), any bruises and swelling in your legs? I am going to ask you some questions to see if you have exposed to liver disease without being aware of that, some of these questions might be personal but it is very important to ask them. Id like you to know that whatever you tell me here is strictly confidential; I wouldnt release any information without your permission unless I am requested by the law: 1. 2. 3. 4. 5. Any travel outside Canada recently? Any raw fish/food, new restaurant? Any history of hospitalization/ surgery, receiving blood, donating blood (screen)? Any tattoo, piercing? Do you smoke, drink? Have you ever tried recreational drugs? If yes; ask about IV drugs/needle. 6. Sexual Hx: With whom do you live? Wife. How long have you been with your wife? 3 years. Before being with your wife did u have any sexual partner? Yes, from which age you become sexually active? 18 From that time till now how many partner have you had? 13 Did you practice safe sex always, I mean did you use condom in every single time? What is your sexual preference? Men, women or both? What type of sexual activity do you practice? Oral, anal or vaginal? Have you ever been diagnosed with any sexually transmitted disease?

5|Gastrointestinal

Within the last 3 years have you had any other sexual partner in addition to your wife? Yes, when was the last time? Did you use protection? Do you have any discharge, any lumps in groin area, and any ulcers in genitalia? How about your wife, does she have any symptoms, fever, and discharge? Whenever you have fever, discharge, jaundice and lymph nodes, you need to ask good sexual history. How do support yourself financially? Have you ever been exposed to blood or bodily fluids at work?

PMHx: cancer, medications, allergies........ FHx: ...

6|Gastrointestinal

Giving the Lab test result to the patient:


1-Introduce yourself 2- Why/where/who ordered it? 3- Explain the result 4- Consequences; symptoms of liver disease 5- Causes of liver disease 6- PMHx 7- FHx

Abnormal liver function test (ALT>AST):


As I understand you are here to get the results of your blood work which was done 2 weeks age and I have the results and I am going to discuss it with you in a few minutes but because its first time I see you I am going to ask some Questions to help me get better understanding of these results. Whats the reason for doing this test? Insurance Is it the first time or have done it before? If yes.....when? And what was the result? Dont need to go through the SPIKE, it is not that much bad to have elevated liver enzyme! Your results show that there is an elevation in one of the markers that use to assess function of your liver; we call it liver function test. If its elevated means there is an injury in the livers cells and they are different causes for that. Before talking about the causes Id like to see if you have any symptoms related to that. Acute symptoms; any recent of yellow discoloration, itchiness, dark urine, pale stool, sever flu like symptoms with joint pain and muscle ache. Any change in your appetite, hate taste of cigarettes, N/V Chronic phase; did you notice any increase the size of your abdomen/belt, bruise, swelling in your ankles, vomiting blood and change in your memory. Have you ever been diagnosed/screened with/for liver disease before? Have you ever been vaccinated for HBV/HAV before?

7|Gastrointestinal

I am going to ask you some questions to see if you have exposed to lover disease without being aware of that, some of these questions might be personal but it is very important to ask them. Start with travel, any travel outside Canada recently, any raw fish/food, new restaurant, any history of hospitalization/ surgery, receiving blood, donating blood (screen), tattoo, piercing, do u smoke, drink, ever tried recreational drugs? If yes; ask about IV drugs/needle. This patient used to use heroin before. With whom do u live? how many partner have u had? How do support yourself financially? Have you ever been exposed to blood or bodily fluids at work? PMHx: blood disease, medication FHx: liver disease Thank you for the information, we need to do further assessment.

8|Gastrointestinal

Problem with drinking (elevated liver enzymes or change in behaviour): First start with drinking habit then find impact in his life (medical, social, familial or psychiatric)

Abnormal liver function test (AST>ALT):


I can see you are upset, can u explain to me why you are upset? P- Did you cancel my insurance? D- Definitely not, I am not aware of what insurance you are talking about, usually insurance companies determine whether to approve your application or not, from my prospective you are here to discuss your blood work which is related to liver. I am not sure if its related to your insurance company or not, most likely this the reason they cancelled your insurance. If the patient insists I can see how much you are frustrated and understand how it is important for you. I can assure you again it is not me who determine thats done in insurance company you can talk to them, however, since you are here there is something important to discuss and thats your liver! The result of your blood work could be concerning to us. Is it the first time or have done it before? If yes.....when? And what was the result? Your results show that there is an elevation in one of the markers that use to assess function of your liver; we call it liver function test. If its elevated means there is an injury in the livers cells and they are different causes for that. Before talking about the causes Id like to see if you have any symptoms related to that. P- Doctor! Why dont you repeat my test? D- Mr..... whenever we do blood test and we find it abnormal we double check, if you would like to repeat that we can do that but usually its accurate. Not only that, based on history if you have any abnormalities in your liver we need to do further tests/assessments. Acute symptoms: any recent of yellow discoloration, itchiness, dark urine, pale stool, sever flu like symptoms with joint pain and muscle ache. Any change in your appetite, hate taste of cigarettes, nausea, vomiting? Chronic phase: Did you notice any increase the size of your abdomen/belt, bruise, swelling in your ankles, vomiting blood and change in your memory.
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9|Gastrointestinal

Have you ever been diagnosed/screened with/for liver disease before? Have you ever been vaccinated for HBV/HAV before? I am going to ask you some questions to see if you have exposed to liver disease without being aware of that, some of these questions might be personal but it is very important to ask them: Start with travel outside Canada recently? raw fish/food? Any tattoo, piercing? Any history of hospitalization/ surgery, receiving blood, donating blood (screen)? Do you smoke, drink, have you ever tried recreational drugs? P- Yes I drink. How much do you drink? How long do you drink? P- Since I was 18. Last week how much did you drink? In a day? Have you ever drunk more than 6 drinks in one setting? What kind of alcohol do you like to drink? (10 beers in one day, 2 bottle of wine or 1 bottle of whisky in one day is considered a lot) Do CAGE: 1. 2. 3. 4. Do u feel u need to cut down on your drinking habit? Have you been annoyed by the people criticise your drinking habit? Do you feel guilty because of your drinking habit? When you wake up in the morning do u feel that you need to take a drink to help you go through your day? (1 for women and 2 for men)

Ask about drinking habit: Do u drink alone or with friends? Do you exceed the amount of alcohol you plan to drink? Did you ever drink to the amount that you lost your consciousness? Do you avoid going to places where you dont have access to alcohol? If you dont drink, would you have shakiness, heart racing or excessive sweating? Impact: Because you have been drinking for a long time Id like to ask some questions to see how it affects your life? With whom do you live? How is the relation? P- Its not good, Why? For how long? Is there any stress? Do you think it is related to your drinking habit? You might ask about sexual function. How do you support yourself financially? How is your relation with your supervisor/coworkers? Do you need to miss a lot of days at work? Do you drink at work? Any legal consequences? Fight, criminal record, licence suspended....? How is your mood? Interest? Excessive fears? Do you hear voices or see things other people cant? Any chance that you might harm yourself or somebody else?
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10 | G a s t r o i n t e s t i n a l

Any Hx of psychiatric disease? Visited by psychiatrist? Any FH of drinking problem, suicide, depression? P- how about you doctor? Do u drink? D- Weather I drink or not, makes no difference, we are here to talk about you and its better to use this time to discuss your condition.

56 y/o male, hasnt been himself for last 6 month


KKK, Hello , good afternoon Mr. Talor, I am Dr. Miller one physician working in the clinic today. As I understand you are here because your wife is concerned about you and she asked you to come here to see me (arrange this meeting). Can you tell me more about her concern? Why she is upset? Why she is not happy? Or whats bothering here? P: Oh she is nagging about everything, she says I am not staying at home (look for the change) and she says I waste my son time! D: You said you stay out more, when did it start? 6 month ago. Why, what happened 6 months ago? (any changes 6 month ago) P: Yes, I am a lawyer, I shifted to family law. D: Interesting, before working in family what kind of law did you practice? What made you change and how do you feel about family law? P: I am disappointed. How this affects you? Do you agree with your wife that there is change? She has a point? How do handle this/disappointment? Either we go for the mood or organic. We should ask about mood, drink and smoke in all the cases like this. Do you drink? Yes. How much do you drink? More than before. When did you start to drink more? 6 month ago. If he says; she is nagging about the fact that I am spending more time with our son. When he was young I didnt have the chance to be with him, now he grew up and I want to compensate for that time! Why she doesnt join you? Because of party! Then you ask about drink, smoke and drug.
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11 | G a s t r o i n t e s t i n a l

A) Mr.... 24y/o with diarrhea for last 4 days B) Mr.... 28y/o with diarrhea for last 6 weeks

A) Hello, Mr. Davis, I am...... As I understand you came here because you have been having diarrhea for the last 4 days. Can you tell me more about it? Do yu remember how it started? Gradually. From that time until now is it all the time or on and off? P: All the time. Increasing or decreasing? Increasing. How many times in the first day? 3 times. How about today or yesterday? At least 7 or 8 times. How about during the night, do you wake up to go to the washroom or you are able to sleep? P: I have to wake up to go to washroom. That must be difficult, how did it affect your life? Is it the first time or happened before? Usually what is your habit? How often do you go to washroom? COCA+B: How about the color? Brown or green? How about the consistency? Is it watery, loos, well formed. Did you notice any blood? Any offensive smell? Is it bulky? Did you notice any undigested food? Any fatty droplet? Does it float on the toilet? Is it difficult to flush? Any mucous (it isnt significant)? Anything increase it decrease it? Any medication? Which, did it help or not? Do you have any nausea and vomiting? No. Any recent flu? Did you eat in a place that you dont eat regularly? Any raw chicken? Did anybody around you have similar complaint? Do you have any abdominal pain? If yes: OCD and ask which started before? Is your abdominal pain relieved when you have bowel movement or not? Do you have it during the night? After you pass your bowel movement do you think that you are done or you need to go again?

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12 | G a s t r o i n t e s t i n a l

Dehydration: ask about weightless? Do you feel dizzy/ light headedness/thirsty. If you stand do you feel you have heart racing? Causes: we covered the food poisoning and infection still we should ask about fever, night sweat, chills, appetite, bump and lumps. Have you used any antibiotics? P: Yes. When? Why? Which one? How long? Other DDx that you can touch them briefly; travel, camping, hyperthyroidism, lactase def, first attack of IBD. PMH, FHx........

B) DDx; cancer, infection, camping-parasite, hyperthyroidism, IBD, lactose intolerance, IBS, celiac, HIV, pancreatic failure.....
KKK. Hello Mr Wolter..... As I understand you came here........ Whenever you feel you want to lie down, dont hesitate to tell me. OCD..... Same as the previous one. During these 6 weeks did you have any time of constipation? Before this did you have any previous attacks of diarrhea? COCA+B...... about the blood; fresh, mixed, separate and dark stool. Go for pain: which started before? Continue with the same Questions for case A Constitution symptoms and add any family history of colon cancer at young age? Go for DDx; IBD: red eye, ulcer in the mouth, back pain, joint pain/swell, stiffness, uretritis, skin rash, nail changes and history of psoriasis.... Lactose intolerance: gases, distension, itchiness, a lot of dairy product than usual. Laxative, antibiotics. If you find HIV important ask about it.

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13 | G a s t r o i n t e s t i n a l

40 years old male, abdominal pain, 24 hours, take history (Obstruction): Female abdominal pain 1. 2. 3. KKKKKKKKK Mr. Doglas, Im Dr. miller, one of the physicans working in the ER today. As I understand you have been having severe abdominal pain for the last 24 hours, can you tell me more about your pain P: after breakfast I went to work, my pain star 2 hours later. - are you comfortable sitting? Do you like to lie down? Bear with me for a few minutes. As soon as I can Ill give you pain killer. - how did it start? Suddenly or gradually From that time till now is it all the time or on and off? P: all the time, now - what about in the beginning? - when did it start to be all the time? P: last night ( empathy, asking sleep here or in severity, and any change in course is important. - is it the first time, or you have had it before? Can you show me where it is? How does it feel? P: dull -from the beginning? P: it was colicky at the beginning? -from score of 1 to 10, where do you put it you pain? Does it shoot anywhere? Were you able to sleep last night, anything increase it or decrease it? Medication, position, leaning forward?
13

Missed period without bleeding= ectopic pregnancy Missed period with bleeding = abortion Discharge= PID

14 | G a s t r o i n t e s t i n a l

(Always for abdominal pain ask nausea and vomiting) Do you have any nausea, vomiting P: Yes -COCA, amount, color, consistency, smell P: the smell was very awful - was it forceful, does it relieve your pain, which started first you pain or vomiting ? ( pain then vomiting =surgery. Vomiting then pain = medical (DKA)) - did you feel dizzy, light headedness, any dark urine( for dehydration)

P: I was out with my friends. - did you eat alone or with them? Anything new, do others have the same symptoms? Any change in your bowl movement? When was you last bowel movement? Usually how often do you have? Any distension? Are you still passing gas? Any blood with stool? ( consider the cause) 1. 2. 3. 4. 5. Any history of surgical abdomen. FHx of bowl or colon cancer. Constitutional symptoms History of IBD, repeated attacks of pain with diarrhoea Any history of groin mass or surgery, have you ever been diagnosed with inguinal herniation, any history of gall bladder stone.

DDx: any flank pain, burning sensation, blood in urine, any skin discoloration, itchiness, and dark urine, any cough phlegm and wheezing, chest pain, Hypertension PMHx FHx Social Hx

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15 | G a s t r o i n t e s t i n a l

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1|Ph.Ex & Management

Counseling scenarios:
Two sessions of smoking cessation, diabetes counseling (DM with impotence, DM with blurred vision), scenario of asking medical note from you which epileptic patients wants to get a notes for driving license, needle-stick scenarios, HIV scenarios, scenario for INR.

There are 32 pediatrics scenarios.

Obstetrics and gynecology: five subjects of history taking, and 10 subjects for counseling (OCP X 2 scenarios -- sexual abuse -- a lady comes for antenatal visit and she's panicking -- 2 scenarios for Pap smear; one wants Pap smear and the other one doesn't want Pap smear -- 2 C-sections; one wants to arrange a C-section and the other one doesn't want to C-section -- HRT scenario.

35 year old male come to clinic having chest pain. 10 minutes counseling. No checklist for this scenario.

Management:
In the ER cases you should do ABCD plus history and physical examination. ER cases are divided to trauma and none trauma cases. Non-trauma cases are divided into cardiac and non-cardiac cases. The cardiac cases are divided to chest pain, heart block and arrhythmias. The arrhythmias are divided into stable or unstable.

The unstable arrhythmias like ventricular fibrillation or ventricular tachycardia which is a code blue situation you should perform ACLS protocol. You cannot wait to take history; you should shock the patient as soon as possible.

In trauma cases you should perform the ATLS protocol. In trauma cases the three situations:

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2|Ph.Ex & Management 1- Patient sustains a physical trauma and the scenarios are either a car accident, stabbed by knife, beaten by baseball bats or kicked by a horse. In the scenarios you should say I would like to initiate ATLS protocol. 2- Patient has sustained trauma and you should manage the patient over the phone. 3- Patient had primary survey done and you're asked to do secondary survey now.

There are four chest pain cases: 1- Patient arriving with evolving MI, so first ECG will be normal. So you should ask for serial ECGs. 2- Patient arrives and already he has got ST elevation. So in this case the patient is almost diagnosed. In this station is no cardiac enzymes and you should only look at ECGs. 3- Patient had chest pain and ventricular fibrillation and he's on the way to hospital. 4- Patient has chest pain and ventricular relation and you found he has taken cocaine (cocaine overdose). You should find the cocaine overdose by taking history.

There are two heart block scenarios: In both cases patient has got the pressure of 90/60 and heart rates is 45.

Non-cardiac cases:

A. GI cases: 1- Patient in ER with acute abdomen who has not know blood pressure and tachycardia. 2- 55 or 65-year-old patient vomited blood 20 minutes ago and his blood pressure is 90/60 and the heart rate is 110 (case of a upper GI bleeding). In 10 minutes manage the patient. 3- 69-year-old patient with rectal bleed having blood-pressure 90/60 and heart rate is either tachycardic or normal due to being on digoxin or B-blockers (lower GI bleeding).

There is no asthma case so far in the scenarios.

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3|Ph.Ex & Management

B. Neurology cases:

1-45-year-old patient who is seizing for the last time two minutes, paramedics gave him lorazepam on the way and brought him to hospital. 10 minutes management.

2-18-year-old patient came to emergency room because of severe sudden headache two hours ago. 10 minutes management.

3-16 year old patient who has been found unconscious in her class 5 minutes ago and her classmates brought her in emergency room. Next 10 minutes manage and counsel her.

4- 40 year old patient who is receiving blood and nurse is concerned about him and ask you to see the patient. This is all about side effects and complications of transfusion. In the next 10 minutes manage and counsel the patients.

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4|Ph.Ex & Management

ER Management
1- Trauma cases 2- Non-Trauma cases In any trauma scenarios, make sure you have proper IV lines and proper monitoring, so you can start primary survey. The purpose of Hx is not for diagnosis in emergency setting. The purpose of Hx is that the patient is alive and can talk to you. After a very brief Hx, tell the patient: I am going to make sure that you are stable, so I am going to give some orders to the nurse and as soon as it is done I am going to ask you some more questions. In the trauma cases you have to do extensive primary survey. After primary survey you have to do a quick Hx (AMPLE: Allergy, Medication, Past medical Hx, Last meal or last Tetanus and Event).

After a quick Hx (AMPLE) we should do a head to toe examination. At the end you should give some orders.

In Non-Trauma scenarios, we should do a quick primary survey, then HPI (History of Present Illness), OCD (Onset, Course, Duration), PQRST (Position, Quality, Radiation, Severity, Time/Triggers), AA (Alleviating & Aggregating factors), AS (Associated Symptoms), RF (Risk Factors), Past Medical Hx, then you should do a focused physical exam and then give some orders.

The common mistake is that to do an extensive primary survey for Non-trauma cases, or perform an extensive Hx on trauma cases.

Sample of Trauma case:

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5|Ph.Ex & Management

Case of MVA:
Introduction: Walk towards the examiner and say: Hello. Because this is a case of trauma I would like to activate ATLS protocol and I will need protective measures including gown, gloves, goggles, and masks for myself and the rest of my team. Then walk toward the patient. While you are walking toward the patient, look if the patient is wearing neck collar or not.

If the neck collar is on, go and greet the nurse. Like: Dr Miller: Hello. Good afternoon, my name is Dr Miller.

If there is no neck collar on, ask the nurse to provide the collar and ask the patient to stay still and do not move his/her neck/head before you greet anybody. You may need to apply the neck collar.

Take a very small Hx:

Dr Miller: How do you feel right now? Patient may tell you he/she is in a lot of pain. So you are interested to know if he/she can talk or not? Patient may start with asking where my wife is.

Dr Miller: Mr Douglas, I know you are concern about your wife, but my priority is making sure you are stable. I will ask around about your wife and when I find out, I will update you. Patient may say I am in pain and I am dying in this hospital, please help me I am in a very severe pain.

Dr Miller: I can see you are in a lot of pain, bear with me for a few minute. I will you pain killer as soon as I can however at the moment I want to make sure you are stable, for that reason I am going to give some orders to the nurse.

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6|Ph.Ex & Management Start with A B C D:

1. A stands for Airway:

Ask the patient: Would you please open your mouth. When he opens his mouth you should verbalize your findings to the examiner like: Mouth is clear; there is no denture, no broken tooth, no foreign body, no blood and no clots. Patient is talking to me so the airway is clear. Then you should check the saturation first and see how much it is before starting O2 and compare it with after O2. If the saturation is not improving with O2, so either patient is not breathing well due to pain or something serious is going on.

2. Checking the saturation and oxygenation is the part of B (Breathing):

The new neck collars have a window in front, but the older ones do not. For the new neck collars you should open the window, but in old types If there is no window you should open the collar to observe the neck. In the neck you look for two things: 1- Trachea 2- Jugular veins Check the trachea to see if it is deviated or not, and jugular veins to see if they are engorged. You should verbalize your findings to the examiner.

Trachea Normal RIGHT Sided tension Pneumothorax Right Sided Haemothorax Tamponade Central Shifted to the LEFT Shifted to the LEFT Central

Jugular Veins Normal /

Air entry Bilateral in the RIGHT side in the RIGHT side Bilateral

Heart Sounds S1/S2

S1/S2

Normal /

S1/S2 S1 / S2

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7|Ph.Ex & Management Needle decompression for tension Pneumothorax will be located in the 2nd intercostal space at midclavicular line. In Tension Pneumothorax the gush of air will be heard.

The proper chest drain should be inserted on the upper boarder of the lower rib.

Once you put chest drain, you should ask the nurse how much blood is draining in the drain.

Call to thoracic surgeon if: Chest drain output is 1500 mL Chest drain output is 800 mL in 4 hr (or output is 200 mL/hr)

If there is a tension Pneumothorax has developed on the LEFT side, you could safely insert a needle for decompression at the 2nd intercostal space in mid-clavicular line as it is as safe as the right side (Far from big vessels).

In the case of cardiac Tamponade (Muffled heart sounds + Low BP + Engorged JVPs), we should perform needle pericardiocentesis.

To perform a pericardiocentesis, use a long needle and syringe. The needle should be introduced just next to Xyphois process with 45 degree angled (aim to the left shoulder or the tip of scapula), and advance the needle while keep applying suction (-ve pressure) with the syringe.

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8|Ph.Ex & Management Always monitor the heart. If the needle hit the myocardium, it will induce arrhythmias. The drained blood is not clotted.

3. C stands for Circulation:

In circulation always start with vital signs. Once you get the vitals; as patient is tachycardic, tell the examiner that you would like to establish two IV lines (Gauge 16) in antecubital fossa. Through one line I would like to give 2L Ringer Lactate bolus (will give to everybody with trauma or GI bleeding, stable or not) as fast as possible. From the second line I would like to draw some bloods. The vitals needs to be checked every 10 min or when 2L Ringer Lactate is finished.

After first 2L of Ringer Lactate, there are 3 conditions: 1- Patient is stable, the 2L is gone and patient still is stable. In this case continue with maintenance. 2- After 2L of Ringer Lactate, the patient is not doing well or the BP is low or border line. In this situation give another 2L. 3- Patients BP is low + patient is not doing well and 2L is given but the BP is still low or BP drops more. In this situation give blood.

From the second line some blood should be drawn for following tests: CBC diff, Platelets, Electrolytes, fingerprint Glucose, INR, PTT, LFT, BUN, Cr, Toxicology, Alcohol level, Blood group and cross match Cardiac enzymes

Order 6 units of blood: 2 of them should be + O if the patient is male or O if the patient is female (or it could be same group, not cross matched), and the remaining 4 units should be cross matched.

Cardiac monitoring is essential + checking the vitals every 5-10 minutes. Also ask for 12 lead ECG.

In case of having no IV access, the interosseous (drill the bone in adults) can be used. It can provide a good access to infuse fluid very fast.

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9|Ph.Ex & Management

If despite giving fluids or blood the BP is not improving, look for the source of bleeding. The skull has got not much space, blood collection in the neck should be visible and in the chest you could exam to find out about bleeding. But in the abdomen you cannot see the bleeding and you should look, listen and feel. If patient has guarding or severe tenderness or can see bruises, you should say: I would like to get surgical consultation, stat.

If the examiner tells you that the surgeon is not available, you should ask for FAST (Focused Abdominal Sonography for Trauma). If the fast is not available then you have to do DPL (Diagnostic Peritoneal Lavage).

After abdomen go to hips and press the pelvis. If patient has pain with this, you should say: I am suspicious to pelvis fracture and would like to wrap the sheet around the pelvis very tight and ask for orthopaedics consult stat.

Then you should check the lower extremities for shortening and external rotation (to rule out the neck of femur fracture).

****Out of audio clip comment**** Here, the speaker explains that for neck of femur fracture, we should apply Thomas Splint, but I think the Thomas splint is applicable for shaft of femur or shaft of tibia fracture.

If you applied a splint, you should check the pulses before and after application. 9|Page

10 | P h . E x & M a n a g e m e n t

In trauma cases you should perform Log Rolling in which you need 4-5 people to help you to role the patient on one side, so you could perform vertebral spinal process exam + DRE (Digital Rectal Examination) After Log Roll you can insert Folly catheter.

4. D can be D1, D2 or D3:

D1 stands for Deficits. The patient is either conscious or unconscious. If patient is conscious tell him, I would like to shine a light into your eYes. Now verbalize your findings: both pupils are round and reactive symmetrical, then ask the patient to squeeze my fingers (check the power of upper extremities). Now ask to wiggle his toes (motor of the lower extremities). Ask about sensation of your touch on the upper and lower extremities. Now explain to the examiner that the patient is neurologically intact. If the patient is unconscious shine the light for pupils reaction and use AVPU to determine the level of consciousness. D2 stands for Detoxification in case of poisoning. D3 stands for Drugs. In case of heart attack give the drugs here. At this stage give Thiamine, Glucose, Naloxan and Oxygen (Universal Antidote). Always give Thiamine before Glucose.

Then check the AMPLE (Allergy, Medications, Past medical history, Last meal or Last Tetanus or Last Period, Event). For event ask if the patient remember what happened? Does he remember everything before and after the accident? How did it happen? Head on collision or T-bone or rearended accident? Did you have head trauma? Did you lose your consciousness? Do you have any headache? Also check for nausea and vomiting.

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11 | P h . E x & M a n a g e m e n t

Important points in telephone conversations: The same as normal scenarios the introduction and asking the name of caller is necessary Always ask about the callers telephone number and address Tell the caller that you will call back if the line disconnected Always start with a very short history If there is an emergency so check the patients ABCDs and give instructions to the caller (In trauma cases the caller is a nurse)

Full checklist of trauma case by Dr Miller:

When you enter the rooms for trauma case after giving a sticker to examiner, always verbalize:

Because this is a trauma case, I would like to activate ATLS protocol.

I would like protective measures (Including Gown, Gloves, Goggles and mask) for myself and the rest of the team.

Walk toward the patient and introduce yourself and talk to him to assess the airway.

IN TRAUMA CASES THE AIM OF TALKING TO THE PATIENT IS TO IDENTIFY IF THE PATIENT IS AWAKE AND IF THE AIRWAY IS OPEN & CLEAR.

Dr Miller: Mr Douglas. Good afternoon. My name is Dr Miller, one of the physicians working in the emergency room.

Patient: Oh Dr. I am in a lot of pain.

Dr Miller: I can see that you are in pain, but bear with me for a few minutes and I will give you pain killer as soon as possible. I need to make sure you are stable, and I will give some orders to the nurse and also ask you some questions. 11 | P a g e

12 | P h . E x & M a n a g e m e n t

Dr Miller: Can you open your mouth? (Checking Airway) Verbalize: The patients mouth is clear; there is no foreign body, denture, clot or secretions.

Dr Miller to the nurse: Can you get the saturation? Nurse: Oxygen saturation is 95%. Dr Miller: Please give him oxygen 4 Lit/min via nasal prongs. After giving oxygen ask if it improved the saturation or not.

Now Dr should bend and get close to the patients face to check the patients Breathing by LOOK, FEEL and LISTEN.

LOOK for chest movement. FEEL for the patients expiration on your face. LISTEN to any breathing effort the patient is making.

Then the Dr needs to check the trachea and jugular veins by opening the neck collars window or by opening the neck collar to observe the area. Look for deviated trachea and engorged JVPs. Always verbalize your findings on trachea and jugular veins to the examiner.

Now you touch the chest wall - in front for any open wound, bruises, deformity and then feel it for tenderness, pain or crepitation.

Then tell the patient that you are going to listen to the chest. Listen for any decreased air entry to the lungs.

If there are JVPs engorgements and deviated trachea along with the decreased air entry to one lung, so you are facing with tension Pneumothorax. You must decompress the tension by insertion of a large bore long needle in the second intercostal space at mid clavicular line in the side of pneumothorax.

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13 | P h . E x & M a n a g e m e n t You will hear the air escaping the chest via needle (Gush of air) and significant improve on patients feeling, saturation of oxygen, JVPs and shifted trachea. Listen again to the lungs.

Always be vigilant about pneumo-haemothorax, if there is no significant improvement.

After decompression, verbalize that you are going to put a proper chest drain in 5th intercostal space at mid or anterior axillary line.

When you checked the B for Breathing, start to check C for Circulation by asking about the Vital Signs. For any kind of trauma cases, you must order the followings: Two 16 gauge IV cannulas into ante-cubital fossa. (Obviously one for each side!) Set up IV infusion from one side. o 2 Lit Ringer Lactate / bolus / stat to be given as quick as possible 13 | P a g e Draw bloods from the other side for the followings: o CBC, diff, Platelets

14 | P h . E x & M a n a g e m e n t o Electrolytes o Kidney function tests (BUN & Cr) o Liver function tests (Liver enzymes, PT, PTT, INR) o Blood grouping and cross match o Cardiac enzymes o Order 6 units of bloods:

: 2 Units of O positive + 4 Units of cross matched

: 2 Units of O Negative + 4 Units of cross matched

o Alcohol level o Blood toxicology Order for 12 lead ECG Finger prick Glucose level Portable chest X Ray ECG monitoring + Pulse oxymetery monitoring

If the blood pressure is not improving despite giving 2 Lit of RL, you should check for the other sources of bleeding.

The skull has not got much space to collect too much blood. So look at the abdomen, pelvis and extremities for major sources of bleeding.

Observe the abdomen and verbalize your findings. Then listen followed by feel, tap and perform special tests to find any trauma to the intra-abdominal organs.

Large span and masses over liver and spleen area are suspicious for rupture. Superficial bruises, abnormal swelling, Cullen sign and Gray-Turner sign are all indications of possible internal bleedings.

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15 | P h . E x & M a n a g e m e n t

Cullens Sign:

Grey-Turners Sign:

If you are suspicious to any intra-abdominal bleeding you should ask for Surgeon consultation, Stat, and if the surgeons are not available, ask for FAST, and if there is no FAST available ask for DPL. Check the pelvis for stability by pushing down anterior superior iliac spine bilaterally. Any pain or laxity indicates fractured unstable pelvis. Ask for Orthopaedics consultation, stat after fixing the pelvis by wrapping and knotting the sheet or apply brace around patients hips. Using sheet and knots or applying special brace for temporary external pelvis fixation:

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16 | P h . E x & M a n a g e m e n t After pelvis, you should check the lower extremities. Shortening and external rotation of one leg indicates the Neck Of Femur Fracture (NOF#). Look for abnormal bruise, swelling and angulations of thigh and lower leg when you are suspicious of lower extremities long bone fractures. Always check the distal pulses, and if there is no pulse, you need apply traction.

Thomas splint can be used for shaft of femur or shaft of tibia fracture. Always check for pulses after applying any splint.

To finish the Circulation assessment, we should perform Log Rolling, which for we need at least 4 people to support 1- Head & Neck 2- Chest 3- Pelvis 4- Lower extremities while we roll the patient to the side. Look for any significant bruise, open wound, deformity, foreign body, and assess for spinal processes and paravertebral muscles tenderness. At the end need to perform anal area sensation followed a DRE to check the sphincter tone, blood in rectum and high-raised prostate.

If there are no abnormal findings, we can remove the hard board and ask for insertion of Foley catheter to measure intake and output especially for traumatic patients in hypovolemic shock.

To check the D for Deficits, start with checking the eYes and comment on pupils and their reaction to shining light. Ask the patient to squeeze your fingers as hard as he can to assess the upper extremities innervations and motor function and also ask to wiggle the toes to assess the lower extremities followed by checking superficial touch sensation over upper and lower extremities.

If all normal, verbalize that the patients neurology is grossly intact. To finish the primary survey, we need to check the AMPLE: - Allergy - Medications - Past medical history - Last meal / Last tetanus booster injection / Last period () - Event (as the patient about the accident/event) 16 | P a g e

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Non-Trauma case management:


Case of SEIZURE: A 40 years old male was brought to the ER by paramedics along with his wife because he had a seizure 20 minutes ago while they were having dinner in a restaurant. On the way to the ER, an injection of 10 mg Lorazepam is given to stop the seizure. You come to see the patient in ER and his wife is with him. Patient is not responding.

Knock. Knock. Knock. Walk toward the wife.

Dr Miller: Hello, Good afternoon. My name is Dr Miller the physician in charge. Nice to meet you. Start to take a very short history from wife and respond to her concerns. Dr Miller: I can see how stressful the situation is for you, and I will do my best to save your husband. At the moment, I would like to make sure he is stable so I am going to talk to the nurse and give some orders, then I will ask some questions about what has happened. Inform her about what you are going to do. Then start to perform primary survey: ABCD verbalize whatever you are doing during ABCD After checking the Airway & Breathing, give some orders for Circulation (ask for Vital Signs and put 2 large bore cannulas to give fluids and take all necessary blood works). The same as trauma case. Here as the patient is non-trauma, give only maintenance fluids (Normal Saline 50 mL/hr). Check the Deficits: D1: (patient is not responding so we can do AVPU and verbalize your findings) and then check for D2: Drugs/Medications: think of giving UNIVERSAL ANTIDOTES (Thiamine 100 mg, Glucose 50 mL of D50%W, Oxygen 4 Lit/min, Naloxan 0.4 - 1.0 mg). Always give Thiamine before Glucose. No need for Naloxan if the respiratory rate and oxygen saturation are normal.

The scenario may change by examiner to an immanent seizure attack if you forget to verbalize about universal antidotes. 17 | P a g e

18 | P h . E x & M a n a g e m e n t Now we have finished the primary survey and patient is stabilized so we should move to secondary survey by taking a long and detailed history. Ask the wife about the event (what she saw before, during and after seizure attack). Ask about the associated symptoms like fever, neck stiffness, vomiting for meningitis/encephalitis, constitutional symptoms for brain tumors. The focal neurologic symptoms before the seizure could be a clue so needs to be asked.

It is important to ask about husbands past medical history, previous hospital admissions and his medications: History of heart racing, history of clot in the leg/lung which for patient may take blood thinner (warfarin) or any history of head trauma which all is important clues as it could be the cause of intracranial bleeding. We should ask about patients regular medicines & social history: Sleeping tablets (withdrawal)? Smoking? Alcohol? Drugs?

After the detailed Hx, ask about the vital signs and start to perform the secondary survey (head to toe examination). Start with neurologic examinations: GCS, Cranial Nerves, Upper & Lower extremities, Special test for meningeal irritation (Neck stiffness, Kernigs & Brudzinski's). Verbalize what you willing to arrange according to your neurological findings (Septic work up, LP, CT, MRI, ICU admission, Neurologist consultation etc.)

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Case of Headache:
Diabetic teenager came to ER because he has severe headache for the last 2 hours and started while he was playing basketball. In these types of scenarios, there are buzz words like: The worst headache in my life or Thunderclap, which give you a clue about intracranial haemorrhage.

Start by taking history of the headache: OCD & PQRST & AS & AA & RF Offer the patient to lie down, if he refuses because of increasing pain (more clues about intracranial event), offer a 45 degree position to give him some comfort position.

Check the vital signs and look for Cushings Triad. Check the BM as soon as possible because the patient is diabetics. (Ask to check the BM regularly)

Usually in this scenario patient will lose consciousness while talking to you, so when happened we should start with primary survey and ABCD.

On D or Deficits, we should perform more detailed neurologic examination, also give universal antidote (Thiamine & Glucose & Oxygen) as patient is diabetic.

In neurologic assessment we have to do GCS, and for sure the patients GCS is <8 and he needs intubation. The intubation is for 2 purposes: 1- Immediate airway management 2- Hyperventilation

Put the patient in 45 degree bed tilt. Admit the patient, ask for immediate neurosurgical consultation, and arrange for urgent CT scan along with normal routine blood tests and monitoring LP. You may order the following medications: - Manitol (20%) infusion 1 gr/kg, (which is neurosurgeons favorite) to reduce intracranial pressure.

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20 | P h . E x & M a n a g e m e n t - Nimodipine which is a calcium channel blocker originally developed for the treatment of high blood pressure. It is not frequently used for this indication, but has shown good results in preventing vasospasm, a major complication of subarachnoid hemorrhage.

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Case of Hypertension (Young patient):

22 years old male was diagnosed with hypertension 2 days ago. Perform physical examination.

Causes of secondary HTN: Coarctation of aorta, Acute renal failure (glumerulonephritis), Polycystic kidney disease, Renal artery stenosis, Acromegally, Pheochromocytoma, Hypothyroidism, Hyperthyroidism, Cushings disease, Cons syndrome (only by blood work and hypokalemia), and Cocaine induced hypertension

Knock. Knock. Knock.

Dr Miller: Hello. Good afternoon. My name is Dr Miller one of the physicians working in this clinic. As far as I understand you are here because you are diagnosed with hypertension 2 days ago. Now I would like to perform relevant physical examinations. During my examination, I will explain my findings to the examiner. Is that OK with you? Do you have any question before I proceed?

Ask for the vital signs or start to take them if you need have to do it. If the V/Ss are given, comment on them when you heard them, like if the followings are given: BP: 180/100 mmHg - HR: 75/min RR: 15/min T: 37

Verbalize: According to BP, patient has both systolic and diastolic hypertension; there is no bradycardia which can be seen in hypothyroidism and there is no tachycardia which can be seen in pheochromocytoma or hyperthyroidism.

Verbalize: I would like to compare the BP in upper and lower extremities to rule out any Coarctation of Aorta. Also I would like to check for orthostatic hypotension to rule out the Pheochromocytoma.

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22 | P h . E x & M a n a g e m e n t Verbalize your general observations: By looking at the patient, patient is sitting comfortably and there are no signs of distress.

Check the neck for cervical fat pad (Cushings disease); verbalize your observation

Physical exam starts with checking the eYes: Verbalize; By looking at the eYes (pull the eye lids down), there is no pallor or jaundice (by pulling the eye lids upwards and look at the sclera above the cornea).

Check the nostrils for any nasal septum perforation, which you may see in Cocaine abusers.

Look at the face and comment; the face is symmetrical, there is no moon-like face or puffiness around the eYes, there is no Exophthalmoses (you should go and look from the side of patient).

Ask the patient to follow your moving finger from top to bottom; there is no lid lags or lid retraction. Comment oh eyebrows; there is normal hair distribution in the outer third part of eyebrows , no loss of outer 1/3 of eyebrow (Hypothyroidism).

Check the visual field to rule out intracranial masses pressing optic nerve, or to rule out Acromegally, which can present with loss of visual field.

Now you should perform a fundoscopic examination with your ophthalmoscope. You should verbalize how to orient the patient about this examination. (I am going to come close while shining the light to your eye in order to look at the back of your eYes. Try to look straight and do not move your eYes).

Verbalize to examiner that you are looking for hypertensive retinopathies: Permanent arterial narrowing Arteriovenous crossing abnormalities (arteriovenous nicking) Arteriosclerosis with moderate vascular wall changes (copper wiring) to more severe vascular wall hyperplasia and thickening (silver wiring). 22 | P a g e

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Sometimes, total vascular occlusion occurs. Arteriovenous nicking is a major predisposing factor to the development of a branch retinal vein occlusion. If acute disease is severe, the following can develop:

Superficial flame-shaped hemorrhages. Small white superficial foci of retinal ischemia (cotton-wool spots) Yellow hard exudates (intraretinal lipid deposition from leaking retinal vessels) Optic disk edema/ papilledema.

Dr Miller: Now I am going to ask some questions, which are the part of my examinations. (Checking the orientation) Do you know where you are now? (Orientation to place) Do you know what date it is? (Orientation to time) Do you know why you are here? (Orientation to person) [In 3 scenarios you should always check the orientation: 1- HTN, 2- SOB, 3- Volume status]

Now check the hands and comment on your findings: Dry or moist, no Nicotine stains, no clubbing, normal capillary refill, on out stretched hand there is no tremor (hyperthyroidism), and no sign of IV drug injection.

Dr Miller: am going to check your pulse now. Check the pulse and comment on the character of pulses; pulses are symmetrical, sinus, normal in volume, and contour. There is no delay on pulses.

Check the power of shoulder girdle power and comment about any weakness you may see, which may be obvious in Cushing disease, Hypothyroidism, Hyperthyroidism, or Hyperparathyroidism.

Now examine the thyroid gland by looking from front, and ask the patient to swallow (look for the movement). Then feel the thyroid bimanually from behind the patient. Also tap over sternum and listen for any dullness indicating retro-sternal thyroid enlargement. Verbalize your findings. 23 | P a g e

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Now you need to observe and then measure the JVP. You should verbalize your intension to perform this exam, and the examiner may stop you and tell you to the result or say: proceed. Examination of the JVP:

In normal person, usually can't see the JVP when patient is at 45, but can see when patient is flat.

Look at the RIGHT Internal Jugular Vein at supine in 45 degree while the patients head is rotated to the left.

Use the internal jugular, not external jugular. External jugular is lateral to SCM and easier to see. Internal jugular is medial/behind the clavicular head of SCM. Shine a torch [light] on internal jugular vein at an oblique angle. You can find a double waved pulsating vein (internal jugular vein) between two heads of Sternocleydomastoid (SCM) where the muscles are attached to the clavicle. You need to do four three tasks at this time:

1. Press gently on the base of jugular vein where it shows up between 2 head of SCM; the mild pressure should cause the vein disappear quickly.

2. Ask the patient to hold his breath and observe the vein. Ordinarily the JVP falls with inspiration due to reduced pressure in the expanding thoracic cavity. Kussmaul's sign suggests impaired filling of the right ventricle due to either fluid in the pericardial space or a poorly compliant myocardium or pericardium. This impaired filling causes the increased blood flow to back up into the venous system, causing the jugular distension.

3. Press against the liver and observe the JVP in the same time; you will see a fill up of the vein by pressure (Increasing preload). It stays up for 10 seconds and then it should drop in normal person.

4. Measure the JVP by; put a ruler perpendicular to horizon at the angle of Lewis (where the manubrium attaches to sternum), then use another long ruler perpendicular to the first one 24 | P a g e

25 | P h . E x & M a n a g e m e n t - and measure the height of the highest filling point of jugular vein from surface of chest. If it is less than 3-4 cm it is normal. Height >3cm above sternal angle is pathologic (raised ventricular filling pressure or volume overload often from RHF). ****** Key is 3cm and JVP has 3 letters ****** Then you need to examine the heart; Verbalize your exam & findings Inspect Check and feel the PMI (not enlargement, not displacement, not diffused, not sustained) Check and for the apex and para-sternal heaves Check and for the thrills

Listen to the heart for any murmur, click and comment on the normal S1 & S2 Ask the patient to roll on his left side and check (with bell side of your stethoscope) for S3 & S4 Now examine the abdomen; Verbalize your exam & findings Inspect for distension, palpating mass Look for caf-au-lait spots or striae Listen for bruits of Aorta (2 above umbilicus), renal arteries (left and right of umbilicus) and iliac arteries (in a 45 degree - half way from umbilicus towards the anterior superior iliac spine) Tap the abdomen for any pain or dullness over renal and supra-renal areas Feel deeper for any pulsating mass

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26 | P h . E x & M a n a g e m e n t Then check the lower extremities; Verbalize your exam & findings Check the femoral pulses (only verbalize that you want to do it) Check for Radio-Femoral delay Check for peripheral edema, Nail atrophy, and capillary refill Check for Ankle Brachial Pressure Index (ABPI)

Ask the patient to sit up and now listen to the base of the lungs for crepitation, between the scapulae for any bruit (collateral circulation due to coarctation of aorta) and feel and press over the sacrum for any edema.

Perform the ankle reflexes (increased in hyperthyroidism, and delayed relaxation in hypothyroidism)

CURRENT Medical Diagnosis & Treatment 2010: Malignant hypertension is by historical definition characterized by encephalopathy or nephropathy with accompanying papilledema. Progressive kidney disease usually ensues if treatment is not provided. The therapeutic approach is identical to that used with other antihypertensive emergencies. Parenteral therapy is indicated in most hypertensive emergencies, especially if encephalopathy is present. The initial goal in hypertensive emergencies is to reduce the pressure by no more than 25% (within minutes to 1 or 2 hours) and then toward a level of 160/100 mm Hg within 26 hours. Excessive reductions in pressure may precipitate coronary, cerebral, or renal ischemia. To avoid such declines, the use of agents that have a predictable, dose-dependent, transient and not precipitous antihypertensive effect is preferable. In that regard, the use of sublingual or oral fastacting nifedipine preparations is best avoided.

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CURRENT Medical Diagnosis & Treatment 2010: Identifiable causes of hypertension. Sleep apnea Drug-induced or drug-related Chronic kidney disease Primary aldosteronism Renovascular disease Long-term corticosteroid therapy and Cushing syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

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Case of Volume status assessment:


A 79 years old male had a total hip replacement 3 days ago. The nurse has concerns as he did not pass urine for the last 4 hours. The folly catheter has been removed this morning.

The best indices of hydration in post op patients are: Orthostatic hypotension and Urine output.

Knock. Knock. Knock.

Dr Miller: Hello. Good afternoon. My name is Dr Miller one of physicians working in the surgical department today. My understanding is that you had a hip replacement 3 days ago, and the nurse is worried about you as you have not passed urine in the last 4 hours. I am going to perform physical examination. Do you have any question before I proceed?

Ask for the vital signs. You may need to demonstrate how to measure the vital signs specially BP. Explain the patient that you are going to check his blood pressure and heart rate while lying down and once again when you ask him to sit up after 2 minutes.

Make sure you choose the right cuff for BP measurement by one of 2 following rules: 1- The width of cuff should be 40% of patients arm circumference. 2- The width of cuff should cover 2/3 of patients length of the arm.

First check the systolic BP by palpation, then check the BP by auscultation (inflate only 30 mmHg above systolic BP by pulse). There is a difference between two readings, which is called auscultatory gap.

Now ask the patient to sit up and wait for 2 minutes to measure orthostatic pressure. During the 2 minute you can continue with other examinations.

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Start with checking patients orientation to place, time and person; Do you know where you are now? (Orientation to place) Do you know what date it is? (Orientation to time) Do you know why you are here? (Orientation to person) Then comment about patients orientation to the examiner.

While the patient is sit up, listen to the lungs and check the sacrum edema.

You can examine the eYes and comment about pallor or jaundice. Also look inside patients mouth for hydration status and cyanosis by asking to flip up the tongue.

Then you can check the hand and comment if the skin is dry or moist, temperature, and capillary refill.

Now the 2 minutes are passed, so you can re-check the HR & BP while sitting. If the HR increased by 20 beats per minutes, or systolic BP dropped by 20 mmHg, or diastolic BP dropped by 10 mmHg (or dropped 15 mmHg in average) will be significant of orthostatic hypotension.

Then tilt the bed to 45 degree and observe and measure the JVP. Verbalize your findings. The same as above.

After JVP, examine the chest/heart, abdomen and lower extremities. In the abdomen you have to tap over bladder area to assess if the bladder is full or not. Finish the physical exam by explaining the examiner that you would like to see input / output and weight chart and also you will do a fluid challenge. You may consider putting a Foley catheter.

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Case of Blood Transfusion Reaction (unintentional medical error):


You are called to see a patient who was receiving blood and he has developed temperature and the BP has dropped. Nurse has found that the patient has received the wrong blood, so she has stopped the transfusion and called the doctor. She insists you not to tell the patient about mistake she has made. Do management in next 10 minutes.

Dr Miller: Hello. Did you called me to see your patient? As I understand he showed some reaction to transfused blood. Nurse: He received a wrong blood transfusion. I am worried about him as he runs a temperature and his blood pressure is low. Patient is angry about what has happened. Dr Miller: have you stopped the blood transfusion? Nurse: Yes I did. I removed the cannula and left the remaining blood and bag to send back to the blood bank. Nurse: please do not tell the patient that it was my mistake. He is going to complaint and I will loose my job. Dr Miller: Errors happen. Its important to make sure that patient is safe. Now, lets go to see the patient first and we will discuss about it later when we made sure the patient is safe. Ethics: When there is an unintentional medical error, we have to tell the patient and fill an incident form. Patient has all the right to know.

Now Dr Miller is talking to the patient: Dr Miller: Hello Mr Douglas. My name is Dr Miller, one of the physicians working in this hospital. Patient: What nurse was telling you? What has happened? Dr Miller: She was explaining about the incident has happened and also about her concerns. As you know Mr Douglas, unintentional medical errors happens. My priority is to make sure you are stable and safe. Patient: Who is responsible for that? Dr Miller: We do not know as yet. We need to investigate and I am going to fill an incidence form. As soon as we have got any result from our investigation, we will let you know. Dr Miller: I should perform physical examination and make sure you are stable. 30 | P a g e

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Start your examination with ABCD

Blood transfusion has three different reactions. One of them is anaphylaxis, so make sure there is no swelling inside the mouth and airway is clear. Can you hear any wheeze?

Check A: Ask the patient how is your breathing? Do you feel any itching inside your throat?

Check B: Listen to the lungs for checking air entry, and heart sounds. Check the oxygen saturation and give oxygen regardless.

Check C: Ask about vital signs. Then ask for removing the previous IV line and insert a new IV line and give fluid. How much? Depend what are the vitals?

Make sure patient has at least one IV access before removing blood transfusion cannula (Be worried about immanent shock, so do not leave the patient without IV access)

The previous IV cannula along with all tubes and remaining blood should be sent back to blood bank for analysis and re-crossed.

Inform the blood bank about the error, to make sure that patients matched blood is not been sent to another patient by mistake.

Draw a complete set of blood samples for routine bloods and coombs test, FDP (Fibrinogen Degradation Products), and Haptoglobuline. Check the bilirubin and liver enzymes along with coagulation profile. Send a urine sample as well.

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Check D: Check the pupils and verbalize your findings when you shine the light. Check for the power and sensation of upper and lower extremities. Verbalize: Patient is grossly neurologically intact. Give Tylenol for his temperature.

Ask the nurse to prepare and keep Epinephrine, Steroid, Diphenhydramine and Fluids close to the patient.

Now the primary survey is over and you should move to secondary survey, by taking history.

History: Febrile reaction questions: Do you feel any temperature or chills? Did you have any temperature or chills before receiving blood?

Anaphylactic reaction questions: Do you feel any itching inside your mouth? Do you feel itching on the skin? Have you developed any hives? Do you feel any wheeze or SOB?

Hemolytic reaction questions: Do you have any back pain? Press on his back and make sure if he feels any pain. Do you have any flank pain? Press on his flanks and make sure if he feels any pain. Check the site of IV line and verbalize: There is no oozing at the site of IV line.

Is it the first time you received blood? If no, why you received blood before? Why you are receiving blood today? Do you have any long term disease?

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Now start counseling: Mr Douglas, blood transfusion is a life saving measure. Its common to receive blood and thousands of people receive blood every year. We take a lot of measures to make sure it is safe. However like any other medical intervention, there are some side effects related to transfusion, which could be serious. The most common side effect is fever or febrile reaction, which is around 3%, usually self limited and it might happen again. We are going to give you Tylenol next time to prevent febrile reaction. The other one is called anaphylactic reaction that is kind of severe hypersensivity or allergy. It is very serious but we cannot predict it and it might happen any time. However we have good treatment for it and we know how to deal with it and the symptoms you showed are less likely to be any anaphylactic reaction. The third reaction is more serious and it is called hemolytic reaction. It happens when patient receiving blood from other blood groups. Bear in mind the blood you received is from the same blood group; however we sent the remaining to the blood bank for analysis and re-cross match. I will update you as soon as I receive any news from blood bank. For the time being, my priority is to make sure you are stable, so we continue monitoring. Two important points you have to verbalize are: I am going to fill an incident form I am going to inform the blood bank about the error and prevent sending patients blood to someone else by mistake.

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Case of Acute Abdomen:


42 years old male has come to the ER because of abdominal pain for the last 24 hours.

Knock. Knock. Knock. Dr Miller: Hello Mr Douglas. My name is Dr Miller one of the doctors working in the ER today. Please to meet you. As far as I understand, you have acute abdominal pain for the last 24 hours. For the next 10 minutes I am going to perform abdominal examination and report my observations and findings to the examiner. During my exam, if you had any pain or discomfort please let me know.

Look at the examiner and ask for the vital signs. Verbalize your finding about general appearance; By looking at the patient he is comfortable lying down without any distress.

Check the eyes for pallor or jaundice. Check the mouth for any sign of dehydration. Then check the hands for capillary refill.

Now you should cover the patient with a sheet (DO NOT EXPOSE BEFORE YOU DRAPE) and always explain to the patient what you are going to do. (Always frame the situation and your actions to the patient) Dr Miller: I am going to drape you with this sheet and then expose your abdomen for examination. Is that OK with you? Dr Miller: could you please roll up your gown? Do you mind if I roll your gown up?

Observe the abdomen and verbalize to the examiner your findings along with your observations; By looking at the abdomen, the abdomen is flat, not distended, abdomen moves with breathing, the umbilicus is inverted and there are no scars or bruises.

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35 | P h . E x & M a n a g e m e n t Ask the patient to turn his head to the left and make a cough to check if there is any cough tenderness. You should observe the patients face. If there is no discomfort, ask for the second cough and now look at the abdomen for any abnormal bulging or herniation.

Then warm your stethoscope and listen to the bowel sounds at McBurneys point. Always explain to patient what you are going to do, check the stethoscope temperature on patients arm and verbalize your findings for examiner. Also check for Aortic, Renal and Iliac bruits.

Now tap the abdomen (in 9 points). Check for tenderness.

Then perform superficial palpation in all 9 areas. Always frame for the patient, what you are doing and verbalize to the examiner about your findings. Now do deeper palpation and look for any palpable masses, and check for kidney sizes.

Perform special tests: Murphy sign (press down at the area of gall bladder while patient takes deep breath) McBurneys tenderness or rebound tenderness Rovsing sign (pressing over left lower quadrant causes pain in RLQ) Psoas sign (only on the right side) Obturator sign CVA tenderness

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Then sit up the patient and check the breath sounds at the bases of lungs, and check for sacral edema.

At the end verbalize you are going to feel inguinal areas for hernias, will perform digital rectal exam for blood, hemorrhoids, and assess the prostate, if patient is woman will do bimanual pelvic exam to look for any discharge, bleeding, adnexal mass or cervical tenderness.

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Case of acute abdomen (Crohns disease):


Male patient with a history of Crohns disease for the last 5 years has come to ER with abdominal pain for the last 24 hours.

Knock. Knock. Knock. Dr Miller: Hello. Good afternoon. My name is Dr Miller one of the physicians in the ER. As far as I understand you have abdominal pain for the last 24 hours. Also you have Crohns disease for the last 5 years. For the next 10 minutes I am going to perform abdominal examination and report my observations and findings to the examiner. During my exam, if you had any pain or discomfort please let me know. Look at the examiner and ask for the vital signs. Verbalize your finding about general appearance; By looking at the patient he is comfortable lying down without any distress. No signs of truncal obesity because of use of steroids.

Check the eYes for redness, pallor or jaundice. Check the mouth for any sign of dehydration or mouth ulcers. Check the face for moon face due to long term steroid use. Then check the hands for nail changes, clubbing, skin rash or psoriatic changes. Check for capillary refill.

Observe the abdomen and verbalize to the examiner your findings along with your observations; By looking at the abdomen, the abdomen is flat, not distended, abdomen moves with breathing, the umbilicus is inverted and there are no scars or bruises. Check for Striae. Ask the patient to turn his head to the left and make a cough to check if there is any cough tenderness. You should observe the patients face. If there is no discomfort, ask for the second cough and now look at the abdomen for any abnormal bulging or herniation.

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Then warm your stethoscope and listen to the bowel sounds at McBurneys point. Also check for Aortic, Renal and Iliac bruits. Verbalize your findings to examiner.

Warm your hands before touching patients abdomen. Perform superficial palpation in all 9 areas. Check the span of liver by tapping from the top and deep palpation from the bottom. Check the spleen span by deep palpation from RLQ towards the LUQ. Now do deep palpation all around and look for any palpable masses, or abscess.

Perform special tests: Murphy sign McBurneys tenderness or rebound tenderness Rovsing sign Psoas sign Obturator sign CVA tenderness

Check the lower extremities for joint swelling and Erythema Nodosum.

Then sit up the patient and check the breath sounds at the bases of lungs, and check for sacroiliac joint tenderness.

At the end verbalize you are going to feel inguinal areas for hernias, will perform digital rectal exam for blood, hemorrhoids, and fissures. If patient is woman you should perform bimanual pelvic exam to look for any discharge, bleeding, and adnexal mass or cervical tenderness.

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Case of Shortness of Breath following a surgery done 3 days ago:

Male patient who had operation 3 days ago has developed shortness of breath for the last 20 minutes. You are called to assess the patient. Do physical examination

Knock. Knock. Knock.

Dr Miller: Hello. Mr Green. My name is Dr Miller one of the physicians in the ER. As far as I understand you had an operation 3 days ago and now you have developed shortness of breath for the last 20 minutes. For the next 10 minutes I am going to perform physical examination and report my observations and findings to the examiner. Do you have any question? Look at the examiner and ask for the vital signs and ask for orthostatic hypotension.

The examination starts with checking patients orientation to place, time and person; Do you know where you are now? (Orientation to place) Do you know what date it is? (Orientation to time) Do you know why you are here? (Orientation to person) Then comment about patients orientation to the examiner.

Verbalize your finding about general appearance; By looking at the patient he is lying down with no pain but some shortness of breath.

Check the eYes for pallor or jaundice.

Check for any nasal flaring.

Check the mouth for any sign of dehydration, central cyanosis, and pursed lips.

Verbalize about any sign of respiratory distress according to your observations.

Then check the hands for peripheral cyanosis, clubbing. 39 | P a g e

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Check for capillary refill and skin to see if it is dry or moist.

Check the pulse and comment on the character of pulses; pulses are symmetrical, sinus, normal in volume, and contour. There is no delay on pulses.

Look at the lower extremities for any swelling or erythema compatible with DVT.

Check the lower legs and feet for skin temperature, pulses of dorsalis pedis and tibialis posterior.

Check for capillary refill and peripheral edema.

Squeeze the calves and look for tenderness related to DVT.

You should compare the calves circumferences diameters by measuring around calves exactly 10 cm below the tibial tuberosities (land mark)

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If the difference of circumferences are >2.5 cm, it is significant for DVT.

DVT specific test: Homans sign: This test is controversial, just verbalize it.

Now you should examine the respiratory system by starting to observe and examine the neck.

Check the neck by looking at trachea and make sure it is central. Check if any accessory muscle is used for breathing. Look and feel for any lymphadenopathy.

Check the JVP at 45 degrees, and verbalize your findings to the examiner. 41 | P a g e

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Then examine the chest starting by inspection of the chest; By inspection there are symmetrical movements of the chest, no intercostal retraction, no accessory muscle is used for breathing.

PMI is obvious. Comment about PMI if you have time. Check for heaves and thrills. Feel the chest for any local tenderness. Check the vocal fremitus by asking the patient to say 99 while you are feeling the chest by palms.

Ask the patient to take deep breath in and out while your palms are on the chest wall and measuring chest expansion. From the back check the level of diaphragm by tapping the chest wall, then ask the patient to take a deep breath and tap again. If the movement of diaphragm is >5 cm so it considered as normal.

Listen to the heart sounds (S1 & S2). Turn to bell side of stethoscope to listen for S3 or S4. Listen to the aortic, pulmonary, mitral and tricuspid valve areas for any murmur, splitting of S2 over pulmonary valve (in Pulmonary Embolism S2 splitting is prolonged).

Now listen to the breath sounds by comparing each point with same point on the other side of chest. Listen over 6 points of chest anteriorly. Listen to the mid axillary line for middle lobes. Listen to the back and base of the lungs for inferior lobes. + feel for sacral edema.

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The sequence of this examination is different with the other examinations. Why? Because in this scenario you must examine the lower leg examination, so the lung and heart examination should be performed at the end if you have time.

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1|Neurology

Headache, temporal arteritis 67 male with headache, 10 days, emergency room, 5 min Hx KKKKKKKK Dr: hello Mr. Douglas Im Dr. Miller one of the physician working in the emergency room. (or Im the doctor in charge in the emergency room) as I understand you are here because you have been having severe headache for the last ten days, could you tell me more about it from the moment it started? P: increasing headache and Not improving Dr: How did it start? P: gradually Dr: from that time till Now, is it on and off or is it all the time? P: it is all the time (So every primary headache is Not related or concerning for long period) Dr: is it increasing, decreasing or the same? Dr: would you say it is the worst headache in your life? P: Yes (But it is Not SAH because 10 days) Dr: did you Notice any variation? Is it more at certain time of the day? And does it wake you up from sleep? P: No Empathy because it is continuous: were you able to sleep last night? P: No, for 3 days Dr: How are you coping, it must be difficult. Youve done the right thing by coming here. Hopefully well be able to deal with it. Dr: can you show me where your headache is? .....Is it always here?..... How does it feel? P: it is vague,

2|Neurology

Dr: is it throbbing? P: No, it is deep and dull Dr: does it shoot anywhere? P: No Dr: on scale from 1 to 10, in which 10 is the worst pain, where do you put it? (Because it is one episode trigger is Not relevant) Dr: anything increase or decrease it? Is it related to coughing? Leaning forward, lifting objects, lying down? Dr: did you try any medication? How much did you take? Did it help? Transition for associated sx: in addition to your headache did you Notice any other symptoms? Constitutional: Dr: do you have any fever, night sweats, chills, lumps and bumps, loss of appetite, weight loss? P: No Infection: Dr: any vomiting, nausea, any neck pain, any bothered by light, any recent flulike symptom, ear infection, skin rash? Anybody around you have headache? Localization, neurological screening: Dr: Do you have any change in your vision, hearing problem, buzzing sound, difficulty swallowing, difficulty finding words, did you have any weakness, numbness in your arm and legs, any difficulty with your balance, any falls, any change in your bowl movement, difficulty passing urine, any dizziness, light-headedness, jerking movement, loss of consciousness, any history of seizure, any mood changes, concentration, memory problem, anybody told you that theres change in your personality? P: I have difficulty with my vision. Dr: what kind of change? P: curtain falling or blurry vision (in TA) Dr: one eye or both, when did it start? (Because we have eNough evidence to suspect temporal artritis we should either roll out or confirm it.)
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3|Neurology

Dr: when you touch this part, does it fell painful? When you combing your hair is it painful? Do you feel any cord-like structure? When you are chewing do you have any cramps? Do you have any pain or weakness in your shoulders and hips? (go back to neurological screening after vision) Any history of head injury or fall? Any blood thinner? Do you drink alcohol? ( for subdural hematoma) (Depressing in elderly is ddx, and we r/o by asking mood) Extra cranial causes: Any pain in your eyes, any redness, do you need eye glasses, do you have history of sinusitis? Any pain in your face, runny Nose, ear pain, pain with your teeth? History of hypertension, Rebound headache Do you take any medication or pain killer? How much? PMHx FHx Social Hx

4|Neurology

Case 24 female headache in the last six weeks

KKK D: introduction, open ended question P: for the last six weeks severe headache Not improving D: Im glad you come here today. Do you have headache at this moment? How did it start? From that time till Now, is it continuous or on and off? How often (how many times)? (Frequency at the beginning and Now) D: How long does it take each time? Can you show me where is your headache? P: always right. D: How does it feel like? Throbbing, dull? Does it shoot anywhere? P: No D: on scale from 1 to 10 where do you put it your pain Now and before? Is there any variation? Do you wake up with headache? Any relation between your headache and cheese, chocolate, coffee and red wine? Lack of sleep, stress, flashing lights, certain smells? Is it related to your period? Do you take any medication? What about birth control pill? What kind? How long? Have you changed it recently? Anything increase it? Anything decrease it? Is it increased by load Noise/ light? Do you try to go to quiet room and try to relax? Does Any medication help? Is it the first time or youve had headache before? Which kind? When? Any treatment? P: it was usually one day.

5|Neurology

Constitutional Sx Local Sx DDx: Any stress in your life? Financial concerns? With whom do you live? PMHx, FHx, social Hx Drug and alcohol Counseling: Most likely your headache is related to migraine you are having, but because youve started new tablet, sometimes in some patients it might increase or trigger the event of migraine. What I recommend is you discontinue it and go back to your family doctor to change it and five you aNother form of contraceptive, progesterone or IUD.

6|Neurology

35 male headache 4 weeks, hx

KKK 1. The patient gives us the clue Introduction P: for the last four weeks I have severe headache without improving and Im concern D: what kind of concern do you have? P: Im afraid Ill lose my job? D: what makes you feel that? P: because I have headache at work. 2. Patient doesnt give any clue D: How did it start? P: gradually D: from that time till Now is it on and off or all the time? P: all the time D: is it increasing, decreasing or the same P: increasing D: did you seek medical attention before? P: No Anything increases it, decrease it, leaning forward, wake up D: How often do you have attack? P: almost every day How long does it last? In the evening: P: after my work? D: what do you do for the living? Any certain setting? What about on the weekends?
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7|Neurology

P: headache free. Associated Sx: What do you do for the living? P: Fork-lifter Is it open or close environment? Do you have any measurement alarm for co poisoning? How often this place get checked and anybody else has the same headache at work? PMHx FHx Social Hx (How to finish 5 min scenario: Ill do PhEx do some blood work and imaging and we will take it from there.)

8|Neurology

24 male has headache for the last six weeks, history and counseling
Approach to headache: 1. Intermittent: primary: tension, migraine, cluster 2. Constant: secondary

KKKK Introduction D: As I understand you are here because you have been having headache for the last six weeks, can you tell me more about it. P: This time it started gradually six weeks ago (so we understand that there was a pervious episode) D: Also, you have been having before? P: Yes D: For How long? Did you seek medical attention? P: If Yes D: what was the diagNosis, which treatment If No D: lets finish your todays headache and well talk about your previous headache later. D: from that time till Now is it all the time or on and off? How often? P: Almost every day D: How long does it last each time? P: On the weekdays few hours weekend 30 min to 2 hours D: Do you wake up with this headache? P: Only on the weekend
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9|Neurology

D: How about during the week? Do you wake up with headache? P: No D: When? P: Before I sleep. D: Where is you headache? Even the weekend? P: No D: Lets talk about your headache in the weekdays later well talk about the weekends. How does it feel? P: Squeezing D: from 1 to 10 where do you put it? Any increasing or decreasing? Did you try any pain killers? Does it help? Your headache on the weekend, where, quality, wake you from sleep, pain with your eyes, runny Nose, horner symptoms Anything brings it? Do you drink alcohol? Did you Notice any relation? Did you Notice any headache at one half of your head, any flashes, lights before your had a headache? Is it increasing by light or voice? Triggers: coffee, chocolate, cheese, red wine, lack of sleep, excessive sleep, stress, hunger, certain smells, periods, OCP, flashes light (Rule out serious conditions) any fever, chills, night sweat, lumps and bumps, loss of appetite, weight loss, head trauma, Localization: vision, hearing, buzzing sound, weakness, numbness, concentration, etc. (Because of the ddx tension r/o or confirm) are you under a lot of stress in your life? What kind of stress? How do you handle it? What do you do for the living? How do you support yourself financially? Any stress at work?

10 | N e u r o l o g y

Explore the headache before 6 weeks. Alcohol? Do you drink more? How much? For How long? Why do you drink more? P: I broke up with my girlfriend D: How is your mood? Or Do you feel depressed? Or How do you feel? If he is depressed then MIPASSECG PMHx FHx Counseling: It looks like you were going to difficult time. That caused you a lot of stress, you are under stress, this stress could sometimes cause or increase headache, you told me youve been having tension headache before but this time because of the stress youre having longer and more severe attack. That could be dealt with relaxation techniques, meditation, counseling and some medication. Sometimes drinking more alcohol can trigger of headache we call it cluster headache, what I recommend is you try to decrease or cut down. ( if the drinking was long cage him) that will improve your headache ( if you find depression or adjustment disorder with impact on life we should advise him: we can try antidepressant.

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11 | N e u r o l o g y

24 year old, male, severe headache for 6 weeks, take history and counsel.
Increase ICP Symptoms: headache in the morning, continuous, wake me up from sleep, increased with cough Causes: 1. Space occupying lesion, primary or metastasis (so we ask any history of tumor (e.g. Leukemia, lymphoma) and family history of brain tumor) 2. Infection with toxoplasmosis or abscess (ask IV drug and HIV status), HIV can cause primary lymphoma too. In young people we can ask directly what is your HIV status? or if it is overwhelming we can say, Sometimes patients having HIV positive or AIDS might have similar type of headache. Have you ever checked or do you have any concern to be checked for HIV?

KKKKKKKKKK Introduction: hello Mr. Davis, Im Dr. Miller one of the physician working in the emergency room. As I understand youve been having headache for the last six weeks. Can you tell me more about it from the moment it started? P: my headache is increasing and its Not improving Dr: How did it start? Suddenly or gradually? Dr: It seems you are in severe pain do you want to lay down, can you bare with me. Dr: From that time till Now, is it all the time or is it on and off? P: it was on and off at the beginning then its constant. Dr: when did it become constant? Are they the same or different? P: from two weeks ago.
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12 | N e u r o l o g y

Dr: In the beginning, How often did you have it? Was it increasing? Any certain time of the day? Was it in the morning or evening? P: morning Dr: Does it wake you up from the sleep? You told me its continuous; However, did you Notice any variation? Is it the first time or youve had it before? Where is your headache? Is it always there? How does it feel? Is it throbbing, pulsating, deep? P: Deep and dull headache. Dr: Does it shoot anywhere? P: No

Dr: On scale from one to ten in which ten is the worst headache where do you put it Now and at the beginning? It looks like you are suffering a lot good you are hear. (Because it is continuous Noneed to ask about triggers) Dr: Anything increase it? Decrease it? How about coughing, leaning forward, lying down, lifting Dr: Anything make it better? Pain killers? Did it help or Not? Dr: How did it affect your life? (Or I can see why you are concern bare with me or How do you feel? Or whats your expectation from todays visit?) Dr: Any fever, night sweat, chills, weight loss, loss of appetite (if positive then when did it star? Did you measure it?) P: Yes, I have weight loss (shows headache is the manifestation of the underlying disease) Dr: How much did you lose? When? Dr: Any neck stiffness, forceful vomiting, skin rash, recent flu, or ear infection, any vision change? Any hearing problem? Dr: Any weakness, numbness in your arm or leg? Dr: Do you have difficulty with your balance? Any fall? Dr: Difficulty passing urine, change in your bowel movement, dizziness, light headedness, loss of consciousness, jerking movement, history of seizure, any mood,
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13 | N e u r o l o g y

concentration and memory changes? Did anyone tell you that your personality had been changed? Dr: Head trauma, head injury Dr: Do you have any history of cancer, brain tumor? Any history of brain tumor in your family? Dr: Sometimes patient having HIV may present with similar kind of headache have you ever been screened for HIV? P: Yes Dr: what was the result? 1. If negative: when? P: ten years ago? then ask risk factors. 2. If positive: when, How, did you receive treatment? When was the last time you had follow up visit? what was your CD4 count? P: I stopped because of side effect of drugs D: what kind of side effect did you have? What was your last CD4 count. (If he was diagNosed Noneed for risk factors, if he wasnt diagNosed go for risk factors: drug, homosexuality, and ask about symptoms of HIV: weight loss, chronic diarrhea, chest infection, cough, TB, skin changes, ulcer in the mouth, burning sensation (heartburn)) Social history (because it is related we ask it here) Dr: Drug, with whom do you live? Med Hx: Any medicine, allergy? PMHx: Hospitalization, any surgery, any other condition? Counseling: Mr. Davis, any question before I proceed? We need to do some physical exam and blood work and imaging for your brain. However, based on your symptoms it sounds concerning for that reason, we need to admit you today. Because you stop your medication you may be vulnerable to have some kind of infection related to HIV virus. We might use some medication, antibiotics, to treat it and it is important youll be seen by infectious disease specialist. Make new combination to decrease your side effects. Any question? Thank you.

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35 year old female headache six weeks clinic Hx and counseling


Presentation for domestic violence: 1.Headache 2.Abdominal pain 3.Insomnia 4.Sleeping pills 5.Vaginal bleeding

KKKKKKKKKK Introduction, Open ended question (Usually they dont have good eye contact and pain is vague and patient is Not cooperative) D: How did it start? P: I cant remember, gradually D: Anything specific at that time? P: No D: from that time till Now, is your headache all the time or on and off? How often do you have it? How long does it last? Where is it? Does it shoot anywhere? How does it feel? Severity? Anything increase it, decrease it? P: more on the weekends. D: anything change in the weekends? What happens on the weekends?

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Constitutional sx (quick primary headache) Transitional: I want to ask you some questions about your social life. D: with whom do you live? P: my children and my husband. D: How do you support yourself financially? Any change in your life? Any stress? (Confidentiality) Id like you to kNow our relation is extremely confidential, whatever you tell me its going to be confidential; we do Not release any information without your permission, unless otherwise Im asked by the law. (Go for something else after confidentiality and come back later) PMHx How is your mood? Interest? (To rule out or confirm depression) Smoking, alcohol, drug M P: .. my husband D: How is your relation with your husband? 1. Is your husband going through a lot of stress? Did he change in his life? Does your husband drink? Does he drink more Now? Does he drink to the extend he lose control and get angry? 2. If he is under stress, How does this stress affect his life? Does he get angry? Do you have more argument, recently? Does he get angry?

When he gets angry, what does he do? Does he start to shout? Does he shout at you? Does he swear at you? Does he call you names? does he try to put you down? How does it affect your self-esteem? Did he ever get angry? Did he ever get angry to the extent that he became physical? Has he ever hit you or pushed you? Did you visit emergency room? How many times? Was there any serious consequence? Does he ever force you to have sexual activity against your will? Who control spending at home?
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Do you have access to bank account? Did he ever mistreat you in front of the children? (If Yesbecause of emotional abuse to the children inform child society) Have you ever thought of ending your life or his life? Do you have access to weapon at home?(Support) Do you bring it to somebody you trust? Did you talk to anybody? Any member of the family or who you trust? Counseling: 1. She wants to get helped 2. She doesnt like to leave but accepting help 3. She doesnt want help and support the abuser 1. Id like you kNow, based on what you told me, what you are experiencing is called domestic violence or spouse abuse. And its illegal, its a crime against law and unacceptable, and you shouldnt tolerate it. And its Not your mistake; you havent done anything to deserve that. And you shouldnt feel guilty. And we kNow from the studies the situation will deteriorate without help. Thing will go out of hand. For that reason, we recommend that you call police to arrest him. P: he is a financial provider for us! What will happen to us? D: being a mother with children and being domestic violent victim you have priority. You have support from the community. There are resources, Ill give you phone number for help groups. They will help you with housing, financial support for yourself and you children. Later they will help you to start your life again. 2. P: he is a good man. D: ok. I can see. That could be the situation. As I told you the situation will Not improve and this the vicious-cycle. The more you stay together the more abuse would be there. My fear is that thing will get out of hand. We kNow from the studies if you involve the police by court they will push him to get help and treatment (dont let her call the police from your office) 3. P: I like him, he is the best. He is great. D: If you go back home Now, do you feel safe? What if thing get out of hand? I recommend you prepare a bag and put your essential needs, some money and document. Put it in a place in case you need to leave, you can immediately take. Id like to see you in 3 days. But you can always call the police. Once they arrest him and put under chare, the court put him on some kind of rehabilitation and probation.

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A case of carpal tunnel syndrome (CTS)

Dr : Hello, good afterNoon. Mr Douglas. I am Dr Miller. I am one of the physicians working in the clinic today. As I understand you are here because you have pain in your right hand for the last 6 weeks. Can you tell me more about it from the time it started? (we asked CC and asked open ended questions) Patient: For the last 6 weeks I have been having increasing pain in my right hand which is Not improving. Dr : OK, I see. Did you seek any medical attention before? Any doctors? Patient: No Dr : What motivates you to choose to come today? Patient: Nothing (or may tell you because of starting of weakness) Dr : How did it start? it started suddenly or gradually? Patient: It started gradually. Dr : From that time till Now it is all the time or it is on and off? Patient: It is on and off. Dr : How often you have it? Patient: Almost every day. Dr : How often at the beginning? Patient: Less often, but it is more Now. (We establish that it increases in frequency. ) Dr : What is the duration of each attack? Patient: few seconds to minutes. Dr : What brings its attack (we want to kNow the relation to position or movement)?

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Patient: I have it at work. Dr : What do you do for living? Patient: I am a carpenter (Show empathy) Dr : How did it affect you? Are you still able to work? Are you missing some days of your work? Good you are here today. Hopefully we will be able to deal with your pain. Is it more in night or in day? (PQRST) Show me where is the pain? How does it feel? Patient: it feels like an electric shock Dr : Does it shoot anywhere? Dr : What is the severity in scale of 1 to 10? Did you take any medication? What makes it better or worse? Associated symptoms: Any swelling? any redness, skin changes, burning, tingling , numbness, weakness. (when it reaches weakness it needs surgery.) What about the other hand? Differential diagnosis: (C6 radiculopathy) Dr : any neck pain, neck trauma, relationship between moving your neck and pain in your hand? fever, night sweat, chills, lumps, bumps, loss of appetite, weight loss?

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Dr: I am going to ask questions about risk factors. We have to ask about diseases and their symptoms. Dr : Now I am going to ask about some conditions to see if you have any medical condition that may explain your pain. (Hypothyroidism) Do you have any history of thyroid disease? (If he tells No, then) Do you feel cold, if everybody is feeling fine? Do you have any constipation or dry skin? Do you have any history of any trauma to your wrist or fall? Do you have any history of rheumatoid arthritis? skin rash? Do you have any history of Diabetes? Drinking more? eating more? peeing more? going more to the washroom? Do you have any history of Acromegally? Do you Notice that your rings are getting tight? Your shoes are tight? If you wear gloves and hats, do you find they are getting tighter? Next time bring me a photo of yourself that you were ten years younger. (If patient is a woman) Are you pregnant? (medications such as steroids) Any medication? (Amyloidosis)

What do you do for living (if you did Not ask before. Some jobs such as Jackhammer are prone to CTS.) Any job with repeated movement of the hand? ( Then we go to PMHx and FHx)

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40 Y/O female, RT. Arm weakness for the last 6 hours in ER:

Dr : Hello, good afterNoon. Ms. Greenwood. I am Dr Miller. I am one of the physicians working in the emergency room today. As I understand you are here because you have weakness in your right hand for the last six hours. Would you please tell me more about it from the moment it started? Patient: This morning after I had my hot shower and when I was preparing my breakfast, my arm dropped suddenly. Dr : Did you burn or hurt yourself? Patient: No. Dr : OK. How did it start? Suddenly or gradually? Patient: Suddenly. Dr : And from that time has it been on and off or all the time? Patient: Nodoctor. All the time. Dr : When you say weakness, what do you mean? Can you move your arm at all or you find it is difficult than before (severity of weakness)? Dr : Where is the weakness: hand, arm or your shoulder? Dr : Any numbness, tingling in your hand? Dr : Any weakness, tingling or numbness in the right leg or left hand and leg Now? Dr : Any weakness, tingling or numbness in your legs or hands before? If patient answers yes, then ask her: How long it lasted and was there full recovery? Dr : With this weakness, do you find any difficulty finding words, or anybody tells you it is difficult to understand you? Have you had at any times including today any complaints such as: any change in vision (if says yes, you have to clarify How many times, what does she mean by it such as blurred vision, double vision and if any change in vision in warm places like taking hot showers), difficulty in hearing, buzzing sounds in your ears, difficulty swallowing, difficulty with balance and falls, difficulty in urination (sometimes when patients have these symptoms they may Notice changes in their urination or even in their bowel movements or they might loose control of their urination or bowel movement. Have you ever experienced these?)
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Dr : Any dizziness, light-headedness, headache, jerky movements, loss of consciousness, seizure? When you bend your neck, is there any electric shock along your spine (Lhermitte sign)? Any electric shock or pain in your face when shaving your face (male) or chewing or eating (trigeminal neuralgia)? Dr : Any change in mood? Memory? concentration? Any change in your personality? Any changes in your symptoms and hot place (Uhthoff pheNomeNon)? Dr : (Now we ask for constitutional symptoms) Any fever, night sweat, chills, lumps, bumps, loss of appetite, weight loss? Dr : (Now we ask for ROS from head to toe) Any chest pain, heart racing, shortness of breath? Cough, wheezing, phlegm, chest tightness? Abdominal pain, heart burn, nausea, vomiting, bowel movement? Flank pain, urine changes, burning sensation, frothy urine, going more to the washroom, and loose of control? Any yellow discoloration of skin, itchiness, and pale stool? joint pain, joint swelling, skin rash, ulcers? red eyes? Anybody told you are pale? bleeding from anywhere, your Nose, your gum, bruises in your body, coughing blood? Do you feel cold or hot when everybody is fine? (thyroid) Do you feel any dry or moist skin, shakiness, constipation, weight gain? (Diabetes) Do you drink more, going more to the washroom, do you feel tired? (Always when asking for anaemia in females ask for) When was the last period? Heavy? Regular? PMHx? FHx of multiple sclerosis, stroke?

If a patient with a chronic condition (like MS) states that if later in life he/she becomes unconscious and needs ventilation, do Not ventilate him/her and on the time of decision he/she was competent, then Now what should we do if the patient looses consciousness and needs ventilation? Answer: We have to respect her decision (because she made the decision when she was competent) and do what the patient asked before.

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67 Y/O male, RT.arm weakness from 45 min ago:

Dr .: Hello, good afterNoon. Mr Douglas. I am Dr Miller. I am one of the physicians working in the emergency room today. (You are starting to shake his hands but may Not be able to do it because of his weakness). As I understand you are here because you have weakness in your right hand for the last 45 minutes. Would you please tell me more about it from the moment it started? Patient: Yes, Doctor, what do you want to kNow? Dr .: How did it start? Suddenly or gradually? Dr .: What were you doing? Patient: I woke up. I was preparing my tea pot, that my arm dropped or I was holding the tea cup that my arm dropped. Dr .: Did you harm yourself? Did you burn or hurt yourself? Dr .: Were you sitting or standing? Did you fall down at that time? From that time is it all the time or on and off? (You can ask if it was the first time or you had other episodes before. You can ask this question later.) Dr .: When you say weakness, what do you mean? Is it completely weak or you can move it with the grip Not as strong as before? Dr .: Where is this weakness? Is it in your hand, arm, How about your shoulder? Dr .: How about any tingling, numbness? In addition to weakness in your right arm do you have any weakness in your right leg? (If he says: yes, then did they start together? same time or different time? Which one is weaker? Which one bothers you more? your arm or your leg?) (if he says: I have weakness in my leg, tell him: were you able to walk? were you dragging you foot? How about your balance?) Dr .: How about your left arm or your left leg? Dr .: Is it the first time it happened to you or you have it before? Patient: No, it is the first time.
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Patient: Suddenly.

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Dr .: At that time, were you alone or with someone else? Patient: I was with my wife. Dr .: Did she tell you it was difficult to understand you? Or did you fine it difficult to find words? (then you have to check for other neurologic symptoms.) Dr .: Do you have any headaches? dizziness? jerky movements? loss of consciousness? (then to check if any involvement of face) Dr .: Did you feel any food stuck in your cheek? Did you feel any numbness in your face? (then we go for the rest of neurologic symptoms) Dr .: Loss of vision or curtain (falling in front of eyes) or blurred vision? hearing (difficulty) or buzzing sound? Difficulty swallowing? difficulty in balance? difficulty in passing urine or change in bowel movement? How is your memory/concentration recently? How is your mood recently? (to rule out any malignancy) Any fever, night sweat, chills, lumps, bumps, loss of appetite, weight loss? Risk factors: Dr .: Any history of high blood pressure? high blood sugar? high blood cholesterol? sugar and cholesterol measured or Not? smoking, alcohol, recreational drugs? Any history of heart attack or disease? Any history of stroke or heart disease in young age in your family? Have you ever diagNosed as having atrial fibrillation? Any history of heart racing? (in this case) Patient: yes. Dr .: For How long? is it regular or No? Can you tap it for me? (if he says No, it does Not exclude it. You can find it with physical exam and ECG.)

Dr .: Do you remember you have any head trauma/injury? Do you take any medication like blood thinner?

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1|OB/GYN

OB/GYN Counseling:
1. Urgent Antenatal Visit Case: 39 Y/O female came to the clinic because she found that she is pregnant last night.Next 10 m. take Hx and counseling. (she asked for urgent meeting).
Role- play: (some important phrases) Pt. has concern about her age + pregnancy. She asks if Dr. can make sure that the baby is healthy 100%, otherwise she wants abortion. Whenever you take Hx: always you should ask about concerns answer take Hx In above case you need to take hx before addressing her concerns. She is worry about down syndrome. Why she is worry about it. When you take hx go for Menstruation: LMP-Preg.test -Preg.sx.(in Canada repeat preg.test) Gynecology.4 questions , Obstetric, Sexual.1 question PMH: you look for RF FHX: you look for congenital anomalies Education advise We have some screening tests for congenital anomaly.

Amniocentesis When Accuracy Risk of abortion + Risk of fetal limb inj Results take 2wk 14-16 wk 99.97% 1/200=0.5%

CVS 10-11 wk 97.% 3% false neg. 1/100=1-2%

48h

CVS is not accurate & risk of abortion is higher. .At age of 35 the chance of having baby with congenital anomaly is 1/180 half of 1

2|OB/GYN them are Down sy = 1/365 The chance keep increasing when we get older. At age of 45 the chance of having child with Down syndrome alone is 1/20=5%. The chance of abortion after Amniocentesis is 1/200=0.5% is smaller than the chance of having kid with congenital anomaly at age of 35 which is 1/180=0.55% 0.5%<0.55% For this reason we offer amniocentesis for all preg. at the age of 35. At some provinces some people dont like to do any test because they believe any child is a gift from god. After you gave knowledge at this moment may be she wants to continue preg. Or abortion. if she shift to abortion let her have a abortion. Abortion could be done easily up to 20wks.

Urgent antenatal visit:


Knock Knock Knock Dr: Hello Ms Grace Im Dr one of the physicians working in the clinic today. nice to meet you. Pt: nice to meet you too Dr: as I understand you came here today because you found that you are pregnant last night and I will told that you asked for urgent meeting. Can you tell me more about your concern? Pt: yes I have urgent meeting because I would like to have a completely healthy baby otherwise I dont want to keep it. (can you guarantee? No ). Dr: What do you mean by normal baby ? what makes you worry about it? Pt: my age. Dr: Do you have any experience? Anybody in the family with congenital anomaly? Pt: my friend has a kid with Down syndrome. (or some program on TV ) Dr: its very realistic, Im glad you are here. We see what the best option to do for you is.(Or there are some measures can take to eliminate/decrease some medical condition but no body can guarantee 100% that you have absolutely healthy child because some condition will appear later in life. 2

3|OB/GYN Go to OBS/GYN/Hx: Dr: How do you know you are pregnant? When did you do it? When was the first day of your last period? How regular is it? How often? how many days? Any spotting from last period until now? Ask about sx of pregnancy: do you have any nausea ? vomiting? How about breast engorgement ? going more to washroom? Dr: have you ever been pregnant? Any abortion? Gyn: have you used any contraception? Dont ask is it planed pregnancy or not. ask do you use any kind of contraception Ask about last Pap smear Any history of sexually transmitted infections? PMHx: Dr: any long term dx. Any hospitalization? Any surgery? Are you taking any medication? any Chemotherapy.radiation. FHx: In your family, any conditions like cystic fibrosis or blood dx? Social Hx: -Do you smoke? -Do you drink alcohol? -Have you ever tried any recreation drug? -With whom do you live? Dr: how do you feel about being pregnant? What about your baby father? How dose he feel ? Have you spoken to him about it? Is he supportive? Plan: Dr: what we need to do is to do a blood test to confirm pregnancy. As we get older chance of congenital anomaly increases and the risk of having Down syndrome at age of 35 is 1/365 and increases with age until 1/20 at age of 45.Other congenital anomaly in addition to Down are present and the overall of having a congenital anomaly is 1/180 at age of 35.In simple words/ if 180 pregnant ladies present one have a child with congenital anomaly. 3

4|OB/GYN

-There are different screening test we offer them for all pregnant after 35 y/o.Test we would like to do is called amniocentesis. The reason to do that is the chance of losing pregnancy after amniocentesis is 1/200 but the chance of anomaly is 1/180. As your age group, the risk is even higher so it wills much worth to do it. Pt: how to do amniocentesis? Dr: At 16 wk, we will insert a fine needle across abdomen under guide of ultrasound, we try to get a small amount of fluids around the baby, and we will send it to the lab. In 2 wks we will get the results. Because they need culture the cells. Its very accurate and almost 100%.It help us to detect other abnormality (NTD) and risk of abortion is very low. If they are abnormal we still have time to do abortion. Is it reasonable? If she accepts is good.if she doesnt accept to wait for that long to have test. .Dr: so other option is CVS. Its another test we can do it early and insert a fine needle through Vagina take a sample of cells from placenta and send to the lab and we will get the result in 48h.chance of abortion and injury to limb is 2% (4 times higher than amniocentesis). Its accuracy is 97% so means 3% chance of having NL result while child is abnormal. If you like to do it that is your choices. Nuchal test and triple tests are can be done earlier but they are not accurate and for your case we took be more affirmative. Make sense? Is it ok? Pt: No, I would like the abortion. Go for counseling of abortion. Optional: our genetic material we call it DNA comes in the form of chains &we have fix number of chains in body each chain has some parts called genes if any abnormal in number & structure we call it chromosomal anomaly. Sometimes it is in a certain part of chromosome and its called genetic disorder & we can not screen for all by amniocentesis. If you would like to do it we can refer you to genetic counseling. Draw blood of you/husband /

5|OB/GYN

Cases of Pap smear :


Case1:39 female came to the clinic to get the result of her pap smear which was done 2 weeks ago. (result is +). Counsel her and take Hx for RF.(10 min).

lab test always ask: for bad news :

1) why 2) is it the first time

SPIKE : setting / perception / invitation (how much do you want me to explain to you? )/ knowledge / expectation(what are your expectations from today visit?). You dont have to go all of them. After that you need to go explain the results in a nice way. Then you go for local symptom : I would like to see if you have any symptoms? After that you go for Constitutional ssx (red flags) MGOS (RF) , PMH ,FH (not very important in this case),SHX. Plan: you need to explain colposcopy. you dont do colposcopy in clinic refer to gynecologist.

Positive Pap smear (Bad news):


Knock Knock Knock Dr: Hello good afternoon Ms Im Dr.the Dr in charge in the clinic today. As I understand you are here to get the results of your pap smear was done 2 weeks ago and I have your results Im going to discuss it with you in the seconds. Because this is the first time I see you I would like to ask you some questions to help me to get better understanding of these results. Dr: why did you do that? Dr: was it as routine or because of certain reason? Dr: is it the first time? Dr: When was the last time ? (if long time ago ) any reason you did it that long away from this one? -What is your understanding of pap smear? Pt: its a test for cervical cancer. 5

6|OB/GYN -What do you know about cervical cancer? -it is a common cancer if we pick it up with Pap smear in early stages the treatment and out come could be good. - What are your expectations of today visit? - I wish I had better news for you but unfortunately, the result came back positive, it shows you have some changes these are called High-grade changes. Pt: is it cancer? -pap smear is the test that shows changes we need to do further assessment to determine it. HX: -before we discuss the plan I would like to ask some question to see if you have any symptoms related with this situation. -Do you have any vaginal discharge, bleeding, blisters, ulcers, warts.? with whom do you live , are you sexually active? Any bleeding and pain with intercourse ? -any lumps , bumps in groin area ? urine changes ? constitutional sx. Fever, chills ,night sweat , wt loss ,lumps, bumps. Menstruation : -when was your first day of your last period? how often , how many days, regular or not? Any bleeding between periods? Gyn: any Hx of Gyn dis,-polyps , cysts, Hx of PID , what kind of contraception do you use? Any pelvic surgery? Obs.Hx : have you ever been pregnant before? How many times? At what age was your first pregnancy (early sexual activity) -How many partners did you have? How long have you been in this relationship ,how about before relationship? -(check multiple partners) -do you smoke? Any Hx of STDs -how do you support yourself financially? (we checked cervical cancer RF) 6

7|OB/GYN PMHx: Any long term disease ,surgery, hospitalization?) +Allergy + Medication

Plan: What we will do now is we need to take further measures to assess the extension of these changes and for this we send you to Gynecologist to do colposcopy. it is very Similar test to Pap smear and started the same position, same way except we use magnifying lens to help us to visualize the cervix better then when we found obvious changes we take samples- otherwise we can apply some chemical to make the lesions white so we can take the sample will send to the lab and when the result come back we will call you and we will inform you. (examiner says, the result) -how do you feel today? Do you have any concern? How did you spend the last 2 weeks? -I have the result and I will discuss it with you.I have a bad news for you and it is these changes are consist with cervical cancer.

I have a good news and it is that if we picked it up early stage its treatable and the stage we call it is stage IA and it is mean its limited to cervix. we will refer you to gyn to start treatment. If you want to get pregnant there is another local treatment so you still will have chance to have baby. The Prognosis is very good. (If you dont want to get pregnant there is other treatment cone biopsy)

8|OB/GYN

Case 2 : 16 y/o female come to the clinic wants to discussion (get information) about pap smear for the first time.(10 m, counsel)
-6 month of sexually active Teenagers add : HEAADDSSS

Pap smear counseling:


Knock Knock Knock Call first name teenage -As I understand you are here today because you would like to get some information about pap smear.is it specific information do you like to know or general information? -What do you know about Pap smear? -How much do you know about Pap smear? -Why are you interested in doing pap smear? -usually we offer pap smear for ladies who are sexually active, for that reason I would like to know you are sexually active? -Are you in any relationship? For how long have you been together? -When did you start to be sexually active? Did you have previous.part? -Are you practicing safe sex? What kind of contraception do you use? -(Any other contraception measures?) Always encourage if she use contraception. Do you have any vaginal discharge, bleeding ? pain with intercourse , blister, ulcer, wart. -Have you ever been diagnosed by STD? Menstruation: -When was the first day of your last period? How often? How regular? Is it painful? OBS: -have you ever been pregnant? Any abortion? GYN: 1. have you ever had Gyn disease PID 2. any pelvic surgery 3. have you ever done pelvic exam

9|OB/GYN PMHx: -long term illness ,.. -hospitalization -any surgery HEAADDSS: Home: Education: Activity: Alcohol: Diet: with whom do you live? How is your family relationship? do you attend school ? what grade? do you participate in sports, social events, club? do you drink alcohol? tell me about your eating habits,(balanced / junk food)(any HX of eating disorders)? Drugs: Suicide: (Sex: have you tried recreation drugs? have you ever thought of harming yourself? what about dating?)

Counseling: 1. Why 2. How

Dr: I am glad you are here to talk about Pap smear Dr: this is a life saving screening procedure(test). one of the most successful screening test and we use it to pick up one type of very dangerous cancer is called cervical cancer. in the past it was responsible for the death of large amounts of ladies but now we pick it up early and that is important because if we dont pick it up early by the time it starts to give symptoms , it is too late and our options are limited so it is very good that you become over on pap smear and do it on regular bases. (Draw a shape to show her the cervix) Explain about different parts. (Explain about virus and affect on cervical cancer.) -When we look at inside ,we can see this area which is called transitional zone it is very important because this area get infected by virus we call HPV similar to virus give us wart but in the cervix this change is to be cervical cancer. (Because its deep to take sample we need use instruments) 9

10 | O B / G Y N -if you decide to do, You can come a week after your period a nurse should be here but you can bring somebody with you (she can bring her boyfriend / mom ) (Explain about the procedure covering lithotomic bed explain about instruments plastic disposable.) -we need to do it in certain position. .when you come here you will be lying on your back on the examination bed and We will cover you.the examination bed has certain pedals you can use to support your feet and that will give us better view of vaginal and cervix. In order to visualize cervix we need a tool called speculum. there is different size and we use proper one and plastic. (we can use plastic speculum, before insert make sure is warm and we can use some lubrication,) We will insert it into vagina in certain position. We can open it and see cervix. It might cause some discomfort but usually it is not painful. we use Spatula ,insert and rotate it 360 to take sample then we spread it on slide +fixed after that we send it to the lab. The inner part of cervix is deep and can not be reached by spatula. We use brush in order to get sample from the inner part and send to the lab. (if there is small brush insert and rotate it 2 times ,put it in the bottle of fluid and send it to the lab if there is big brush insert and rotate it 5 times) -Results come back in 2 wks. -If we dont contact you it means the results are normal. -Any question? -Repeat it every year for 1st 3 years. as long as you are with one partner If neg after 3 years repeat it every 2-3 yrs.(unless change partner or other situation) (-then you go for rest of HEAADDSS. Dont forget explain about helmet when she riding)

10

11 | O B / G Y N Case : 22 y /o female she came to clinic because she found she is pregnant 4 days ago next 10 min counsel her pt wants to know:( Antenatal visit) -Am I going to have Down sx or not? How much will I get weight? -I have a cat at home. what should I do? -sex issue can or not? Breast stimulation. -How often should I come here? -drinking wine. -Diet +folic acid , fish + mercury once/week

Antenatal visit: KKK


-AS I understand you are here because you found you are pregnant and during the next few minutes after asking some questions and hopefully we will have a working plan related to that. -how did you know it?(test, no period go for LMP) -How do you feel about pregnancy? Pt: I am happy -congratulations ! it must be a very exciting time of your life. -when was the first day of your last period? how regular ? how often? How many days? Any bleeding between periods? (Check and compare the last 2 periods make sure the last LMP was not the implantation bleeding)(for calculation : -3 +7)

Symptoms of pregnancy: - any nausea / vomiting / If vomiting check for dizziness ? dehydration ? -small meals + TX : B6+Doxylamine -any breast engorgement, going more to washroom? Obstetric : -have you ever been pregnant or it is the first time? -any abortion , miscarriage in your life? -any Hx of abnormal pregnancy (ectopic,mole) any difficulty (placenta previa) 11

12 | O B / G Y N GYN: -Any pelvic surgeries/ procedures/ injury? -any previous women problems? Fibroids? Pelvic infections? Cysts? -how about contraception? What did you use for birth control? -ever screen for HIV/HBV? - any HX of STDs , when was your last pap smear done ?if <6months you should repeat it today. PMHx: -do you have allergy? -any long term illness? hospitalization? surgery? DM ? HTN? Medication(if using Aspirin she should change it to Tylenol).folic acid? Multi vitamin? vaccination(ever been vaccinate for rubella? measles? titer of AB? Schedule of last tetanus shot? -What is your blood group? Rh? Your partners blood group? FHx: -any FH of complication during pregnancy? Twins? HTN? DM?any placenta previa? abruption? any congenital anomaly? Social Hx: -how do you support yourself financially? -what do you do for living? - exposed to chemical , heavy lifting, exposure to cat? Other animals? (Job not. if she does shifting/ lifting job switch to office job) -do you smoke? -do you drink alcohol? -We dont have safe limits for alcohol and cigarette for that reason we recommend all pregnant to quit / stop drinking and smoking. With whom do you live? How does your partner feel about it? Do you feel safe at home? -I can see that you have a note in your hand. is this a regular visit ? (Note; down sy., food, work or stop, smoke.) (Write them down.1st and then address) 12

13 | O B / G Y N Patient asks about Down syndrome: -any FHx of Down sy? Any family member with Down sy? Any reason you are concerned about it? -you are young and risk is low , but at 9-11 wks there is some screen tests and we talk about it later.

Counseling: - first we need to confirm your pregnancy by blood test and U/S -we Set a regular F/U visits. Till 28wk 28-36wk 1/mon 1/2wks after 36 every wk)

-we will see you once every 4wks for 28wk , then every 2wk up to 36wk , then once every wk till towards the end. -normally during pregnancy you will gain wt 15-25 lb. (1 Ibs /month 1st pregnancy 1 Ibs /wk 2nd pregnancy)

-And it is depend on your wt. thinners gain more. if you dont gain enough or if gain more have to see Dr. -in the first visit we will do some blood work and it is including: -Confirm the pregnancy by blood test + CBC + Lytes +BG & Rh +Rh AB + BUN-Cr -U/A , U/A Screening for syphilis(VDRL)+ HBV +STI (gonorrhea, clamydia , swab for BV) -we dont do HIV for every body , but we offer it. -later we do Ultrasound at 10- 11wk to see if there is any baby. and second one around 20 wk we do 2nd to see any malformation and the location of the placenta / growing of baby. (1-first 10-11 wk (confirm) 2- Second 20 wk ,(make sure not ectopic pregnancy)

-we also do screening test that we call it integrated pregnancy test which is combination of blood work+ ultrasound to make sure baby is well baby. Because you are young , you dont need take further measures. Diet: we recommend balance diet- fibers- avoid uncooked meat /fish/poultry -avoid unpasteurized dairy products and cheese 13

14 | O B / G Y N -dont exceed tuna (once a week -2 per months ) for mercury content. -are you taking acid folic? (-if yes continue acidfolic) We recommend -Folic acid 0.4 mg/day(4mg in who has Hx) (-for morning sickness; ginger/ small meals frequent/ fluids ) (exercise is important) -be active ,exercise like fast walking or swimming (20-30 m/day 4/wk)-helps your delivery to be easier -as long as you can , you can do your job, otherwise we will give a letter to your supervisor to modify your job. -sexual activity: you can continue ,no limitation (Unless placenta previa) -Try to avoid breast stimulation toward the end.

Cat: is it a new cat ? if not , previously exposed. We recommend that you keep away from the cat and ask your husband to deal with the litter of the cat.

-you can Travel ,not after 36 week

14

15 | O B / G Y N 54 year old female comes to clinic concerning about using HRT:

Knock knock knock

Dr Miller:

Hello Mrs. Douglas good afternoon my name is Dr. Miller one of the

doctors working this clinic. Nice to meet you.

When a patient has concern about any subject, address it very soon. Don't wait to the end.

Dr Miller: As far as I understand you're here as you have concern about using HRT.

Patient: Yes Dr. I feel I am confused about using HRT.

Always ask what you mean by HRT. So the patient will tell you how much they known about HRT.

Dr Miller: I'm glad you're here so we can discuss about it and address your concerns and hopefully by the end of the session you can make a decision regarding using HRT. Or hopefully by doing this discussion you will have a better understanding of HRT.

Or you can say: I agree with you as there are a lot of confusion about HRT and the reason for this confusion is that in the past because it was used to be given routinely to all women who reach a certain age, however 10 years ago there was study called " women health initiative" in which the authors found that the numbers of the patients with serious side effects are very high. However those ladies used HRT for a long time.

Serious side effects are cancer, heart attacks and strokes. For that reason the routine use of HRT was stopped.

15

16 | O B / G Y N Dr Miller: Now-a-days we have a better understanding and have better guidelines.

Not only that we do it on the individualized basis. We use it only for short time, they don't exceed five years. So using HRT within five years is safe. So I would take some information from you and we will discuss about the risk factors and if you are a good candidates we can make a decision to prescribe it or not.

Dr Miller:

What makes you interested in HRT?

Patient: Because of hot flushes. At this stage if the patient gives you the symptom; ask if this is her chief complaint. But if patient doesn't give you any symptoms, you should start with her last periods.

If she starts with the symptom of hot flushes, ask the patient when hot flushes started, are they all the time, on and off or continues, how many attacks, day or night, how do you feel that when you have it.

Patient: Started at three months ago, on and off.

Dr Miller: How about nights episodes, you have any night sweating, does it wake you up?

Ask the patient if the hot flushes wake her up during the night, and if she needs to change her gown because of sweats.

Also ask how does it affect your sleep and how does it affect your concentration. Any change in your mood, anybody has told you that your short tempered, and if you feel tired.

Dr Miller: With whom do you live? Some women with the same symptoms may notice some change in their sexual life. Are you sexually active? Any dryness or pain during the intercourse? Any change in your urination? Have you ever lost control? 16

17 | O B / G Y N

Dr Miller: When was your last period? Are you periods regular or not? If it's irregular, when did it start to become irregular? Are your periods heavy or not? Any clots? Any bleeding or spotting between periods? This is a very important point.

Dr Miller: Any bone pain? Any fractures? Any family history of osteoporosis?

If Yes, tell the patient that you will discuss this in another meeting. Because that's another session to discuss about using steroids, smoking, alcohol, caffeine, warfarin and diet. If she takes calcium supplements.

MGOS for GYN cases: Menstural, Gynecologic diseases, Obstetrics, Sextually transmitted disease

Dr Miller: Any history of gynecological disease like polyps, cysts, or any pelvic intervention / instrumentation, surgeries.

Dr Miller: Did you use to take any oral contraception? If Yes, which one and did you have any side effects? Also you should ask about her last smear.

Because she is 50+ you should ask about her mammogram. At any age you ask about Pap smear, once you reach 50 to ask about mammogram and when the patient passed 65 you should add bone density.

You can ask about her obstetrics history, like have you ever been pregnant if Yes how many times you have been pregnant.

Now use the transition... Dr Miller: Because this is the first time I met you, I would like to ask you about your

past medical and social history. Is there any long-term disease, hospitalization before, 17

18 | O B / G Y N any surgery, diabetes, or hypertension? Ask about any history of allergy, and the medication she takes.

ABCD: Active liver disease, vaginal Bleeding, Cancer, DVT

For A you ask about any history of Active liver disease. Have you ever been yellowish? Any dark urine or pay stool?

For B you should ask about any vaginal Bleeding? ... You have already asked these question before

For C you should check about Cancer. I would like to ask about constitutional symptoms here to see if there is any endometrial cancer. Fever, chills, weight loss, appetite, lumps & bumps. A history of cancer in yourself or family (breast cancer, endometrial cancer,and colon cancer).

For D you should ask about any history of swelling in the legs (DVT), any history of heart attacks, pulmonary embolism or stroke.

Now we go to social history: ask about smoking, taking alcohol, recreational drugs, how she supports financially herself, how does this affect her life and ask about osteoporosis.

Usually in this set of scenario, you tell her on the basis of the history you are good candidates for HRT. However as I told you it is an important information to tell you to make your decision.

Dr Miller: As we go through different stages of life usually for ladies, we go to the stage called menopause which is vary between different people. At this stage there is a hormonal change and ovaries start to produce less hormones specialty estrogen and progesterone and that changes affect the whole body. It can explain about dryness, 18

19 | O B / G Y N decreasing or absence of periods. And that's why we try to replace those decreased hormones by HRT. They are the same hormones but we give it through external sources either tablets or skin patches.

Dr Miller: As I told you before there is a balance it's your decision to make. And the balance is to use it up to five years. Using more than five years would increase the risk of stroke, heart attack or some cancers depending on what we call it estrogen dependent that includes breast and endometrial cancer. And some studies showed that it might increase the risk of Alzheimer's disease. So the risk of use for less than five years is not significant and still acceptable. So if you want to use it the shorter the better.

Dr Miller: To get rid off the hot flushes that are other measures like exercise or herbal supplements that you can try to improve the symptoms. The HRTs are the same as OCP's but in this smaller doses and you can take one tablet a day. They have a few side effects like weight gain, bloating, nausea, abdominal distention and pain but they improve by time. These serious side effects are headaches, swelling of the legs or chest tightness which whenever happen you should go to emergency room. By using these HRT's your periods may stop or you may see spotting.

If the patient had hysterectomy before you only give estrogen without progesterone, otherwise you should give both. Because you take it regular its important to do regular ultrasound scans to check the thickness of the endometrium and sometimes we should take endometrial samples.

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1|Pediatrics

Cases for pediatrics: Focused Hx: A pregnant lady is in the clinic she was diagnosed with IUGR. A child has jaundice and he is 5 days old. A 6 weeks old child is crying. A 6 weeks old child is vomiting. An 8 months old boy is pale. A 9 months old child has diarrhea for last 6 weeks. A 3 year old child has fever for the last 3 days. A father of a 4 year old child is in your clinic he wants to renew his antibiotics, the child has been coughing for the last 4 weeks. 9. A mother of a 3 year old child is in the clinic because she is concerned, her childs weight is 14 Kg. Psychiatric cases in pediatrics: 1. 2. 3. 4. 5. A 15 year old teenager is having eating disorder. A 16 year old teenager is in the ER because of overdose on ASA. A 3 year old child cannot talk well. An 8 old child is wetting himself for the last 3 weeks. A father of an 8 year old boy is in your clinic because he is concerned, his son was diagnosed with ADHD recently. A) 1. 2. 3. 4. 5. 6. 7. 8.

B) 1. 2. 3. 4.

Hx & Ph. Ex: A teenager is having acute abdomen, she is 17 year old. (Case of PID) A 14 year old teenager is having knee pain. A 16 year old teenager is having lump in the neck. A child is having upper respiratory tract infection.

C) Hx & Counsel: 1. A 35 weeks pregnant lady is in the clinic she needs counseling for breast feeding. 2. A mother of a 6 weeks old child is concerned about vaccination. 3. A father of a child is in your clinic because his child had anaphylactic shock last night. In this case if the child had the episode at school we cannot take history we can just counsel because the father has not witnessed the event, on the other hand if he had witnessed the event we have to take history and counsel.)
1

2|Pediatrics

4. A 10 year girl is in the clinic with her mom for follow up, she has DM for the last 3 years. 5. A 3 year old child ended up having febrile seizure at home the parents brought him to ER and he is stable now council with the parents. 6. A 16 year old teenager is in your clinic because he wants medical note for ministry of transportation. 7. A 16 year old teenager had concussion 2 days ago and he was admitted now he wants to get medical note because he wants to play soccer. 8. A mother found marijuana in his sons belongings and she is worried.

D) 1. 2. 3.

Phone cases: manage in 5 minutes: A mom has called, her 3 year old son has swallowed some acid or alkali. A mom has called, her 3 year old child has swallowed medication. A mom has called, her 3 year old son is seizing for last 3 minutes.

A case about childs weight. A 19 old mom is in clinic she is concerned because her 14 months old child is 8 Kg. (the child should be at least 10 kg but it depends on the childs birth weight. Case of child abuse: A mother has brought her 3 year old child to the ER he has femoral fracture. These are clues for abuse: XRAY shows spiral fracture, fractures at the same level, multiple fractures. There used to be a case about counseling a child with obesity, the approach is like obesity in adults but the deference is that in children we do not decrease the calories he intakes we increase the activity.

3|Pediatrics

General format for history taking in pediatric cases: Chief complain Onset, Course, Duration PQRST Alleviating, aggravating Associated symptoms Risk Factors Differential Diagnosis Past medical history Based on the age we go for: 0 to 6 years (BINDE) Birth Immunization Nutrition Development Environment 6 to 14 years School performance 14 to 18 years(HEADDSSS) Home Education Activity, Alcohol Drug Diet Smoking Suicide Sexual activity

(Good question for sexual activity is: Are you dating?)

BINDE:
B (Birth): We divide Birth in two subgroups: Pregnancy & Delivery. Pregnancy: The questions we have to ask for pregnancy: 1. 2. 3. 4. 5. 6. Was it a planned pregnancy? (If it is planned abuse is less likely) Did you have regular follow up? How about ultra sound, was it normal or not? During pregnancy did you have any illness, fever, rash? Did you take any medication during pregnancy? Did you smoke, drink or take drugs during pregnancy?

4|Pediatrics

7. Where you in contact with sick children or a child with skin rashes during pregnancy? 8. Where you in contact with pets during pregnancy? (Looking for toxoplasmosis) 9. Where you screened for group b strep (GBS)? 10. What is your blood group? (Usually in Canada in prenatal visit the ladies are screened for HIV, HBV and syphilis.) DELIVERY: 1. Was it term or not? 2. What was the route, vaginal or caesarian? If she says c/s it shows there has been a complication. 3. Was it prolonged or not? Was there early gush of water? (How long did gush of water last? The first pregnancy it should be less than 18 hours after that 12 hours) 4. Any complication? The need for instrumentation? 5. Was there any bulging or bruises in your baby after delivery? 6. Did your baby cry immediately? 7. What was your baby apcar score? 8. Did your baby need any special attention? 9. When did you leave the hospital? (if they stay more than 24 hours shows something was wrong) in case of c/s mom stays 3 days in hospital. 10. At that time were you told that your baby has any congenital abnormality? like down syndrome? 11. Did you(mom) develop any fever after delivery? 12. Any medication? 13. Any foul smelling discharge? (pink discharge is normal, foul smelling discharge is sign of infection and the baby could be affected with the same organism) 14. Do you know what is your blood group? Your baby blood group? 15. Were you screened for GBS? Immunization: In Canada it is not mandatory. 1. Is your childs vaccine (shots) up-to-date? 2. When was the last one? If she tells no, there are not up-to date Ask why? is there any reason? If she tells you it is against my religious belief it is end of story do not discuss.

5|Pediatrics

If she tells that the reason is that I read in the newspaper that vaccines cause autism Do counseling. It is false information If she tells the reason is that I was busy or I forgot. (Alarming of abuse and neglect) If we find vaccines are late and the child is underweight call for child aid society. NUTRITION: 1. What do you feed your child? She might say breast feed, if the child is for example 6 month ask: Did you start any solid food? Which solid food? when did you started? 2. Did you start any supplement? (for children we should start Vit D from the beginning, iron supplement at 4 month for term babies and at birth for preterm.)if the child is pale ask these questions. 3. For child with chronic diarrhea ask for cereals, biscuit, wheat, bread (gluten)? Ask relation between the diarrhea and food? 4. If mom says I give formula ask: When did you start formula? I started from the beginning ask: Any reason prevented you from breast feeding? Do not sound judgmental. 5. What is your baby weight now, at birth? What was his highest weight? Do you have his growth chart? (you will be surprised)

Formula for weight: Weight doubles at 5 month, triples within one year, 4 times in 2 years. If at birth the baby is 3 kg, 5 month is 6 kg, 1 year 9, 2 years 12kg. Age multiple by 2 plus 8, this formula for after 2 years old. Formula for height: Height in the beginning 50cm First year: 75cm (add half of 50. so 50 +25) 2 year: 88 cm (add half of 25, so 75+12, 5)
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3 years: 94cm (add half of 12. 5, so 88 +6) Then add 3-4 cm per year, around 4 year he is one meter. in the year 2 the child has the half of his adult height. Development: 1. Speaking: a. At one year they say words. b. At the end of 2 year they use 2 words in one sentence. c. At the end of 3 year they use 3 words in one sentence. d. At 5 they should speak normally. 2. Motor: At 6 month they sit alone. crawl at 9 month, standing one year, tricycle at 3 year , climb up the stairs 18 month. walk 14 month. coming down the stairs is later. 3. Draw: Draw circle at 3 years, square 4 years, triangle at5 year. 4. Social smile 6weeks, sepration anxiety 9 month, stranger anxiety 6 month. Autism and down syndrome have not separation and stranger anxiety. ENVIRONMENT: 1. 2. 3. 4. 5. 6. 7. 8. 9. How do you support yourself financially? With whom do you live at home? How is the relation between your son and your boyfriend, other children? Who takes care of your son most of the time? (primary care giver) How much do you spend with your son? (look for neglect) Do you live in old or new home? Do you have basement? Anybody at home smokes, drinks, or recreational drugs? Anybody was seen by psychiatrist at home? Tell me about your childhood?

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Teenagers: HEAADDSSS (Home, Education, Activity, Alcohol, Diet, Drug, Smoking, Suicide, Sexual life) Home: 1. With whom do you live? 2. How is your relation with your parents? Education: 1. Do you go to school? Which subject do you study? which grade? 2. How about your marks now and before? what are your plans for future? Activity: 1. What are your hobbies? (in anorexia nervosa the hobby is sport)in epilepsy is important to ask. Drug: 1. Do you drink? 2. Do you smoke? recreational drugs? (Sometimes people at your age may drink or smoke or experiment drugs, do you know any of friends do that, how about yourself?) Diet: 1. How about your diet? how do you see your weight? do you think you are overweight? We might have anorexia in men. Sexual life: 1. Are you dating? have you ever been in a relationship? are you sexually active? Suicide: 1. How is your mood? any chance that you may harm yourself or someone else?

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Case 1: A mom of a 5 days old child is in the clinic, the child has yellow
discoloration it started when he was 2 days old. Feedback: It is not physiological because child is floppy. It is important to ask for number of dippers she changes and finding out decreased urination. Not suckling well is concerning. You should have asked for high pitched cry. The mom has greenish discharge for the last couple of days. How large the bruises are? Mom was concerned about mental retardation you should address it. There are 3 presentations for jaundice in the exam, do not rely on physiological jaundice until you rule out all the other causes. Most likely is pathological. (in QE2) But if they ask to take history and counsel it is most likely physiological. There has been a phone case in Alberta. In CE1 the mom is concerned about mental retardation. Do not reassure until you are sure. Knock, knock, knock Hello, good morning I am doctor Miller I am one of the physicians working in the clinic today. As I understand your son is having jaundice for the last 3 days. Before I proceed I would like to know his name. (If she uses jaundice we should clarify) , if she says yellow do not clarify Dr: When you say jaundice what do you mean? P: His color is different doctor he is not like before Dr: So do you mean he is pale or is yellow? P: No he is yellow

Dr: When did it start? How did it start? Did it start early in the second day (deal with it like the first day) or late in the second day? Where did you notice it first? In his body where did it start first?? Did it spread? Does it cover all over his body even his feet? How about his eyes are they yellow? Is the color the same or do you feel it is getting darker or more intense? Dr: Did you notice any change in the color of his urine or stool? is the stool pale? Dr: I would like to ask you some questions to see how did this affect your son. Is he crying? Does he have high pitched cry? What do you feed him? Breast feed or formula? Is he suckling like before? Is he feeding well? Do you feel that he is floppy? (You need to rule out infection)
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Does he have fever? Any runny nose? Any discharge from his ear? Does he cough? Any foul smell urine? Dehydration: How many dippers do you change now and before? (if it is less than 6 it is concerning) Going back to your pregnancy, Was it planned? Did you have regular follow up? How often? ultra sound? During pregnancy where you sick? Did you take any medication? Any contact with sick children? Any skin rash? Fever? Did you smoke, drink, drugs? Where you screened for HVB, HIV, syphilis? How about the delivery? Was it term or not? Was there any need for instrumentation? Was it prolonged? difficult? Was there early gush of water? how long did it last? APGAR score? Was there any bulging or bruises on his body? When did you live the hospital? Did you need any special attention? Where you told if he had any congenital abnormality like Down syndrome? Did you have fever or foul smell discharge? What is your blood group? What is your baby blood group? Screened for GBS? Immunization is not important but nutrition is. What do you feed him? How many times? Do you know how to prepare formula? Do you use one breast or two? How many times and how long? Any family history of liver disease or blood disorder? Environment: How do feel of being a new mom? If everything is fine you can assure. And say that is physiological But if everything is not ok we should say we need to examine your child. We do not ask about weight because normally the child loses weight in the first 10 days.
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Case 2: A 42 year old father is here because his 5 weeks old son has been
crying for the last 2 weeks. Feedback: When I told I swing him you should ask about it. If you find it is an abuse you should keep your smile to the end and try to be neutral. say to the patient: I know you are doing your best and it is very challenging to take care of a child which is crying all the time, however; I am sure you agree with me that the safety of your child is concerning why dont you call the CAS if you need help. You maintain your gentle attitude until the end, in that way you do not make it personal. It was normal for a child to cry the abnormal part was the reaction of the father. You should ask about any chance that you shake him. The rule of 3 for colic, how many hours per day, how many days per week, how many weeks. Symptoms for colic, pulling his legs, relation to feeding, gases and distention and everything else should be negative. The things that make a baby cry: too cold or too hot, wet, neglect. You should ask when you change the dipper does he have any rash. if he has rash it shows that he is not changing him as frequent as he is telling.

Knock, knock, knock Hello, good afternoon I am doctor Miller one of the physicians working in the clinic today. As I understand you are here because your son has been crying for the last 2 weeks before I proceed I like to know what is his name is. And tell me more about crying from the moment it started. P: Yes doctor it has been going for 2 weeks and it is not improving. Dr: How did it start? Did it start suddenly or gradually? P: gradually

Dr: From that time till now, is he crying all the time or on and off? How many days a week? How many hours a day? For how many weeks? Is he crying during the day or the night? Dr: How did this affect you? How about your wife? How did this affect your sleep? Are you coping with that?
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Dr: Anything decreases it, increase it? 1. Any chance that he is crying because he is hungry? Do you make sure that you feed him? How often? 2. Any chance that he is crying because he is too cold or too warm? 3. Do you adjust the temperature? 4. Is there any chance that he is wet? Do you change his dippers? 5. Any rash in buttock? (Proof that he is changing frequently) Dr: When he cries what do you do? Do you hold him? Do you hug him? Do you try to burp him? Do you walk? Do you take him for a walk? Do you play some music for him? Do you take him for a ride? Dr: Do you swing him? Did you ever shake him? P: Yes

Dr: How many times did you shake him? When was the last time? What happens after you shake him? Dr: In addition to that did you notice any symptoms? Fever, shivering, sweating, bumps in his body? Does he have any vomiting, turning blue, runny nose, discharge from his ears, diarrhea, foul smell urine? How is his appetite? What is his weight? Is he losing weight? What was his weight at birth and now? Is he drowsy all the time? Cough? Skin rash? joint swelling?

(screening from head to toe) Dr: Did you notice any relation between his crying and feeding? Any distention in his tummy? does he pull his legs? Passing gases?

BINDE: SELECT WHAT IS RELEVENT TO ABUSE Dr: Was it a planned pregnancy? Follow up? Smoke, drink, using drugs during pregnancy?

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For delivery: Was it term? Was there any congenital abnormality? Prematurity is a risk factor for abuse. Was there any separation? Did you stay longer in hospital? (the baby might not connect) Was there any need for special attention? There are no shots till now, no need to question. Developmental: Mental retardation is risk factor for abuse and also hyper activity is another risk factor. Ask: Is he a difficult child?

Environment: How do you support your self financially? with whom do you live? other children at home? Are there repeated visits to emergency room? Smoke, drink. drugs? Anybody in the family has been seen by psychiatrist? In exam they ask for the risk factors for abuse.

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Case 3: A 22 year old mom is in your clinic because her 6weeks old son has
been vomiting for the last 10 days. Feedback: Paula: In all the situations you are telling me what I am, you are not asking me how I feel. Leading question: Do you feel you are depressed? (How do you feel? Is better) Take one napkin. (Wrong) Paula: I am not married do not call me Mrs. Even if a lady has a child it does not mean she is married. If you are not sure that she is married or not call her Ms. Dr : a lot of people get preoccupied with the vomiting and ignore the mom and fail this case. Paula: No one gave me empathy. A good empathy can be: you know, I know some times having a baby can be hard. She looked frustrated. Ask her: is anybody helping you? It sounds you are going through a hard time. Differential Diagnosis: 1. 2. 3. 4. 5. 6. 7. GERD Pyloric stenosis Any brain mass or infection (meningitis) Any infection Jaundice Over feeding Change in the formula

In this age 6 weeks options are limited: Jaundice, crying, vomiting. If we find that the child has been vomiting but he does not have Failure to thrive (FTT) less likely to be Pyloric stenosis. Also the vomiting should be projectile and forceful. When both doctors asked Paula about the color she said white. It is consistent with pyloric stenosis.

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Yellow and green color makes it less likely pyloric stenosis. There should not be bile. Duodenal Atresia: Vomiting should start from birth not after 4 weeks. If it is GERD vomiting should be small amount and spiting not projectile. He would not have FTT because of vomiting but after one year of having GERD the child will have FTT due to anemia. In this case GERD is ruled out because the child is 6 weeks and has FTT. We have to look for constitutional symptoms to rule out brain tumor and look for signs of infection. Over feeding: he would be overweight not underweight. There was no change in the formula so it cannot be the reason of vomiting. The diagnosis does not fit in these differentials the only positive findings we have is that mom looks depressed. Whatever we asked from the mom she said I dont know. In post encounter: the questions were about abuse, neglect, growth chart, acid base changes and the measures you take. You should always start with rehydration and electrolytes correction.

Knock, knock, knock, Hello MS David I am doctor Miller I am one of the physicians working in the clinic today. nice to meet you. P: nice to meet you too. Dr: As I understand you are here because your child has been vomiting for the last 10 days? Before I proceed I like to know what the name of your son is. (You will notice that she is depressed you have to keep this in your mind for later. do not question in the beginning.) Dr: How did this vomiting started? P: gradually Dr: From that time till now is it all the time or on and off? P: I guess all the time.
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Dr: How many times is he vomiting in a day? P: I dont know. Dr: lets say today, how many times did he vomit? P: 5, 6 I am not sure. Dr: How about yesterday? Did he vomit less or more? How about in the beginning? P: I do not know. (Try to go more with closed ended questions, do not get frustrated) You have to do COCA. Dr: Can you estimate the amount? P: I dont know. Dr: Do you breast feed or give formula? If she tells formula tell her how much of the bottle you gave did he vomit? All of it? Half of it? Dr: can you tell the color? P: whitish or milkish Dr: Did you notice any blood or yellow or green discoloration? Dr: How about the consistency? Is it watery or cheesy? (If he vomits after half an hour it becomes more solid) Dr: How about the smell? Is it bad? Is it forceful? Does it go far? Anything increase it? Anything decrease it? Is it related to position? (In GERD they vomit after they lie down) In pyloric stenosis position does not make any difference. How is the relation to feeding? Is it immediately after feeding? (In pyloric stenosis always after feeding, half an hour after feeding.) Do you burp him after feeding? After vomiting does he like to feed again? (In Pyloric stenosis they are always hungry.)
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Look for impact on child: dehydration, weight loss. What was his weight at birth? What is his birth now? What was his highest weight? (Not gaining weight for 2 weeks is equal to FTT at this age) How many dippers do you change? Now and before? (Should be 6 at least) In addition to that does he have other symptoms? Fever, cough, runny nose, discharge from his ears, yellow discoloration, foul smell urine. Bruises in the body, swelling in his body. Is he crying all the time? Is he drowsy?

Nutrition first: How much do you feed him? How many times? Do you know how to prepare the formula? Did you change the formula recently? Now about the mom: How do you feel? How is your mood? Any chance that you are depressed? Any chance that you harm yourself or your baby? (Very important) Planed pregnancy? Term baby? Regular follow up? Support? With whom do you live? Other children at home? (Immunization and development skip it)

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Case 4: A 19 year old mom is in the clinic because her 8 months old son is pale
for the last days.

Feedback: I found I was being interrogated. I had to listen to you. More transitions was better. Sometimes you asked a couple of questions together. He did not care about the patient. There was not spice. I thought we were rushing. Slow down the pace. Listen to patient. More transitions. Ask how did you find out your baby is pale? Answer: in day care they found out. When she said I am not Mrs. Say owe I am sorry. The reason that the mom did not notice the baby is pale is that the house is old and lightening is not good it is dark. The baby is crawling around and puts everything in mouth and the paintings are falling of the wall and the baby is picking it up. I am living with my boyfriend. we dont make a lot of money.

Knock, Knock, Knock Hello MS I am doctor Miller I am one of the physicians working in the clinic today. Nice to meet you. P: nice to meet you to. Dr: As I understand you are here because your son is pale. Before I proceed I want to know what the name of your son is. Dr: When you say pale what do you mean? (She might be talking about jaundice) P: The pink color in his cheeks disappeared. Dr: When did you notice that?
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P: 3 days ago Dr: Who noticed it? (Important question) P: I noticed it, or (she might say I took him to daycare and they told me) Dr: If you think about it, is there a chance that this pallor started before or just 3 days ago? P: maybe it was going for 3 to 4 weeks but I was not aware of it. (Sudden pallor can occur because of bleeding) (The fact that someone else noticed the pallor means that it has been there but she was not aware of it) Dr: Is it all the time or on and off? Anything increase it? Anything decrease it? Dr: I am going to ask you some question to see how this affected your child. Dr: Do you feel he is tired all the time? What can Mike do by this age? P: What do you mean? Dr: Can he walk? Run? Crawl? P: He can crawl. Dr: Is there any limitations? Or can he crawl like before? Dr: If he is doing an activity does he have any excessive sweating? Any shortness of breath? Dr: Did he have any loss of consciousness? (These are the symptoms of advanced anemia) Dr: I am going to ask you some questions to see what could be the cause of his condition. Dr: Did you notice that your son has any bleeding? Bleeding from his nose? Coughing blood? Vomiting blood? Bleeding from his gum? Dr: Any bruises in his body? Dark urine? stool (I think he means melena but I could not understand from the recording sorry). swelling in his joints? Dr: Does your child have any fever, night sweats, chills, lumps, bumps, loss of appetite, weight loss? (Malignancy is not common in this age but in this scenario we have to ask)
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Dr: What was his weight at birth and now? (If he walks ask if he has limping) if he does not walk ask if he has tender points in his body. Till now we asked about two differentials, bleeding and hematological malignancies. Dr: What do you feed him? P: breast feed Dr: Did you start any formula? P: No Dr: any supplement? P: No Dr: Have you considered starting any iron supplements or fortified cereals? P: No Dr: What is the reason? P: breast feeding is the best Dr: that is true however you need to start some supplements at this age. Dr: Is he term or not? Dr: Is his shots up to date? (Rule out neglect) Developmental we do not need to ask much. Dr: With whom do you live? Any support? How do you support yourself financially? Do you live in an old or a new house? Did you notice he is eating from the paintings of the walls? Dr: Does he have any long term disease? Any kidney or lung and heart problems? Does he take any medication on regular basis? (Chronic disease can give anemia)(Congenital heart disease) Dr: Any family history of bleeding disorder? Any family history of repeated gallbladder surgery or spleen surgery? (Hemolytic anemia has gallbladder surgery and spherocytosis have spleen surgery.) Dr: Some blood diseases are more common in certain parts of the word for that reason I want to know the back ground of you and the father of the child? (thalassemia) Dr: Is there any consanguinity between you and the father? Are you related by blood? (Put the impact and the serious causes early)
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Case 5: A 49 year old mom is in your clinic because her 9 month old son has
diarrhea for the last 6 weeks. (10 minutes history) Feedback: Question: His biological mom is on the phone are you going to release any information? NO. We should know who has the legal custody. Paula: I said he had a hard life I want him to be happy. What do you mean by hard life? Well he has been sick it is nicer if he is healthier. What did he have? He had pneumonia. How many times did he have pneumonia? Twice, first at 6 month and then 2 weeks after. Was he hospitalized? P: YES.

Paula had a paper in hand it was growth chart. Whenever the patient has something in hand ask for it. The chart begins from 6 month. You should ask what about before. The chart shows FTT. She gave clues that this was not her biological child like I dont know if his father has allergies and my kids love him and are happy that he lives with us. Dr : When we have a child with diarrhea we have to distinguish, is it with FTT or without FTT. If it is with FTT: Celiac or Cystic fibrosis or schwachman diamond or HIV. If it is without FTT: Toddlers diarrhea or lactose intolerance. This is not the age for hyperthyroidism. Start with introduction analyze the diarrhea and determine is there weight loss or not.
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In acute diarrhea we look for dehydration and in chronic for weight loss. You need to cover for celiac and cystic fibrosis. In the role model the doctor asked about swelling and Paula said what do you mean. And doctor said lumps and bumps. Paula was looking for the distention of abdomen. So whenever the patient is stocked it means she does not know if she has to answer you or not but there is something. If the actor starts to take time before answering you and starts to balance it this is telling you that there is something try to change your question and make it more specific.

Knock, Knock, Knock Hello good afternoon MRs. I am doctor Miller I am one of the physician working in the clinic today, Nice to meet you. P: Nice to meet you too. Dr: As I understand you are here because your son has been complaining of diarrhea for the last 6 weeks. Before I proceed I like to know your sons name. P Dr: That is a nice name. Tell me more about the diarrhea from the moment it started. P: It started 6 weeks ago and is not improving. Dr: Did it start suddenly or gradually? P: gradually OCD+COCA Dr: From that time till now is it all the time? Did he have any periods of constipation? P: No it is continuously Dr: Can you estimate the numbers? How many times does your child have bowel movements? Can you tell the color? consistency? Any foul smell? P: large amount, 4 to 5 times, bulky, loose, offensive smell Dr: Any blood? P: No
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Dr: Any fat droplets? P: Maybe. Dr: Is it difficult to wipe? P: Yes it is sticky and difficult to wipe. (This tells us it is maldigestion and malabsorption) Dr: Do you notice anything decrease it increase it? Is it related to certain time? Certain food? P: No Dr: Is it the first time or did your son have this before? Dr: What is his weight today? What was it at birth? What is his highest weight? P: I dont know his weight at birth. Dr: I noticed that you do not know his birth weight any reason for that? P: Yes we adapted him. Dr: Do you have his growth chart? (In the growth chart you will see that he is crossing two lines or from the beginning he is under the third line.) Dr: I noticed he was not followed for the first 6 month any reason? P: We adapted him at that time Dr: Are you the biological mom? With whom do you live? Dr: How about his diet? Can you describe his appetite? (Children with cystic fibrosis have good appetite but with celiac they have poor appetite, in celiac every time they eat they have pain thats why they do not like to eat.) Dr: Does your child have any repeated chest infection? P: Yes he had 2 pneumonia. at six month and seven month. Dr: Was he admitted? How many days did he take antibiotics? Dr: Does he have chronic cough? After delivery did he pass his first bowel movement early or was there any delay? (Delay in passing the first bowel movement is consistent with cystic fibrosis) Dr: Did he have any yellow discoloration? (Prolonged jaundice in cystic fibrosis)
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Dr: Did you notice any bulging in the buttock area? (Rectal prolapse in cystic fibrosis)(Nasal polyps happens later) The symptoms from the birth in CF: first delay in passing the first bowel movement, prolonged jaundice, rectal prolapse, nasal polyps, pulmonary failure, infertility. Dr: If she was the biological mom ask: is there any family history of cystic fibrosis? Dr: What is the childs back ground? (You should be very careful in your phrasing) Dr: What do you feed him? Any biscuits? Any cereals? Dr: Which started before, the cereal or diarrhea? Dr: Does your child have any distention in abdomen? Does your child pull his legs to his tummy after feeding? Dr: Does he have any flat buttock? Thin arm and legs? (he has lack of protein) If it is prolonged we look for deficiency for fat soluble vitamins, like bone fractures, vision, skin changes, bruises, bleeding. Ask about nausea, vomiting, yellow discoloration? constitutional symptoms? Do you send him to day care? Other children have the same like that? Anybody else in the family with the same symptoms? Any redness in the buttock area? (for lactose intolerance) This is not toddler diarrhea because he has Failure to thrive. Dr: during adaption was your child screened for HIV? Dr: Ask about immunization, development, financial, environment. Dr: Ask about using antibiotics and medication. What is your differential diagnosis? 1, cystic fibrosis 2, celiac The examiner asks: His biological mom is on the phone and wants information. In order to release any information I should know who the legal guardian is.

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Case 6: A father is in your clinic and his son was diagnosed with ADHD two
days ago. Council him about the treatment. His son is 8 years old. (10 minutes) Feedback: What is your diagnosis? The fact that last year before age of 7 he was doing well makes ADHD less likely and sitting in front of TV does not rule out ADHD. Even though we have in 2 settings but it did not start before age 7 which is a part of the criteria. Even though the symptoms are consistent, ADHD is less likely. You will not say that the teacher is wrong you should say even though the teachers usually pick up ADHD first but the diagnosis cannot be done by a teacher. Was he seen by a nurse, by a doctor, by a trained person? If the father answers no we should say: ADHD is less likely but we have to see your son first. From the beginning you should talk about Ritalin. Because the father was concerned. If a patient keeps bugging you about something that means you should definitely deal with it because that is their concern so you cannot move on unless you deal with that door. About the accident you should ask what kind of accident it was and where the children watching their mom die? Was the child close to his mom? How is his sons relationship with Margaret (babysitter)? Does Margaret live with them? Has she fulfilled the place of her mom? Differential Diagnosis: 1. 2. 3. 4. 5. 6. 7. ADHD Adjustment disorder /Depression ODD OCD Conduct disorder autism learning disability (if he cannot read or calculate or writhe he will be frustrated in the class, he starts disturbing the class) 8. epilepsy
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Knock, Knock, Knock Hello, good afternoon MR Davis, I am doctor Miller one of the physicians working in the clinic today. As I understand you are here because you have concern about your son who was diagnosed with ADHD 3 days ago at school. First thing I like to know is that who diagnosed him? Tell me more about your concern. How was he diagnosed? P: My concern is that my son was diagnosed with ADHD and I checked the internet and found that you treat him with Ritalin. Dr: This is true if the diagnosis is ADHD one of the treatment options is Ritalin however I am not sure how your son was diagnosed. P: forget that doctor is it true I cannot believe that youre going to give amphetamine to my son. (In this case you should start to talk about Ritalin because if you dont he will push you back again to Ritalin) Dr: You are right, Ritalin is from the same family called methylphenidate , but it is not the same like amphetamine which you can buy in the street and the reason we use that in children is that it has a paradoxical effect, we dont know exactly the mechanism but helps children to increase their concentration and makes them focus on one subject. It does not make them agitated and even though in long term we may not be able to cure ADHD it is important to help children to have proper education and the ability to learn and later they have independent life and can live on their own. It is not addictive and we can stop it at any time, we used to give children holiday free of medication. Generally it is safe but there is some side effects, if you give it later in day it might cause insomnia for that reason we give it early in the day, and it might slow the growth of the child but they will be able to capture later and grow normally. (If you know more side effects talk about it but if you dont know tell I will check and give you brochure) Dr: Before we talk about Ritalin why dont we see if your son needs it or not. (In this way you dont avoid it) Dr: How was he diagnosed? Was he seen by a doctor? Any social worker? Any psychologist? P: No, the teacher told me.
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Dr: Even though the teachers are those who pick up ADHD early, usually it is not diagnosed by teachers. It needs special training not all the doctors can diagnose it. (Usually parents tolerate their children and think they are nice and energetic and are not aware but when they send the child to daycare or school they cannot tolerate.) For the symptoms think of a child with a lot of energy running all over the place. Dr: What did the teacher complain of? Did the teacher complain that your child does not stand still in one place. Is it difficult for him to work on one project for more than half an hour? Can he finish his homework? Does he have a lot of energy? Does he move all the time? Does he talk if he is not asked? Does he answer if he is not asked? Can he stay in a qui? Does he jump the line? Can he focus on one task? Does he loose his stuff? Ask about hyper activity. Are these symptoms only at school? How about at home? Who takes care of him most of the time at home? P: babysitter Dr: What does the babysitter complain of? P: finishing his homework, focus on one task, losing his stuff, a lot of energy Dr: How about you? Did you notice any of that? P: No with me he does not have problem. (Video games and watching TV does not count) Dr: For how long these changes? How about last year when he was in grade one? Did he have same complain or not? Any changes happened between grade one and two? How about his mom? P: Mom is dead Dr: I am sorry to hear that. How did she die? Was he involved? Is he aware of that?
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How did he react? I am going to ask more questions to see if your child has any other symptoms. Opposition defiant disorder: Does your child like to oppose orders? Does he like to challenge his teacher? (they do not break the law they have just challenge) Is your child aggressive? Does he have a lot of fights? Does he beat other children? Does he have a pet? How does he treat his pet? Does he set fire? Does he take things from others without telling them? Did you notice that sometimes he does not tell the truth? Does he have any repeated movement or act like washing his hands? Or keep checking things? Any history of seizure or loss of consciousness or jerking movements? Does he show emotion? Does he have good eye contact? Any movement, like head banging and rocking? Does he have any specific difficulty,. like difficulty in reading, writing or calculating? (He is old we dont have to go for BINDE) PMH; FH: Any family history of autism or ADHD? or mental retardation. Counseling: I know you came here today because you are concerned about your child, and you are worried about ADHD. Based on the symptoms you told me and the fact that your wife died in the summer and your son was doing well last year before age 7 he did not have any symptoms, all these makes it less likely that your son has ADHD, on the other hand ;because your child lost his mom a few month ago there is a chance that his symptoms are related to the loss of his mom. Most likely the loss of his mom is reflected in change of his behavior. At this age children are very attached to their parents. they cannot deal with the loss. This area needs somebody with more experience so I need to refer your child to child psychiatrist. (Ask him how he feels about the teacher. maybe the teacher is abusing or ask about babysitter) (Does he enjoy going to school?)
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Case 7: A father is in your clinic because his 4 year old child has fever for the
last 4 days. Feedback: In the exam if we say urination or wheezing the patient will not answer we should not use these words. Instead of wheezing say noisy breathing, for urination say peeing. You should ask where his rash is. It was in buttock and lower extremities. This is a case of Henoch-schonlein purpura. Without GI manifestation; flu like symptom, urinary symptom, swelling of joins. Just fever and rash in buttock. Paula: Vocal variety makes what you say more interesting. Bring energy into your voice change the dynamic of your voice. Ok can you tell me a little more about this, and how about that? Have you noticed this? ok lets go into past medical history.

Knock, Knock, Knock Hello good afternoon MS David I am doctor Miller one of the physician working in the clinic today. Nice too meet you. As I understand you are here because your son has been having fever for the last 4 days. Before I proceed I like to know what the name of your son is. Dr: interesting name, Can you tell me more about your sons fever. How did it start? Gradually or suddenly? All the time or on and off? Increasing, decreasing or the same. Did you measure it? How did you measure it and what was the highest measurement? Did you try any medication? Did you give him any Advil or Tynanol? Is it the first time he has fever? (You do not give ASA to children with fever) Is his fever more in day or night? With the fever does he have any excessive sweating and chills or shivering? How is his appetite? Weight loss? (Basel thinks that in this age children do not have lumps or bumps) but you can ask Transition: I am going to ask you some questions to see what could be the cause. Does he have any headache, forceful vomiting? Is he drowsy? Is he playful? Is he
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bothered by light? Any neck pain? (Look for meningitis first) Does your child have any discharge from his ears? Any pain in the ear (in younger age they pull their ears)? Runny nose? (it is not the age of teething). Any sore throat? When he is swallowing does he have any pain? Cough? Wheezing? Chest tightness? Shortness of breath? (he might have foreign body) Any abdominal pain? Distention? Diarrhea? Change in his bowel movement? Yellow discoloration? Burning sensation? Does he cry when he pees? Did you notice any change in urine? Did he complain of any burning sensation? Any joint pain? Joint swelling? Skin rash? P: Yes he has skin rash Dr: When did it start? Suddenly or gradually? Which happened before the fever or skin rash? Where does he have the rash? Is it flat or do you feel it elevated on his skin? The color? Before he had these symptoms, did he have any flu like symptoms? Do you send him to daycare? Other children with the same fever? Any history of cancer? Hospitalization before? Any long term disease?

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Case 8: A father of a 3 year old child is in the clinic he wants to renew the
antibiotics for his son. (in this case you have to decide are you going to renew or not)

Feedback: The clues: there is a trigger, the husband is a salesman and he travels a lot and he is at home just in the evening and he smokes. When the dad is not home she is ok. You should ask about pet and who else lives at home . Whenever there is a chronic cough ask about smoking. The check list for asthma is the same like adults just we do not ask about ASA, b blocker, and puffer. Ask about the event, past history, triggers. Chronic cough in children is asthma until proven otherwise, you might find zero triggers but the infection itself is enough. Up to 10 weeks cough after infection is hyper reactive airways. In this case we have to decide to renew or not. We should look to the symptoms and overall condition and presence or absence of triggers.

Knock, Kock, Knoch Hello, good afternoon I am doctor Miller one of the physicians working in the clinic today. As I understand you are here because your daughter has been coughing for the last 4 weeks. And my understanding is that you like to renew her antibiotics. Dr: When was it prescribed? Who prescribed it? What was the diagnosis? Was she admitted to the hospital? How long did she stay in the hospital? Was the antibiotics renewed? When was it renewed? For how many days did she use them? Was any investigation done? P: pneumonia and she was admitted for4 days (Original event) What were the symptoms at that time? Productive cough? Phlegm or not? fever?
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shivering? flu like symptoms? poor appetite? Right now what symptoms does she have? Fever? productive cough? is she energetic like before? (Analyze the cough) Is it continues or on and off? P: on and off

Dr: How many attacks? Is it increasing, decreasing? When in the day? (the time in a day is significant, asthma cough is more in the early in the morning.)When he coughs how long does it last? Does she cough to the extent that she gets shortness of breath, wheezing, turning blue or vomiting? Did you notice anything that increases this cough? Is it related to playing, cold weather? Any renovation or construction at home (dust)? Does anybody smoke at home? Anybody around she smokes? Any pets? Food? carpet? Lenin, basement(molds), feather Any history of rash and eczema? Any family history of asthma? Any history of chronic diarrhea? Wrap up: I know that you came here because you would like to renew the antibiotics, however ;based on the symptoms you told me I have to do physical exam. It looks like your daughter doesnt have any signs of infection. The symptoms are not consistent with that. Even if we renew the antibiotics it will not help her. Your daughters cough can be explained by condition called hyper reactive airways sometimes after 10 weeks of infection the windpipes or the airways of your daughters lungs become narrower and that makes it difficult for her to breath Still she needs treatment but other kind of treatments we call it puffer of ventolin and steroids.

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Pediatrics counselling:
1) 45y/o male comes to E.R. after his child 7y/o had anaphylactic shock in party. Counsel him for next 10 minutes. The patient is stable now but still in E.R.
-Hello Dr. How is my son? - He is quite well now. As I understand, you are here because of your son. Tell me more about what happened last night. - He suddenly could not breathe, we called 911 and the brought him here. -What was he doing when it happened? -He ate peanut. Suddenly he dropped and could not breathe. It was very scary. -Was it his first exposure to peanut? -No, he ate it before. _Any history of allergy in your son? -No -Any history of allergy in family, you and your wife? -No -what other symptoms did he has? -i told you, falling down and difficulty breathing. -What is his name? -Jonathan -Nice name. -Thank you Dr. -when you called 911, what did they do? -They did some things and then brought him here. The physician in E.R. told us that it is an anaphylactic reaction.

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-You know that some people have some allergic reaction to some foods. The most severe form is anaphylactic shock. It seems that your son has severe allergic reaction to peanut.

-what about other nuts? -Maybe to another nuts, as well. -What should we do? -Your son should not be exposed to peanut, at all. At schools, there is a law against bringing peanut to school. You should inform his school and use badge or bracelet contains information about his condition. -Why did it happen? -It is because of allergic reaction. It means a more than usual reaction to some things. -How did it work? -You know, there are some white blood cells in our blood to protect us from diseases. In allergic reaction, they show their reaction to allergen, in this case peanut. -I see, what does happen if he eats again by accident? -you should be ready for it. Your son should have two ready-to-inject Epipen and inject the first one then call 911. -Could I do CPR by myself? -If you know CPR, it is a good option, but the most important thing is prevention not treatment because it is a life threatening condition. -Thank you, Doctor.

Done by him:
-Hi, nice to meet you. I know that you are here because your son had an anaphylactic reaction last night. Fortunately, my colleges looked after him and he is stable now. Did you stay in ER last night? -Yes -It seems that you could not sleep last night; it is a very hard situation.

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-Yes, it was very scary. If it happens at home, ask him about details and how did it start; like hives, swelling, erythema, musical breathing (wheezing), chest tightness, itchiness, ability to drink, ability to speak, turning blue and losing his consciousness. Ask him what happened after that and what interventions the paramedics did. The situation is very scary and needs empathy. _Has any swelling been in his face? -Was he able to breathe? -What did you do? -Do you know what the paramedics did for him? Any injection? -Was it his first time? -Are there any other children at home? Usually, they give one or two doses of epinephrine to the patient with or without steroid. -Any history of anaphylactic shock in family? Any history of allergy in him or in family? -Now, I want to tell you some information about anaphylactic reaction and allergy. Do you have any idea about anaphylactic shock? Tell me what do you know about it? -Anaphylactic shock is a very severe form of allergic reaction. Sometimes, it happens from first day of life and sometimes it happens later in life even for things you used to expose to it before. This is a hypersensitivity reaction against some specific foods, medications or chemicals. In your child case, it is to peanut. Even he used to eat peanut before, it seems that his body starts to show allergy to peanut, now. At certain stages, body starts to produce some chemicals which we call them antibodies to react to some things we call them antigens. Antibodies affect his vessels, airways and skin. The vessels become leaky and widened and lead to general swelling and low blood pressure. Thus, the patient cannot breathe well, loses his consciousness because of low blood pressure. It is a very severe condition and you should know how you could deal with. Do you have any question so far? -It may happen again and the best therapy is prevention. I should talk to your son after talking to you. He should avoid peanut and everything contains peanut. You should
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check every candy and any kind of food to be sure that is peanut-free. You should inform his school, as well. In Ontario, all schools supposed to be peanut-free. If you send him to parties, out of school activities and sleep over, you should inform them about his allergy to peanut. _In case of exposing to peanut, you should be ready for it. It is a very severe condition. You should have two epipens ready to use at any time, one at it should be hold like a pen in hand, pooling the cap, inject it into his body and hold for ten seconds. It will be injected automatically and keep the blood pressure high for about twenty minutes. Then you have enough time to take him to emergency room. In addition, your son has to know how to use it. Any time he goes somewhere without family, he should have epipen with him. It is better for him to use a med alert bracelet to show his problem and what should be done in case of finding him unconscious. I, also, will send you to an allergy specialist to do some skin tests for him and other kids at home to show which allergies they have. -Is it a life-long condition? -It could be, however certain percentages of these children later in life become allergy free. -Do you have any other question? -No doctor, thank you.

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2) Mrs.Ukraina, 30y/o comes to office because she has some concerns about breast feeding. 10 minutes counsel her.
-Hi, Mrs. Ukraina, nice to meet you. I know that you are here because you have some concerns about breast-feeding. Is it your first baby? -Yes, it is. -Do you have any previous experiences? -Yes, I had some with my sisters kids. -Tell me what you think about feeding of baby. -I know that breast-feeding has some advantages but I am not sure about them. In addition, I think that formula is nice because I am a lawyer and should return to my work soon and my husband can take care of the baby. -As you said, breast-feeding has many advantages. For example, it does not contain heavy elements and is more compatible with infants digestive tracts. -I see. -Now, I should ask you some question to find that are you a good candidate for breastfeeding with it. Have you used any medication? -No -Some skin problem on breast may prevent you from breast-feeding. Do you have some? -No, but, I have concern about cracks. I think that it is so painful. -There are some solutions for that; it is not a major problem. -I know that it is very painful. -Yes, it is, but there is some ways to prevent it. -How? -By good hygiene. -My sister has a very good hygiene and had cracks.

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-Yes, sometimes it happens and there are some other problems like mastitis. Even with cracks, it is better to continue feeding the baby because it is very helpful for babys health. -You know my mother did not feed me by breast and I am doing well. What is the reason of feeding baby when I am doing so well? -There are some advantages to breast-feed babies. For example, studies showed that you will lose weight sooner, there is a better contact with baby and breast-fed babies have higher IQs. In addition, babys immune system is working better. -If I want to go back to work, could I put the milk in the fridge? -Yes, you can. You can milk it before going to work and your husband can give it to baby. -Why do they put formulas in the market when it is not good for babies? -It does not mean that formula is harmful for baby. For example, for some types of metabolic diseases feeding with formula is necessary. Do you have any metabolic problem in your family? -No -How many days can I put it in the fridge? Time is over for first physician. The second physician: Hello, I am Dr... Nice to meet you. I know that you are here today because you have some concerns. _Yes, I am pregnant about 35 weeks now and I want to know about feeding the baby more to decide between breast-feeding versus formula feeding. -What is your concern about breast-feeding? -First of all, it is painful. I saw my sister and she has pain when fed her baby. Besides, I am not breast-fed and my sister as well and we both are doing very well. What is the point of breast-feeding when we are doing so well? -OK. Actually, I think that breast-feeding is a nice process, physiologic and natural. If you do not mind I want to ask you some questions: do you work?

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-Yes, I am a lawyer and it is another concern because I should go back to work. I heard from my mom and my sister that it is very painful. -OK, there are many options for you. You know, the most important cause of pain is cracking nipple. If you use right ointments and emollients and position the baby in right way, you can prevent it. -What about breast engorgement? - Yes, it may happen, also. But there is some treatments for it as well. - My advice is for first months of life every time baby cries start to feed him, even every two hours. - Thank you it is not possible for me! I should go back to work. - You can keep the milk in the freezer and in the fridge. - My mom had breast abscess and my sister had fissure. Does it mean that I will have these problems, as well? - No, it does not. If you need more information, I will send you to a nurse who is professionally trained for teaching and counselling about breast-feeding. There are some websites as well that I will give you the addresses. - Thank you Dr.

Breast-feeding counsel:
-Hello, Ms... I am Dr... Nice to meet you. As I understand, you are pregnant and you have some concern about breast-feeding. Tell me more about your concerns. Is there anything specific you have concern about? - Mostly my concern is about pain. -Have you had any pregnancy or breast-feeding before? - No, but my sister had pain when she fed her son. In addition, my sister and I were not breast-fed and we both are doing well, so what is the point in breast-feeding? -Breast-feeding is a natural process and physiological and usually there is no pain in breast- feeding, but sometimes it happens. It may cause by cracks, mastitis and abscess, all of them are preventable and treatable. - My sister had nipple cracks and it was very painful.

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- For breast-feeding you should be always be sure of proper nipple positioning and keep the nipple moisturized. With good nipple care, it can be prevented and if it happens treated. There are some special nurses to teach you proper techniques for breastfeeding. In these classes, they show you what proper techniques are and how you can prevent cracks, engorgement and abscess. You can be in contact with them to learn more and tell them your concerns during feeding the baby. - What could I do in breast engorgement? I know that it is too painful. - Yes, it is. In cases of breast engorgement, you should continue feeding the baby until it resolves. However, if localized infection that we call it abscess develops, it should be locally drained and some antibiotics should be prescribed for it. Do you have any question? - No - At first, you had better feed the baby whenever is awake and cries. Gradually, s/he sleeps more and you may prolong the time between feeding to 3-4 hours. You can control the enough nutrition by number of diapers per day and weight gain. There are some bulletins and web sites, I will give you to read and get more information about breast-feeding. - Now, let me know that you are a good candidate for breast-feeding or not. There are some conditions that breast-feeding is not permitted. - OK - Do you have any history of HIV? Any history of long-term disease? Any history of TB? Any plan for chemotherapy and radiation? Any plan to start a medication after delivery? Any history of drugs and/or Alcohol? - No - It seems that you have no contraindication for breast-feeding. - Thank you Dr. But, I want to return to my work, what should I do? - How long is your maternity leave? -... months. -That is good. You may start by breast-feeding then start to use some pumps to put the milk in the fridge or freezer. You can keep breast-milk in the room for 6 hours, in the fridge for 24 hours and in the freezer for few months. Do not put it in the microwave or on the stove to rewarm.
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If it is not enough for the baby, you can add some formula to it. It is important to do not discontinue breast-feeding, it is better than nothing. You should be aware that every foods and medications are secreted in breast milk and you should tell your physician before any prescription about it. In another scenario, she does not accept breast-feeding and wants more information to decide: -You told me that you and your sister did not get breast-feeding and are doing so well, arent you? - Yes, we are and I want to know what benefits breast-feeding have over formula to be convinced about it. - OK, many studies have shown that breast-feeding is ten times more match to gastrointestinal system of the baby than formula. First 24 hours of breast-feeding is called colostrum that is very critical for baby because of immune globulins, antibodies and essential amino acids that are necessary for the baby to prevent diseases. In addition, breast milk has a better fat-sugar ratio that prevents babys obesity; type of amino acids are better absorbed, iron is less than formula but in a form that is more available for the baby; less salt load to babys kidney and efficient amount of calories. Also, babies on breast feeding has less chance of getting diarrhea, having allergy and even some studies shows more IQ for breast-fed infants. There is a strong mother-child emotional band and good psychological support for baby and kid. Mothers who choose nursing their babies lose weight faster and catch up their figure before pregnancy better. In addition, after delivery, breast-feeding decreases the amount of bleeding by contraction of uterus. Other advantages of breast milk are always available, clean and economical. Do you have any other question or concern? If you decide to feed your baby yourself, I will introduce you to some supportive groups and special nurses to teach you more about it.

Do not mention to contraception, but if the patient asks about contraception by pills, tell her about mini pills.

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3) Vaccination counsel: She is a new comer from Ukraine, has a ten weeks son and wants to ask about vaccination.
She speaks English a little; thus, consider asking her about the language by these kinds of questions: Am I clear? Do you need an interpreter? Do you have any friend or family to help us for a better communication? Am I fast? Note the facial gestures and repeating sentences, because maybe there is language barrier.

She has two major concerns, the first one is vaccination and the second one is the relationship between vaccination and Autism. The physician should focus on vaccination, the schedule, its benefits and side effects. Then try to clear the fact that there is no relation between vaccination and autism based on studies. Consider that vaccination in Canada is not mandatory. The origin of autism and vaccination goes back to a study in England that showed there is a relation between vaccination and autism. It was based on wrong population sampling and the tendency to marketing for another companys product. Use slower pace and simpler words based on patients language knowledge. The case is done by him: Hello, Mrs...., I am Dr...., the physician in charge today. As I understand, you are here to know more about vaccination. -Yes, doctor -At first, welcome to Canada. Is everything going well? How do you find Canada? -Yes, thank you. It is good. - Tell me, what is your concern about vaccination?

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- My neighbour told me that vaccines are good but I heard that vaccines cause autism. The other one is if there is no such disease in Canada, what is the reason to vaccinate the kids? -It is a misunderstanding and it is not true. There is a wrong belief based on a wrong study. There are many studies after that wrong one which showed there is no relation between vaccine and autism. Because of the importance of vaccines to save kids lives, further reliable studies were done in many countries and approved that there is no connection with vaccine. It is just a coincidence of finding autism at the same age of injecting MMR vaccine. -OK, doctor, it seems that you are sure about it. -Yes, I am. Do you have any other question about autism and vaccine? -No, thank you -You asked about what is the reason of vaccinating kids when there are no such diseases in Canada. You know, today world is like a global village, people are travelling to here and there. It means that there is no safety, yet and kids should be vaccinated to prevent diseases. Although we do not have these diseases in Canada because of vaccination, but people bring it with them when they are travelling around the world. We do not want that your son to be vulnerable and being infected by any of them. -OK, doctor. -Now, I want to ask you some questions to know that is there any contraindication for vaccination or not. If the baby is older and gets some vaccines before ask about previous allergies and side effects for previous shots or not. In cases like this ten-weeks boy there is no reason to ask about it just mention it. -Is there any history of previous illnesses? Any medications? Any allergy to egg? Any allergy to antibiotics like Neomycin? Does he has fever or cold today? -No, doctor. -OK. It seems that he is a good candidate for vaccination. As I told you vaccines are lifesaving measures. Before vaccination, every year, many children died because of potentially preventable disease, like measles, rubella and diphtheria. -How do they do this?

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-The scientists use some bugs like bacteria and viruses or some of their products like toxins. Then other kill them or weaken them to a degree that do not cause disease but body knows them and fight back to produce some chemicals against them. We name these chemicals antibodies. Later in life when your sons body has exposure to these bugs, his body knows them already and can protect against them. -Does he have them for all of his life? -Some of them bring us life-long immunity and some need injecting boosters. Am I clear? Do you have any question? -Yes, I understood. -To reduce number of injections, they mixed five of them together as Pentacel or Pediacel. It is a vaccine for tetanus, diphtheria, polio, pertusis and H.influ B. The other one is MMR, which is against measles, mumps and rubella. We give you schedules and calls to remind the time of injection of every of them. -OK, doctor, is there any kind of side effects? -Yes, there are minor side effects. The most common one is fever, local pain and tenderness that both are well controlled by Tylenol. After fist time of vaccine, if these side effects develop we will give him Tylenol before vaccine to prevent them. -The more serious side effects are; prolonged crying, floppy baby and anaphylactic reaction that is a severe form of allergy. Seizure is not a concern, yet, because of acellular pertusis. All of these side effects need medical attention and are important. -Thank you doctor. Isnt it late for my son? He is ten weeks, now. -No, we will start now and everything will be OK.

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4) 10Y/O girl comes with her father because of diabetes, next 10min counsel her.
They have two major problems. The first one is doing not good in her basketball team because she is tired all the time and going to washroom and the second one is eating chocolate all the time. The father is interfering all the time and trying to direct the discussion to eating chocolates and lecture her about the disease. Thus, it distracts the interviewer many times. To control the situation, you should ask the father to be quiet for a few minutes in a polite way and talk to the real patient first. Position the chair to see both the father and the girl. Done by him: Hello, Melissa, I am Dr..., nice to meet you. Hello, Mr..., nice to meet you. As I understand, you are here because of Melissa has diabetes for the last two years (look at her face when you talk about her). Is it a regular follow up or a new concern? There are three different scenarios: -She is not doing well at her school because she is not seeing well. -She is not doing well in her basketball team. -She had a recent D.K.A. recently. -Then, tell the girl: In next few minutes, I am going to ask some questions from your dad about your diabetes, and then we talk together. -How was Melissa diagnosed? -When was her last follow up visit? -What was the last HgbA1C? - Look at the girl: Do you eat more? Pee more? Drink more? Any weight loss? -How are you feeling today? Any blurry vision? -What do you use for diabetes? How many times per day? By whom? What is the insulin dosage? Do you skip any doses? Do you monitor your blood sugar? How? Do you have your log book? What was the last blood sugar? Do you know how important is a log book for diabetes? -If the patient has her glucometer to show you, ask her;Are you the only one use this or not?
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-How much weight did you get from last follow up visit? (Risk of hyperglycemia) -How much weight did you loose from last follow up visit? (Risk of hypoglycaemia) -Are you using a new medication? (For example; steroids) -Do you control your diet? Any candies? Any chocolates? _ Tell me what you know about diabetes. Do you know that candies and chocolates contain carbohydrates? Do you know that a lot of sugar is not healthy for you? It does not mean that you cannot eat chocolates at all, but youd better to watch it? -Have you ever seen by a dietician? If you want, I can arrange an appointment with a dietician for you. -Try to correct the dad who keeps telling the kid: you are not normal. Tell him that there are many kids with diabetes, and with good control, she has a normal life. -How many times did she have DKA? In which setting? What happened for her? -Has she ever had low blood sugar? Then start to talk about diabetes more with the kid: As you know diabetes is about insulin that is necessary to work on sugar. Our body needs sugar to work well and sugar needs a key to go inside our cells. The key is insulin. In diabetes, the body has no or a little insulin, thus you need insulin injection to keep your body doing well. When you skip a dose or using too much sugar, your body tries to get rid of this extra sugar from your kidney by peeing more. You become thirsty and hungry and need to eat and drink more. You lose energy; feel tired, see blurry and not doing well in your basketball team and at the school. How we could control the blood sugar? By injecting insulin, watching diet, regular follow up and checking blood sugar regularly. Do you have any question? If you agree, I will send you to dietician and diabetes clinic to be under control. -What do you know about D.K.A? -It is a very dangerous situation, if you control your diabetes well, we can prevent it. -There are some brochures and websites to read more about diabetes that I give to you. In addition, I arrange an appointment for dietician and another one for diabetes clinic. -Do you have any other question? -No doctor, thank you.

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5) A teenager comes to get a medical note for her driving licence. Counsel her for the next ten minutes.
The physician should ask about the history, the last episode, the medication, and regular follow up. Then, the doctor tries to tell her what the concerns are and why she cannot give her the note. It is important to care about both yourself and the patient. Ask her about her life more, go through HEADSS and ask about the risk factors of her recent attack, living condition, doing at school, sexual life and contraception, drugs, alcohol and smoking, depression and suicidal ideation. Put empathy as much as you can, ask about her feeling after last episode, what happened and where. Tell her how she can deal with the seizure and how she could prevent it to happen. Paula: Do not tell informations, it is information. Do not order the patient to avoid this or that activity, just suggest. Done by him: Hello Henry, I am Dr..., nice to meet you. As I understand, you are here because you want a medical note for driving licence. Would you please tell me more? -I want a medical note to get my driving licence. -OK, what is it about? Do you have a medical condition? -Yes, I have epilepsy. -OK, let me ask you some questions to know more about it. -When did you diagnose? Who did diagnose it? What type is it? What medication do you use? How many times per day? Any blood level? Are you in regular follow up? When was your last seizure? When was your last follow up visit? Tell me, what did happen in last attack? Where were you? Put empathy here. For example; oh, it seems so hard to deal with it. How does it affect your life? -The first possibility is that the patients last attack was eight years ago, then you have no problem by writing the letter. -The other scenario is a patient with many attacks in last year:

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-Any reason for this new attack? Change in dosage? Change to a new medication? Any new medication? Drug? Alcohol? Smoking? - How often do you take medication renewal? -When was the last attack? Tell me about the last attack, what happened? Describe it for me. Are these attacks similar to old ones or a new type? Before attacks, do you have any strange feeling or smell something odd? How long did it last? Did you bite your tongue? Did you wet yourself? Did you turn to blue? How did you regain your consciousness, on your own or after intervention? Were you able to continue the day or went back home? Any kind of weakness, numbness, tingling, difficulty finding words, imbalance or vision change? Does anybody tell that you are acting differently? Any fever, neck pain, headache, vomiting, lumps and bumps on the skin? Head trauma? It is important to rule out any new pathology. -Do you start any new medication? O.C.P.? What do you feel about phenytoin? Are you feeling bad because of side effects? Are you sleeping well? Are you under stress? Do you expose to flashing lights? -Then go rapidly through HEADDSS: With whom do you live? Are you doing well at school? Any drop in your marks? What sports do you like? What is your activity? How is your diet? Any recreational drug? Do you drink alcohol? Do you smoke? Are you dating? -Any hospitalization? Any surgery? -Any family history of epilepsy? Now, you can focus on his activities and interests to guide him. At first, ask him: what is your understanding of epilepsy? -Epilepsy means increased electrical activity in our brain. Some triggers start an increased electrical activity in one part of our brain, which suddenly spread all over brain and cause involuntary body movement and unconsciousness. By preventing triggers and using medication we can control it. -You are underage and you should not drink. In addition, it affects on your brain and increases the risk of seizure. It is the same for drugs. -Youd better to have good sleep and relaxation, avoiding drugs and alcohol to have a healthy life. As your seizure is not under control, I cannot write the letter for you.

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48 | P e d i a t r i c s

-Imagine that I give you the note and suddenly it happens. It is very dangerous both for you and for the others. I have a legal obligation to inform the ministry of transportation. After one year of good control on medication and have no attack, you can apply for it, again. -I know that you like to be a truck driver and it is very interesting career, but it seems that it is not very fit career for you because lack of sleep and flashing lights can induce attack. You should have no attack for five years without medication to be a truck driver. -And about your activities; there are some important tips. It is important to not to go to climbing, at all. In addition, swimming and hiking without anybody around can be very dangerous for you. Chewing the gum is not recommended because the risk of choking. Operating heavy machines is not suggested as well. -There are some brochures and websites that I give you. You can read them to know more about epilepsy. In addition, I will arrange you a neurology appointment. -Do you have any other question? -Thank you doctor.

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6) A middle age mother comes to clinic because she found pots (Marijuana) in his sons room.
Important points: Consider that Marijuana is not harmful drug by itself. However, there are some important tips. It is a bridging drug to more severe drugs, there is some effect on memory. They eat more and there is a risk of getting overweight. In addition, it changes the voice somehow. In U.S., using marijuana is one of the major causes of going to jail. It is called joint in Canada. Although using marijuana is not a criminal act but selling it, is. It is at least socially addictive, but physical addiction does not approve until now. It decreases reaction time, impairs fair movements and cognition, apathy, decrease sexual interest and fertility. In certain people and in large doses it may unmask schizophrenia. In form of smoking, it will increase lung cancer. Try to keep good relation to the teen and provide safe and secure environment for him at home. Done by him: Hello, I am Dr... one of the physician working in the clinic before. As I understand, you are here because you have some concerns about your son. -Yes, I am very concerned because I found marijuana in his room. -How do you find it? -How much did you find? -Are you sure that it is marijuana? What makes you believe that it is marijuana? -Did you talk to him? -Are you sure that it belongs to him, or just carrying it? -Was it the first time or you saw it before? -Did you find any behavioural changes, laughing erratically, exciting inappropriately, talking to himself or someone who is not there, and acting psychic for no reason? -With whom do you live? How is his relationship to other family member? -Any fight? Bad marks? More isolated than before? Spending more time in his room? -How much time does he spend outside of home? Do you know his friends? What do they do when hanging over with each other?
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-Any change in memory? Slow reacting? Loosing objects? Any arrest? Any criminal records? -Does he ask for money all the time? Do you find that something in home is missing? -Is there any chance of depression? How is his mood? Did he lose his interests to previously loved activities? -Any more than usual anxiety? -Any hallucination? -Any alcohol? Smoking? -How about his diet? Is he eating so many junks? Is he always hungry? -Is there any history of drug or alcohol dependency in family? -You know that marijuana belongs to soft drugs family. It is from cannabis family and a stimulant drug. It is commonly used by teenagers and gives them a feeling of elevation, highly excited and happy feeling. In large doses and prolonged use, it might cause some side effects including apathy and less motivation, mild interference with their memory and study, ability to work with fine machines and decrease response time and the man under influence might do some risky behaviour. It can cause lung cancer, interferes with sexual function and could cause obesity. Marijuana could be addictive but people can quit it very soon if they want. The most important thing about marijuana is that it is a bridging drug to more dangerous drugs. Those drugs like heroin, morphine and cocaine are severely addictive and very dangerous. Using those drugs are criminal act, against the law and addicted people lose their family, jobs and social values. Try to be his confident person. Try to know his friends more and being active in antidrug programs at the school or in the community. Make sure your son is joining them. Knowledge is very important for him. If bring him here I will talk to him. -Do you have any other question? -Thank you doctor.

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1|Psychiatry General format in psychiatry Hx taking: When the patient arrives to the clinic you have to determine is this medicine, psychiatry or counseling. They give you clues: 1. do mental status exam 2. brought to the ER/clinic by somebody else 3. concern about somebody else (doesnt have insight) 4. organic presentation but it says patient was seen by 2doctors You have to determine early, should I follow the medical format or psychiatry format? Once you know its psychiatry its easy because its three major categories and subcategories. In psychiatry there are 3 major areas: mood problems (patient is too happy or too sad), psychosis (patient going crazy, ghosts are chasing me, seeing or hearing things), anxiety (the patient is afraid).

When dealing with medical cases there is a general format. First introduction, then the chief complaint either it is known or unknown. If you have known CC, starts with analyzing it, if you dont have the CC you have to figure it out or make a guess. Once you get the chief complaint you need to know onset course duration. Thats analyzing the chief complaint. Then you go for character, thats PQRST, and then you go for alleviating, aggravating factors. Then you go for associated symptoms and there are different ways to do it either by systems or differential diagnosis or by causes and consequences, and always you have to ask about risk factors and constitutional symptoms. Then past medical history is divided to three areas: medication, allergy, over the counter, herbal supplement. Then long term disease, diabetes, heart attack, HTN, stroke, cancer. Then go for history of hospitalization, surgery. After that you go for the same condition in the family and then you en it up with the social history.

2|Psychiatry Social history includes: money; how do you support yourself financially? Habits: smoking alcohol, and with whom do you live? It was the general format. Now we have to modify it for psychiatric cases. There are three major psychiatric areas: mood, anxiety, psychosis and others. When you realized its mood still you have to cover anxiety psychosis and organic. Because patient can be crazy, afraid, and sad at the same time; same for other conditions. Under others you have: somatization, personality disorders, eating disorders, alcoholism, substance, suicide, dementia, delirium. These are still psychiatric problems but they dont match under the three major areas. After you do that you go for MOAPS; moods organic anxiety psychosis, and the s for self-care, suicidal homicidal ideation. After that you finish with family history of psychiatric. If we want to diagnose a patient we should look at its duration and its criteria. Somatization: To diagnose somatization: duration of complaints is not important. There should be 8 symptoms: 1. Four different (sites or functions) types of pain such as joint pain, abdominal pain, headache, pain with intercourse, muscle pain, BUT neck pain and back pain and hip pain and knee pain and shoulder pain are

counted as ONLY one pain. 2. Two GI symptoms not including pain such as: nausea, vomiting (maybe), bloating, gases, change in bowel movement, constipation BUT stool with blood or fat offensive in smell or difficult to flush or bulky are NOT somatization. In somatization there should be no fever, weight loss, jaundice, blood. 3. One sexual symptom not including pain: such as (impairment) in desire, pain with intercourse, (lack of) orgasm. 4. One pseudo-neurological symptom: weakness, numbness, tingling, dizziness.

3|Psychiatry

After finding 8 symptoms you should ask about mood (how is your mood?), organic, anxiety (are you worried?), psychosis (do you hear voices or see things (that other people can not hear or see)), suicidal or homicidal ideation. The reason for these questions is that there are comorbidities between somatization and depression OR between somatization and anxiety.

Mood disorders:
If a patient comes to us because of a sleep difficulty and based on the symptoms we find that the sleep problem is due to depression, we first ask for the depression (MI PASS ECG) but then we ask for the rest of MOAPS. If his problems are in favor of mania, we first ask for mania (DIG FAST) and then for the rest of MOAPS. (So the idea is: if a patient comes with a psychiatric problem, we first check for that problem and then the rest of MOAPS.) Depression: Always ask: Have you ever been depressed before? In depression we have to rule out some organic diseases like: hypothyroidism, pancreatic cancer, lupus, (consumption of) steroids, beta-blockers. Then we have to check if there are any symptoms in favor of psychosis or anxiety. In social history we ask about alcohol, smoking and drugs. We should also ask about self care, suicide and homicide, with whom you live and how you support yourself financially.

4|Psychiatry Depression: MI PASS ECG Questions for depression: Mood: hows your mood? Or how do you feel recently? You look down to me, Is there any chance that you are depressed. Interest: is there anything make you happy or not? What kind of hobby do you have? Are you still enjoying/interested doing that? Anything brings happiness to your heart? Psychomotor retardation: its more by observation but still you can ask; do you think things are getting slower? Do you think you need more time to do things which you used to do before? Appetite: how about your appetite? Any change to your appetite? Did you lose weight? How much weight did you lose? Was it intentional or not? Sleep: how about your sleep? When do you go to bed? How many hours do you get? When do you wake up? Why do you wake up? Do you wake up during the night? Why? Suicide: any chance that you might harm yourself? End your life or end somebody else life? For example if the patient tells you I wish I was dead you can ask: How? Have you thought about it? Any plans? Which measures did you take? Did you act on it or not? What is preventing you? Did you write any note? Did you start to give your belongings to others? Energy: do you feel tired? Concentration: if you are reading an article or watching a TV program are you able to finish it or you keep starting again and again? Guilt: do you feel that there is no hope in life? (Alarming) Do you feel guilty?

To diagnose somebody with depression you need to have 5 criteria out of 9; however one of them should be either loss of moos or loss of interest and the symptoms must last for 2 weeks at least. That gives you major depressive episode. If somebody has 2 major depressive episodes (with at least 8 weeks gap) it shifts him to major depressive disorder. The difference is in duration of treatment. The exception is in teenagers, which you dont need low mood or loss

5|Psychiatry of interest. Irritability or decrease in the school performance is the symptoms. Still you need the 5. In geriatric population you might have somatic presentation instead of that.

Mania: DIG FAST Distractibility: do you find it difficult to focus on one subject? Are you working on more than one project at the same time? Are you able to finish it or not? Impulsive behaviors with painful consequences: spending: Are you spending more money than before? Are you barrowing money from other people? Are you using your credit card to the max? Are you drinking more than before? Do you smoke? Have you ever tried recreational drugs? If he says yes cocaine ask: which one happened first? Getting high/feeling great or using cocaine? With whom do you live? Are you sexually active? How many partners did you have recently? Are you using protection? Do you have any problems with the law? Any speeding tickets? Any fights? Grandiosity: do you feel that you are special person? Do you feel that you deserve to be treated differently? Do you have special power or special mission in this life? Flight of idea: do you think you have a lot of thoughts racing in your head? What type of thoughts? Goal directed activity: more observational; how much time do you time on your activities? Sleep: do you have lack of sleep? Talkative: did anybody tell you that you are talking faster than before? Do you always talk in this speed? One manic episode Bipolar I, you need to get elevated mood plus 3 out of 7. Or you need to have 4 if its irritated mood instead of elevated mood. This should be for a weak unless patient end up hospitalize for the degree of damage.

6|Psychiatry Hypomania is like mania but they still have function, they have insight, dont have psychotic features and duration is 4 days. Hypomania + major depressionBipolar II So start with today and see what kind of episode is that? (Depression, mania, hypomania) Then ask is this the first time or had it happened in the past? How about the opposite? If its depressed patient; have you ever felt high or elevated for one continuous week? If its mania; have you ever felt sad or depressed for two weeks? Have you ever seen a psychiatrist before? Dysthymia: (feeling sad for 2 years, but never fulfill the criteria for depression, and its low mood, indecisiveness, low self-esteem, eat more/less, sleep more/less. They get 4 out of the 9 and the gap between attacks should be less than 2 months) Sleep problem how can I help you? Analyzing, matching depression fulfill the criteria Determine major depressive episode is it the first time? No have you ever been the opposite? No have you seen a psychiatrist before? No because its the first time I see you Im going to ask questions about your past medical history (ruling out organic): Do you have any long term disease? Hospitalization? Allergy? Do you take medication? Now you need to rule out the conditions that might give you low mood: Do you have any history of thyroid disease? Do you feel cold when everybody else feel fine? Do you have any constipation? Any dry skin? Constitutional symptoms: do you have any fever/chills? Lump/bump? Sweating? Ask about steroids and beta blockers (can give depression) Do you smoke/ drink/ drug? Alcohol depression and suicide always go together, when you find one look for the other two. Prolonged use of alcohol and cocaine cause depression.

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Anxiety:
Screening questions for anxiety: 1. Are you a person who worries a lot? 2. Do you have any unrealistic excessive fear? 3. Do you have excessive fear of being in a place that you cannot leave? If chief complaint of the patient is anxiety, then we have to determine which kind of anxiety problem (panic attack, generalized anxiety disorder, phobia, obsessive compulsive disorder, and post traumatic stress disorder) the patient has. 1. Panic attack: students fear the 3 Cs. Do you have periods of intense fear (that you feel that you are going to loose control, or getting crazy or dying) lasting for 10 minutes happening suddenly and improving on their own (without any intervention)? 2. GAD: Do you worry a lot generally? 3. Phobia: Do you worry a lot about specific object or situation or place? Does it mean that you avoid some activities? Do you fear to be in a place (such as elevator or high place or with an animal) that you can not leave? Do you fear to give speech in a public place? 4. OCD: Do you have any repeated thoughts or ideas or images that are disturbing for you? What are you doing to relieve them (such as ideas about cleanliness and then washing your hands or about order or religion or sexual thoughts)? 5. PTSD: Have you ever been in a place or had an experience that you felt that your personal well being or emotional or psychological safety was in danger? If response is yes, then what happened? When was that? Then asking about images and flashback? After asking anxiety related questions, ask about mood, psychosis and organic. Also ask if patient previously has been diagnosed with a psychiatric problem. Then ask about pheochromocytoma, hyperthyroidism, smoking, alcohol, drugs, self care, suicide, homicide and history of psychiatric problems in the family.

8|Psychiatry

Psychosis:
Screening questions for psychosis: 1. Do you believe anybody wants to harm/hurt you? How do you know that? 2. Sometimes people having such experience or having low mood hear/see things that other people dont hear/see do you experience that?

If patient comes to the clinic with symptoms of hallucination or delusion (as chief complaint), we are dealing with psychosis. First we have to ask questions about psychosis.

Do you believe anybody wants to harm or hurt you? If yes, who and how? Anybody wants to control you? Anybody puts thought in your head or steal thought from your head? Do you believe other people are able to read your thoughts or mind? Do you have special mission/power? If patient says that he/she has special mission, ask the patient, what is that mission? Do you believe you are special person? Do you believe that you are to be treated differently? Do you think any part of your body rotting (nihilistic ideation, seen in severe depression)? Do you think everyone is falling in love with you? Do you believe that when you are reading a book or watching TV, they are talking about you (delusion of reference)?

After asking psychosis related questions, ask about mood, anxiety and organic. Also ask if patient previously has been diagnosed with a psychiatric problem. Then ask about cocaine, head trauma, brain tumor, steroids, alcohol, ephedrine, amphetamines, smoking, alcohol, drugs, self care, support, suicide, homicide and history of psychiatric problems in the family.

Schizophrenia: at least two symptoms of 5 (delusions, hallucination,), only 1 symptom if delusion is bizarre) AND social/occupational dysfunction markedly

9|Psychiatry below before the onset AND continuous signs of disturbance for at least 6 months. Delusional disorder: one non bizarre delusion AND functioning NOT markedly impaired.

Self-care:
How do you support yourself financially? If tells I get disability support from government ask why? With whom do you live? Hows the relation? If alone do you have friends/ someone you can talk to?

Family history: Im going to ask you some questions about your family Do you know if anybody was depressed/ had depression in your family? Anybody have problem with drinking or substance abuse? Any history of suicide in the family? Anybody seen by psychiatrist or been hospitalized in the family?

10 | P s y c h i a t r y To diagnose a psychiatric disorder we should determine its axis. To do this we have to do a full assessment, then we put them in axis.

1. Axis I: major psychiatric problem, 2. Axis II: personality disorder, mental retardation, 3. Axis III: medical problem, 4. Axis IV: psychosocial & environmental, 5. AxisV: GAF = global assessment of function (0-100).

Example: patient is 40 years old that comes to emergency by police. He was not himself for the last three days. He has a lot of fight, has a lot of speeding tickets. He is a bouncer in a bar. He does not sleep recently. He is not focusing, very agitated, talking fast, he refuses to sit, keeps pacing in the room. He previously worked in a jail, but was fired because he beat the prisoners and stealing their money and throughout the years he had minor crimes such as selling marijuana and beating people. He is also diabetic (taking Metformin) and hypertensive (taking water pills and beta-blocker). Two months ago he broke up with his girl friend. You could not determine GAF, because he is not cooperative. Axis for this patient: I: probably manic episode, II: antisocial personality disorder (Note: antisocial more common in male, borderline personality in female), III: DM, HTN, IV: recent broke up with girl friend, V: not performed.

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Mental Status Exam:


ABCD, perception, thought process, thought content, cognition, judgment, insight.

1. A: Appearance: well dressed, well groomed, dressing matches the weather, given age matches the apparent age, 2. B: Behavior: agitated, psychomotor retardation, (good or bad) eye contact, cooperative, hostile or not hostile, abnormal movement (jerks, lip smacking, ticks), 3. C: speech: volume, tone, pressure of speech, fluent, (normal or abnormal) articulation, 4. D: mood: How do you feel, affect (mood is what patient tells us about his/her feeling, affect is what we observe of patients feeling), quality (sad, low, flat, anxious, depression, euthymic, high), congruent and incongruent (between mood and affect), range (full, restricted), stability, appropriate to situation, 5. Perception: A. Illusion (misperception of real stimulus) B. Hallucination (perception when there is no stimulus)

1. Somatic: Do you think any ants or bugs crawling on or under your skin? If yes cocaine, alcohol withdrawal

2. Smell (epilepsy and brain tumor) and taste 3. Visual (alcohol withdrawal, brain tumor, cocaine, epilepsy): Do you see things others cannot see? 4. Auditory ( psychiatric): If you are alone, do you hear voices? Do you hear voices inside your head? How many voices? Do they talk to you? Are they familiar? Can you recognize them? What they are telling you? Did they ever tell you to harm yourself or others?

12 | P s y c h i a t r y If says yes what prevents you from doing that? How do you feel about these voices: excited, worry, indifferent, happy, afraid of?

6. Thought (process): thought block, loose association, flight of idea, circumstantiality (lots of unnecessary information, but at last answers the question), tangentiality (lots of unnecessary information and never answers the original question) 7. Thought content: delusion, obsession, suicidal, and homicidal ideation. Delusion: fixed, false belief not consistent with patients cultural and religious background. 8. Cognition: How is your memory? Do you loose your stuffs? 9. Judgment: If there is a fire in this building, what would you do? If you find an envelope on the floor with stamp and address on it, what would you do? 10. Insight: Are you well? (this question is better than this question: is anything wrong with you?)

Now if you see a patient in clinic and after examination you may give him prescription and send him/her home or the patient has no problem or we admit that patient. But it may happen that we need to admit patient against his/her will, such as patient wants to harm others OR we can not finish the exam because he/she wants to leave and we do not know if the patient is harmful to himself/herself or others. We have to say to examiner that I have to file form one and I have to call security to bring the patient back. Form 1 is for assessment and patient can not appeal. After filling this form, another physician (not the same doctor) should see the patient in 72 hours. We can not hold the patient in hospital after filling form 1 for more than 72 hours without assessment of the patient by another physician. Sometimes happens that we see a patient in clinic with for example his wife and we finds that he is not normal but not so severe to keep him at hospital. We give medication and send him home and tell his wife that at

13 | P s y c h i a t r y anytime you find the patient deteriorates you can bring him to hospital and in that situation you can fill form 1 after maximum of 7 days after initial visit. In that case patient should be assessed by another physician. What are the options for the second doctor? This doctor may completely disagree by the first doctor and sends the patient home OR that doctor convince the patient to be admitted voluntary OR the patient needs admission but the patient refuses, then the second doctor fills form 3. Form 3 is admission without voluntary consent. This form is valid for 2 weeks. Now either in that time patient improves and discharges OR consents to voluntary admission OR needs further hospitalization against his/her will. In the third case the physician fills form 4 and this form can be renewed repeatedly (by the same or other physicians). Patient can appeal to form 4 by appealing to the College. So form 3 and 4 are for involuntary admission. Form 5 is for voluntary admission. Note: we can not give medication to a patient against his/her will.

14 | P s y c h i a t r y Psychiatric Cases: Psychosis: -patient 55 came to the clinic because has strange feeling in his/her hand for the last 6months. Do mental status exam. 55 is not a common age for schizophrenia, it could be late onset but its not common so either youre dealing with organic condition or schizophrenia, substance abuse, or relapsing or deteriorating preexisting condition. -patient 24 brought to the ER by his roommate because he hasnt been himself for the last 10 days. (Age matches schizophrenia, the duration is inconsistent) could be acute psychosis, substance abuse, in young age could be homosexual HIV encephalopathy, doesnt have insight could be mania). -patient 35 came to the clinic because believes RCMP are chasing him. (Paranoid, persecutory delusion, believes somebody wants to harm him, substance abuse, schizophrenia, organic base) reassurance about safety is important, then diagnose. -patient came to the clinic 30, wants to arrange DNA test for his 2 children. -17y male came to the clinic because hes worried about contamination; he wants you to admit him. -patient 22 was diagnosed with schizophrenia 4 weeks ago, came to the ER, and has concern. -17y male came to the ER because he has pain in his neck. Nest 5min take focused history. -35y male brought to the emergency by police because he was about to slaughter his children, next 10min talk to him. Once you have agitated patient in the ER you should ask early hows your mood today? because you want to distinguish between mania with psychotic feature and acute psychosis.

15 | P s y c h i a t r y Mood: MI PASS ECG; mood, loss of interest, psychomotor retardation, appetite, sleep, suicide, Energy, lack of concentration, guilt -young female/male having difficulty sleeping -35y female having difficulty sleeping -75y female having difficulty sleeping. All of them for 6 weeks -40y male with tiredness -patient 40y came to the clinic because he hasnt been himself for the last 3 weeks; his wife has concern and arranged for the meeting. -patient 70 having back pain for the last 3 weeks (2 cases) -lady having low mood for two years

DIG FAST; distractibility, impulsivity with painful consequences (spending more money, substance abuse, sexual activity without protection, having fights with the law), grandiosity, flight of idea, goal directed activity, speed, talkative -had a fight in the office or wanted to slaughter his children -havent been himself brought to the office by his family -patient coming to the clinic because he has been diagnosed with bipolar I, now wants to discontinue his medication

Anxiety: -presentations: heart racing, shortness of breath, chest pain, dizziness and numbness -patient already diagnosed with panic attack/generalize anxiety disorder/ phobia 3days ago, next 10min discuss the treatment options with her/him

16 | P s y c h i a t r y Cognition: -patient 57 came to the clinic because she has difficulty with his memory; next 5min take history and do mental status exam. -67y female came to the clinic having difficulty with her memory, mental status exam is done and the score is 20, next 5min take history -patient 67 came to the clinic with his wife, she is worried about his memory, next 15min talk to him. -patient 70y had hip replacement surgery 3 days ago and the nurse calls you to come and talk to him he didnt sleep last night and he hasnt been himself. *fragmented sleep cycle is dementia and reverse sleep cycle is delirium. -patient comes to you because his 70y old dad at home hasnt been himself for the last 3 days. -you talk to the son of a person in the nursing home, he came because his dad/mom wasnt him/herself, you know it was a mistake they gave him 15units of insulin instead of 5. Next 10min talk to him. (Always tell the truth, it looks like some kind of medical error took place, we dont know who is responsible for that well investigate and file an incident report, as soon as we get the results well update you. At the moment its important to make sure that you mom/dad is stable) Eating disorders: -teenager 16 came to the clinic her parents have concern about her, because she is losing weight. (Anorexia underweight + amenorrhea, bulimia usually overweight) Personality disorder: -patient 22 comes to the ER; she wants to be admitted next 10min talk to her. She wants to kill herself. Check if she is border line, check if its the first time. If yes admit her. If this happened before you have to see which program she is fallowing who is treating her you have to finish the assessment to decide whether you want to admit her or let her leave. You cannot admit her without doing assessment. If she leaves the room you have to file form 1. And ask the security to bring her back.

17 | P s y c h i a t r y If she has scars on her hands, youd say: I see that you have scars on your hand; how many times have you done this before? Have a ever been seen by a psychiatrist before? What kind of diagnosis you have? Do you have crisis team? In case of crisis who do you contact? Do you have a case manager? What prevented you from contacting them? Somatization and conversion: Anytime they give you a patient with sudden loss of function; patient became paralyzed/blind suddenly/ cannot talk suddenly, and have been seen by 2 doctors one of them specialist in that field youre dealing with somatization disorder. -patient lost his/her vision in right eye 2 weeks ago, seen by 2 doctors one of them ophthalmologist, next 10min talk to her. -patient 22 with abdominal pain for the last 3 weeks, seen by a surgeon a week ago, next 10min counsel her. -patient 24 having abdominal pain/headache for the last 6 months she is here to renew her Tynelol3 (2 scenarios) Alcoholism: -patient has done LFT; AST>ALT and GGT elevated. -patient 55, came to the clinic because his wife has concern that he hasnt been himself for the last 6 months. Suicide: -patient 16, overdose of Aspirin, she is medically cleared, next 10min talk to her. Technically you use SAED PERSONS, its a 10 points scale. Scores1-4 consider release, 5 and above admit!

18 | P s y c h i a t r y

Patient hasnt been himself for the last 3 weeks; his wife has concern and arranged for the meeting. Next 10min talk to him.
Role play: Doctor: Hi Mr. Ford Patient: hello D: Im doctor Miller. Nice to meet you. P: good D: I understand that your wife has been concerned about you so you are here. P: yes, she is worried for no reason. D: can you tell me why she is worried? P: she says that Im staying at home most of the times D: ok and for the last 3 weeks you were been staying at home P: yes D: and how do you feel about that? P: its ok, I feel I need some time by myself, I think staying at home is not something wrong. D: during these past 3weeks have you been through anything? Any stress in your life? P: I dont know what to tell, everybody has stress in his life, almost everybody. D: ok, you seemed to be upset to me, P: maybe because Im frustrated. D: can you tell me why you are frustrated? P: I trusted the wrong person D: I see, can you tell me more about it? P: I was the senior accountant in the company, where I used to work and I trusted the wrong person, so we ended up both fired. D: oh I see that must be difficult for you. P: after 15 years working there yes it was sad. D: and are you looking for any other job right now? P: no not in these 3 weeks, Im staying at home. D: Im really concerned about your mood how do you describe your mood?

19 | P s y c h i a t r y P: not the best, definitely I was better before. D: hows your sleep? P: I cant sleep. I wake up 3 in the morning and I cant sleep. D: it must be difficult did you lose interest in the things you used to enjoy doing them? P: yes D: what you did used to enjoy? P: playing golf D: do you have some kind of feeling like being guilty? P: yes this is my mistake. D: you trusted wrong person? P: yeah, you know hes young he doesnt have a lot of experience; I thought I can trust his judgment. I said its fine, I didnt check after him D: I see P: didnt happen to me before D: do you think life is not worth living? P: I have strong religious belief I wouldnt do that. D: I see, have you thought about harming other person? P: no I dont think he intended to do that, it was a mistake D: ok, have you experienced similar sad mood in the past? P: no first time in my life. D: I want to know more about your personality in the past, would you describe yourself as a person who worries a lot? P: no D: do you have fear of going to the public areas and speaking in public? P: no I used to enjoy giving speech D: have you ever had thought keep coming to your head that you were not able to push them away? P: yeah D: what kind of thoughts? P: why I didnt check after him?

20 | P s y c h i a t r y D: so you get keep thinking about this? P: yes I cant forget it, it was my mistake D: does it bother you at all? P: I lost my job of course it bothers me D: do you also see things that other people dont see? P: no Im not that crazy. D: what about hearing voices that other people dont hear? P: no D: I want to ask you some question about your past medical history if you dont mind? P: ok D: were you a generally healthy person in the past? P: always D: are you on any medications? P: no D: also I want to know about your family, does anybody in your family was diagnosed with depression? P: my mom D: your mom? And was she treated? P: yes she was treated D: is she fine right now? P: yes I guess shes ok, Im not sure I think shes still taking medication. D: any history of suicide in your family? P: no D: any history of alcohol problem? P: no D: also I want to know about your personal life. I know that you have been working as a senior accountant for a long time, P: I was good at my job I never made mistakes D: I hope youll find another soon, job after you feel better. Do you live alone or with somebody?

21 | P s y c h i a t r y P: no I told you my wife, she arranged for the meeting D: and is she supportive? P: yes she is. D: how is your relationship? P: she is a great person; shes very supportive and concerned about me. D: do you also have habits like smoking, drinking alcohol? P: no D: ever taking street drugs? P: oh no D: ok, thank you for your information, I think from what youve told me you seem to have a condition called depression P: like my mom? D: yeah. Maybe you already know about depression because your mom has been diagnosed with this condition. P: she was crying all the time D: so how much do you know about this condition? P: not a lot D: this is a common condition; many people have this condition, sometimes its triggered by some event in the life like loss of a family member or a job, so its not uncommon. I can arrange you for talks therapy; I can arrange a social worker talk to you. P: social worker D: yes P: you mean psychologist? D: yes or a psychologist talks therapy just takes you out of this negative thinking. P: would it work fast? D: it usually doesnt work so fast but also we have another way to help you, we have medications. P: is it safe?

22 | P s y c h i a t r y D: it has side effects but most people found it tolerable. Maybe I can give you some brochure about this medication you can think about and discuss with your P: can we start now? D: we can start if you like P: how long should I take them? D: for 6 months and then depend on your situation we can see whether we can take you off. P: is it safe? D: generally its safe but there are some side effects. P: which one? D: some GI side effects like nausea and constipation in some people. P: anything else I should know about? D: it may affect your sex life

Feedback: Dr.: -should ask more about organic, at least hypothyroidism,


-Whenever talking about antidepressant mention the window, there is something special about this medication, the improvement in your mood will likely high your energy, so this is the concerning period, the first 2-3 weeks because people find enough energy to end their life. If this ever happened to you, contact me. Paula: -use more transitions Its better to say: -Do you ever have a guilty feeling? -have you ever thought of harming anyone else?

23 | P s y c h i a t r y

55y male came to the clinic has a strange feeling in his right hand for 6 months , next 10min talk to him
D: Mr. Klogman? D: my name is Doctor Miller; Im the physician in charge today. I understand that youre here because you have a strange feeling in your hand for the past 6 months can you explain what kind of strange feeling is that? P: yes my hand feels different D: whats the difference between two hands? P: this one has strange feeling? D: all of your hand? P: no mostly its here, to the tip of fingers. D: Ok and it has been going on for 6 months? Does it start suddenly or gradually? P: suddenly D: what were you exactly doing at that time? P: I was walking from my bedroom to my kitchen. D: were you in house with someone else? P: I was alone; my neighbors were leaking radiation at that time. I saw radiation at my hand. D: do you hear voices that other people dont hear? P: yes how do you know? D: its just a routine question that I ask patients. Do you also see images that other people dont see? P: no just the radiation. D: have you ever felt anxiety that you cant keep it under control? P: well Im worried about it because I know they want to kill me. D: do you feel someone is controlling you? P: theyre trying but I keep resisting. D: who do you feel is controlling you? P: its the Russians. Theyre trying to control me.

24 | P s y c h i a t r y D: do you feel anything else besides this? P: strange feeling in my hand D: ok Id like to ask you some questions about your previous health. P: are you Russian doctor? D: no P: are you sure? D: yes, please feel free youre not in any danger here. P: so youre not with the Russians? D: definitely not. So you dont have to worry about it. Have you been seeing a doctor for any other purpose previously? P: I had high blood pressure D: how long was that? P: its 20 years now, started when I was 35. D: have you been under regular fallow up for that? P: I stopped seeing my doctor D: when did you stop seeing the doctor? P: 6 months ago I found that he is a Russian D: I like to know few more things about your family is there any history of depression in your family, you parents? P: I dont know my mom was depressed, and my dad jumped from the bridge when I was 8. D: are you having any problem with your sleep? P: no D: any change in your appetite? P: I dont eat regular food you people eat. D: why is that? P: they want to poison me. They want to put poison in my food. D: and how do you make sure not to get it? P: I eat special food. Im eating cat food. D: any other change in your life lately? P: I was to the police station and ask them to arrest my neighbors but they refused. They said Im crazy. Do you agree with them doctor?

25 | P s y c h i a t r y D: there can be reasons for your feelings, well look into that to come to conclusion and Ill tell you more about that. P: Do I look crazy to you? D: No you dont look crazy to me, like I said there are different reasons for this feeling you have and there is solution. Do you feel like you will be harming someone? P: Im not harming anybody; Im just standing up for my country. D: do you feel like you might harm yourself? P: no D: do you have thoughts racing in your mind? P: no I think we should leave this place. D: why is that? Why do you keep looking at the ceiling? P: I told you about the Russians right? There will be radiation in 2minutes. We have to leave this place. D: well do that as soon as we finish, you dont have to worry, and youre secure in here. P: but the radiation will hit us soon. D: well make sure it doesnt hit us. P: how youll do that? D: Id like you to know that P: would you join us? We need a doctor D: I cannot agree to that at the moment.

Feedback:
-When asking if youre Russian you need to know why the patient is worried about that. -asking what were he doing at that time was a good question; when it says start suddenly ask what he were doing at that time? -when talking to a schizophrenic patient never downgrade you mental ability to match his, you maintain your professionalism to the end. -when asking if the doctor is helping him should ask what he is going to do and why he needs help, maybe he is going to harm someone.

26 | P s y c h i a t r y

Johnny Wilson, 70y came to the clinic with the back pain for the last 4 weeks, next 10min take history. Role-play
D: hi Mr. Wilson, Im doctor Miller the physician in charge of the clinic today. P: nice to meet you doctor D: nice to meet you too. As I understand youre here because you have back pain for the last 4 weeks. Can you tell me more about it? P: yes for the last 4 weeks Im having back pain and its not improving, I thought its better to come and see you. Maybe you can help me with that. D: so how did it start? P: gradually, D: and is it all your back? P: no its the lower part of my back. D: and do you have pain in your legs? P: no mostly in my back. D: how much is the pain? P: not very severe, its constant all the time D: does it affect your routine activities? P: yeah, Im staying at home all the time, actually lying in the bed. I used to go for golf, I dont do it anymore. D: because you cant walk? P: I can walk but it hurts. D: does it disturb your sleep? P: Im not sleeping well D: you have difficulty falling sleep or? P: I fall sleep but again I wake up and sleep again. D: does is take you falling back to sleep? P: takes me time D: do you get up early in the morning? P: around 7

27 | P s y c h i a t r y D: is your sleep refreshing? P: not anymore, I wake up exhausted. D: so you feel tired, that must be hard for you P: it is. I lost motive in life, I think maybe its the time for me to go. D: you mean? P: maybe I dont know D: when did you start feeling like that? P: maybe 2-3 weeks D: what made you start feeling like that? P: the pain and staying at home D: With whom do you live? P: I live with my wife, she is 63 and has rheumatoid arthritis she is not doing well. D: is her condition worsening? P: its been the same for the last 5 years; she takes a lot of medications. D: so do you look after her? P: I was able to do it but not now. D: so who looks after her? P: we have support worker staying in the apartment for last 3 weeks. D: did you go to physician for your back pain? P: no you are the first one. D: so how do you cope with this pain? P: Im staying at home D: did you take any medication for that? P: I took a lot of aspirin and Advil doesnt help. D: hows your appetite? P: Im losing weight D: so you dont eat well. Im going to ask you some more questions to see if there is any reason for this condition. Do you feel usually warm or cold? P: I feel warm mostly. D: did you feel your heart racing P: if I do activity only.

28 | P s y c h i a t r y D: do you feel shortness of breath sometimes? P: with activity only D: you said maybe its time to end for you; do you have any suicidal ideas? P: no, I believe nature would do that. D: and you dont have any idea of harming someone else? P: no D: did you have any other medical conditions in the past? P: no D: any allergies? P: no D: so what do you want me to do now? P: I dont know if you can fix my pain, give me my life back. D: so you think the pain is caused your mood and if your pain is gone youd feel better P: I think so, the pain is really bothering me. D: Ill ask you some more questions about your personal life; do you drink alcohol? P: yeah, 2 glasses of wine every day. D: do you use recreational drugs? P: no never. D: now about your family, you said youre living with your wife. how about your other families, your parents? P: theyre dead D: did they have any special medical condition? P: my dad had stroke, he had prostate problem and toward the end his memory wasnt good. He had Alzheimer. D: at what age was he diagnosed? P: he lived till 85, he was 82. D: do you have any psychiatric problem in your family? Anyone under care of psychiatrist? P: no

29 | P s y c h i a t r y D: how do you support yourself financially? P: I used to work, construction D: what about now? P: pension plan, stuff like that. D: bear with me as soon as we are finished Ill give you something for the pain. But Im more concerned about your sleep problem and your feeling because your back pain is not severe and its mild. Before you started having this sleep problem how was your mood? P: I was fine; I never had good sleep lately D: why? P: I wake up a lot D: why? P: for going to the washroom D: so you need to go to the washroom more? P: yeah. D: do you have an urge to go to the washroom? P: most of the time D: how was the stream? P: its weak. D: did you have dribbling? P: yes D: Mr. Wilson Im going to do some physical examination P: what do you think I have? D: Ill give you my primary diagnosis, based on what you told me so far I think you have a condition called benign prostatic hyperplasia, its a benign medical condition for enlarged prostate, its very common condition. P: how about my back? D: yes, your back pain can be associated with that. Or it may be related to a different cause, well do some physical examination and some x-rays for your back and we may do an ultra sound for your prostate and Im sure

30 | P s y c h i a t r y

Feedback:
-She twisted the information to match with the mood, but always you have to rule out organic first. Back pain at this age, you have to rule out the cancer. -you have to ask if the pain is during the day and night or just during the day! If it wakes him up during the night then its not psychological!

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Case of 42y male, hasnt been himself for the last 3 weeks, his wife has concern and arranged for the meeting.
D: hello Im doctor Miller one of the physicians working in the clinic today P: nice to meet you You should observe him and pay attention that he is sad but do not mention it very early, first build a relation. D: as I understand youre here because your wife has some concerns about you. Can you tell me more about her concern? P: Ive been spending more time at home and I think shes worried about that. D: so this is always the situation or it happened new?/ is this a habit? P: no it happened 3 weeks ago. D: anything happened at that time? P: I lost my job D: Im sorry to hear that. (then talk about his job) what kind of job? How long youve been there? How was your relationship with your coworkers? And what happened? Was there any serious consequences? How did this affect you? How do you feel about it? How is your mood? Even if he says Im fine, ask: is there any chance that youre depressed? You look down for me. How about your interests? What kind of hobbies you used to have? Are you enjoying life? Anything brings happiness to your heart? How about your sleep? How many hours? Appetite/ weight loss? How much did you lose? Was it intentional or not? Do you think things are getting slower? Any chance that you might harm yourself or somebody else? How about your energy? Do you feel tired? Can you finish an article? Do you finish a movie to the end? Do you feel that there is hope in life or not? Is it the first time you feel low? Or have you been depressed before?

32 | P s y c h i a t r y How about the opposite? Did you feel at any time that you are elevated or high, or you are at the top of the world? Have you ever seen a psychiatrist before? Have you ever been under care of a psychiatrist before? -because its the first time I see you Im going to ask you about your past medical history. How do you describe your health in general? Do you have any long term disease? Any history of hospitalization/surgery? Do you have any allergy? Do you take medication on long term basis? Any history of HTN? How about diabetes cancer? Have you ever been diagnosed for thyroid disease? Do you feel cold when other people are feeling fine? Any dry skin? Any constipation? Then ask constitutional symptoms; fever/ chills, lumps/bump, night sweat, weight loss, change in appetite? Do you smoke? Drink? Do you use recreational drugs? -Are you a person who worries a lot? Do you have excessive fears? - do you believe anybody want to harm/hurt you? Sometimes people having similar experience/ similar changes in their mood might hear/see things that other people dont hear/see, did you experience that? Did it happened to you? - how about your family? Any history depression? Any history of suicide/ problem with drinking? How do you support yourself financially? With whom do you live? How about your wife? Is she supportive or not? Counseling: Im really sorry for the loss of your job. If it was lay off; its a very difficult time, many people are losing their job Based on what you told me, your symptoms are consistent with a condition called depression. Its a mood disorder, similar to what your mom had. Id like to know what do you know about mood disorders/ what do you know about depression? P: I dont know a lot. D: sometimes it happens for people without any reason, or sometimes its an event or stress in their life, or loss that might trigger an attack of depression. We

33 | P s y c h i a t r y believe its due to imbalance of the chemicals in our body especially in our brain. Its common condition and its treatable. What we need to do first is to rule out other causes, for that reason Ill do physical exam and simple blood work. Once its confirmed then we can treat you. Every 45 seconds stop and ask any question till now. For treatment there are different options. You can choose between talk therapy, medication or combination. If you chose to do talk therapy I can refer you to psychologist, on the other hand you can choose medication, the medication we use now are generally safe, theyre mostly called SSRI; that stands for selective serotonin reuptake inhibitor, similar to Prozac. These medications are safe; however like any other medical intervention they have some side effects. Most of the side effects are minor and usually improve with time, thats why we start with small dose. Side effects include: headache abdominal pain, difficulty sleeping and some sexual difficulty. However there is something you need to know about this medication; thats the improvement of your mood will lag behind your improvement of energy. This is the concerning period for us, we call it the window gap, because sometimes patient might have enough energy to hurt him/herself or go and end his life. If you decide to get the medication any time if you feel you want harm yourself or anybody else call my office or 911 or nearest emergency room. This is contract, he has to promise you. Its not written contract but its verbal. All the contracts with the patient are verbal except drugs and alcoholic patient when entering a program. This is written.

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Check list for elderly abuse, old lady with difficulty sleeping
D: hello Im doctor Miller one of the physicians working in the clinic today. P: nine to meet you D: nice to meet you too, as I understand youre here because you have difficulty with sleeping for the last 6 months. Can you tell me more about this difficulty form the moment it started? P: yes for the last 6 months Ive been having difficulty and its not improving. D: did you seek any medical attention till now? P: no D: ok, how did it start? Suddenly or gradually? P: Id say gradually but its increasing over time. Anything happened at that time? P: not really, normal stuff D: and from that time till now, do you have this difficulty all the time or on and off? P: its all the time. D: did you have some period of time when you felt better? P: no, always Ive had difficulty. D: when do you go to bed? P: Id go around 10 D: and when do you fall asleep? P: sometimes I sleep early sometimes take me time. D: and when do you wake up? P: early D: what comes to your mind, before you fall asleep what do you think about? During the night you have good asleep or you keep waking up? Do you have any nightmares? How often? And when you wake up are you able to sleep again or not? P: I have to wake up at 5 every day D: interesting what makes you to wake up at 5 every morning? P: I have to prepare breakfast for my son

35 | P s y c h i a t r y D: interesting, how old is he? How long is he living with you? Cant he prepare breakfast for himself? Does anybody else live at home? Any other children? How about your husband? P: he died 5 years ago. *(its too late for depression even if it was anniversary it should last for few days) *we go for criteria for depression but even if you have all the symptoms for depression it does not exclude abuse, anxiety, malignancy, so you have to go through all the symptoms. Then you need to touch on Organic quickly at least the constitutional symptoms, long term disease, hospitalization, medication. Then you go for social history: D: so as I understand your son has moved back with you. How old is he? When did he move back? What does he do for living? How does he support himself financially? Is there any financial concern? Does he have family? Is he under stress? And how is the relation between you and him? This is the time to give confidentiality! How do you support yourself financially? How about your son? Does he distribute? Is your son under stress? Does he drink a lot? How often? When he drinks does he get angry? Does he lose control when he gets angry? Does he shout? And does he swear at you? Does he have access to your finances? Did he ever physically hurt you/ push you? Did you talk to anybody about it? Do you feel safe going back to home? Is there access to weapon at home? Have you ever thought of putting an end to this by killing yourself or harming your son?/ Is there any chance that you might harm yourself or end his life?

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Counseling: Based on what you told me it looks like the difficulty in sleeping you face with is related to the changes/to the stress of presenting you child in your life and what youre going through; it is called: elderly abuse. Its illegal; its a crime, against the law! Its not your mistake and you shouldnt accept it. What you need to do is call the police. The situation will not improve, your son needs help. If you call the police the will help him, theyll take him for rehabilitation and anger management. If you like you can try to convince your son to check for rehabilitation, and he can contact social worker to find financial support. If she refuses; we know from the studies that if involve the police situation will improve, first of all theyll protect you, and theyll push your son to seek help, even if he ends up in the court it doesnt mean hell go to the jail. *you can give her sleeping pills for 3 days and arrange a fallow up visit to check how the counseling impacted her. *in Ontario if elderly abuse is in nursing home you have to report, otherwise you dont have the right to report.

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Male 54 coming to the clinic because he feels he has low mood for the last 4 weeks, next 10min counsel him. (Pancreatic cancer)
D: Hello good afternoon Mr. Cash Im doctor Mohsen one of the physicians working in the clinic today P: nice to meet you D: nice to meet you too, as I understand you are here because you have low mood for the last 4 weeks, can you tell me more about it from the moment it started? P: yes doctor for the last 4 weeks I feel low and Im not getting better, and I thought in need to seek help. D: how did this start? Suddenly or gradually? Was there any event or loss at that time? When you say low mood what do you mean? During last 4 weeks did you feel sad all the time or did you feel some variation? Did you feel ad in certain times of the day? Did you have any period of time that you felt ok? In scale of 1 to 10, which 10 is the lowest youve been and 1 is normal, where would you put yourself?( you can use scale if you want) Then interests hobbies, appetite, and psychomotor retardation, Do you think things are getting slower? How much weight did you lose? Over how long? Was it intentional? About energy? Then Is it the first time? Have you ever been depressed? How about the opposite? Have you ever seen a psychiatrist? Now go to organic: since its the first time I see you Id like to ask some questions about your past medical history; hypothyroidism, constitutional symptoms for malignancy When you find organic if you know which one you are looking for go directly, if no you have to screen it from head to toe.

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You know from the statistics and text books that pancreatic cancer is something high; Do you have any pain in your body? What about the abdominal pain? If yes OCD PQRST does it shoot to your back? Urine changes? Stool changes? Itchiness? And look for the risk factors: alcohol and family history of pancreatic cancer Always when you have a case you feel any type of cancer ask about family history of that cancer? You can ask about anxiety but psychosis really doesnt matter here. Then ask about suicide/homicide and self-care. Wrap up: instead of telling him you have a condition that is common tell him: I know that you came here because youre having low mood and your symptoms could be consistent with depression and there is treatment for that. However based on the weight loss youve had other symptoms and the history of alcohol and smoking for long time it looks like its more serious than that. Its concerning/alarming. Its important to me to do some physical exam and order some imaging.

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35y female, in clinic for difficulty sleeping for the last 3 months (case of abuse)
D: Hello Ms. Davis Im doctor Millr, one of the physicians working in the clinic today, as I understand youre here because you have difficulty sleeping, can you tell me more about it from the moment it started? P: yes doctor it started 3 months ago and its not improving and I thought its better to come here and to get some prescription. D: how did it start at that time? did it start suddenly or gradually? P: I dont remember doctor. D: ok and from that time till now its all the time or is it on and off? When do you go to bed? When do you fall asleep? When do you wake up? P: at 3! D: what wakes you up? P: the noises, TV D: oh thats interesting, you need to wake up and watch TV or anybody is watching TV at that time? P: my husband D: and the shower, who is taking shower at that time? P: my husband This an area for you to shift: with whom do you live? Husband any children? D: if you dont hear the noises or if he doesnt turn on the TV would you be able to sleep? And when you wake up are you able to go to sleep again? And when this happens what would you do? Do you talk to him? How does he react?

40 | P s y c h i a t r y How did this lack of sleep impact your life? You seem tired, I see that you are yawning, are you able to function? Here you should give the confidentiality

And then how is the relation? You need to touch up depression and ask about the relation between the husband and the children. How does he feel about them? The job? Ask about drinking (herself or her husband) , if he drinks how much? How often? Does he drink more recently? If doesnt drink? Any stress in your/his life? Any change? P: he was promoted. D: when he was promoted? How did this affect him? If not tell her: you told me that youve been married for 15 years, and the relation is stable. However recently did you notice any change? Any shift? Did you notice more arguments recently? What kind of arguments do you have? Either drink or stress or argument! (Same position) If he drinks; does he drink to the extent that he loses control? If he loses control does he get angry? When he gets angry what does he do? Does he start to shout/swear at you? Does he call you name? Did he ever get angry to the extent that he pushed you/hit you/ become physical? How did he push you? How often was the incidence consequence? If she has bruises oh I see you have bruises, how long have you been having these? What happened at that time? Did you seek medical attention at that time? Do you need to visit emergency room a lot? For what reasons? When these bruises happen usually are you alone or with somebody else? P: with my husband, is there any chance that he is responsible for this? Do you have it all the time? How did this affect your self-esteem? Does he try to put you down? Did he ever force you to have sex against your will? Who controls spending at home? Do you have access to money?

41 | P s y c h i a t r y Did he ever mistreated/hit the children? Did he ever abused/mistreated you in front of the children? P: the children are safe, he likes the children. They are not aware of that. D: you might believe that but you know the children are usually smart and they are aware of that and this is not healthy for them. Have you ever think of putting end to this? Hurting yourself/him? Do you have access to weapon? Have you talked to anybody? A friend or a family member. *its all about delivering; timing, pacing yourself and saying it in the right way and with the right tone!

Counseling: Based on what you told me what you are experiencing is called domestic violence or spousal abuse. Its unaccepted in Canada its illegal, its a crime and against the law. Its not your mistake and you shouldnt accept it. I know you dont deserve to be treated like that and shouldnt feel guilty about it. And we know from studies that the situation will not improve, and it will deteriorate. Without proper help things might get out of hand. 1) If shes interested and wants to get help what you usually should do in this cases is calling the police, theyll come and press charges. P: I cant he is the main earner in the family, what should I do with my children? D: if thats your concern Id like you to know there are a lot of resources, a lot of help in the community, being mother alone or with children you have priority, Ill give you the number of a social worker. He/she will help you with proper housing, financial support for you and your children and theyll help you to start your life again. Youll give the number to her to make the call outside your office.

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2) P: no, hes a good person but hes having a difficult time, hell be back once the stress goes out of our life. D: I see your point but as I told you we know from the studies that the situation will not improve and it will deteriorate, and the best option is involving the authority, if you involve the police the outcome overall will be better. He will be having some restraining; usually they push/send him to do anger management. On the long term things will get better and situation will improve. 3) P: no he is a good man my children like him and I dont want to destroy my family. Then talk about escape plan: as I told you I emphasize this is risky and things will not improve. So when youre going through this situation you should have escape plan, simply means you put a bag with your essential belongings in a safe place where you can pick it up if you have to leave urgently, you and your children. Arrange for a fallow up in 3 days!

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Case1: Patient came to ER because she has strange feeling on her right (R) hand. Good Afternoon Mrs. Anderson, I am Dr. Miller doctor in charge at ER. As I understand you are here because you are feeling strange feel on your right hand for the last 6 months. Dr: Could you tell me more about this strange feeling from the moment you start to notice it? Pt: From 6 m. ago I feel this strange feeling, which is not improving. Dr: When do you say strange feeling what do you mean? Strange because of radiation in my hand. (If she did not answer, ask her is it like shock, wave or particular feeling that you cant describe it.) Dr: How did start Suddenly or Gradually? It started suddenly. Dr: At that time what were you doing? I was going from my living room to my bedroom. Dr: What happened at that time? There was some radiation leaking that I saw on the wall. Dr: Who is leaking it? My neighbor. (If said started gradually, ask anything happened at that time?) Dr: From that time is it all the time or on and off? On and off. Dr: Any certain time of the day? Not really. Dr: Did you have any specific place for sitting? Whenever I go to the kitchen my neighbors are leaking the radiation. Dr: In your opinion what is the responsible for this? They are Russian. Dr: Do you have any idea why they are doing that? They want to kill me and want to get ride of me. Dr: Why do they want to get ride of you? Because I know their plan. Dr: What is their plan? They are spies but dont say anybody. Dr: Did you hear them? Besides your neighbors do you hear any other voices? Besides your neighbors do anybody want to harm/hurt you? (If yes, ask WHO/WHEN/WHY?) Does anybody want to control you? Dose anybody wants to put thought in to your head? Dose anybody wants to steal thought from your head? Do you believe that other people can read your thought? Do you believe that you are special person?

44 | P s y c h i a t r y Do you have any special mission? Do you have any special power? (In this case for example she shows you a hanger and tells you this is my power and say this effect on radiation.) Dr: Do you hear voices? How many voices do you hear? Are they talking to you or about you? What are they telling you? They tell me that I have to stand off my country. Dr: Do you talk to anybody? Anybody is joining you? Do you have access to weapon? Do you have any plan to attack your neighbors? What is preventing you doing that? How do you feel about this weapon? (May be he telling you would you join us? The answer should be I am working here and I have no time to do any other activities.) Dr: Is this first time or happened before? Did anybody try to hurt you before? Have you ever seen the psychiatrist before? Yes in 1990. Dr: Why and what was the diagnosis at that time? What was a treatment? What was the last follow up visit? Are you still taking a medication? No I stop medication. Dr: Why did you stop medication? He wanted to poison me, they were Russian and work with my neighbors. (If she asks you are you Russian? Weather I am Russian or not, it make no differences. I see you need help and I am here to help you on the other hand I am a doctor and I am working at ER.) Then Go To The Mood Dr: How is your mood today? Are you depressed? Do you feel low? Then Go To Organic Dr: Because it is a first time that I see you, I would like to ask you some question about your past medical history. Dr: Do you have any long-term diseases like DM or HTN? (Side effect of antipsychotics typical and atypical) Do you have any hospitalization and surgery?

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Then Go To Head Trauma Dr: Have you ever had any head trauma/head injury/headache (Because brain tumor can give that.)? Do you have fever/lumps and bumps/chill/weight loss/change in your apptit/night sweet? (If Patient take a lot of steroid would take psychosis but not serious like that.) Social history Dr: Do you smoke? Drink alcohol? Use drug? How do you support your self? With whom do you live? Do you have any family and friends? Note: If the Patient asked you am I crazy? There is no medical condition called crazy, however sometimes some patients having difficulty in the way they perceive the reality or they handle their thoughts and we called that schizophrenia. It is look like that your schizophrenia relapsing because you stop your medication. What we can do for you admit you at the hospital and psychiatrist will see you later. Examiner may ask you what is the Mental Status Exam? Patient was well groom, well dressing, and her dressing match together, she was younger than her given age and she was educated. She had poor eye contact, she was not cooperative all the time, but she was not hostile. There was no side effect of medication and any abnormal movement and lip smacking. Speech wise: She had normal voice with normal flow, voice tone and there is no pressure speech. Mood wise: She was anxious, agitated. Perception: Patient admits because of visual and tactile hallucination. Thought processing: She had good and directed goal. Thought contact: She had Delusion, potential Ideation. Judgment: Not intact, She had no insight.

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Case2: Patient comes to the ER, his roommate concern about him because he is not himself in last 10 days. Good Afternoon Mr. Gokowich, I am Dr. Miller doctor in charge at ER. As I understand you are here because your roommate concern about you and he decided to bring you to ER today. Dr: Could you tell me more about your roommate concern? I was in the balcony and I wanted to jump. Dr: what was the reason for that? Because I follow the light. Dr: It was the only reason of his concern and do you agree with his concern? The reason of his concern and he done that is that I am different because I am changed. Dr: What do you mean that I am changed? I have new life style. Dr: For how long was it changed? About 10 days. Dr: When do you say new life style or different person what do you mean? I have chosen different life and I do something that I have to stop it. Dr: How did this change happen suddenly or gradually? It was happened suddenly. Dr: When did happened? 10 days ago. Dr: Do you remember what happened at that time? No Dr: What were you doing at that time? I was going home. Dr: Then what was happened? I saw a light at that time. Dr: What was a light? I saw a Lord he found me. Dr: What do you mean he found you? Dr: How long did that last? Dr: From that moment till now It is all the time or on and off? I still see him but not all the time. Dr: What was the last time you saw him? Dr: Could you describe what do you see for me? Dr: Do you hear any voices besides the light? Dr: Did the light have any special mission for you? Dr: Is it the first time or it happened before? Dr: Is it related to you changing of your life style or not? Dr: What is the concern dose your roommate has if you have new life style? Note: Visual hallucination is part of organic and we have to rule out it.

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Dr: Because it is the first time that I see you I have some question about your social habit. Do you smoke? Dr: Do you drink Alcohol? Dr: Do you use any recreation drug? Yes I used it before. Dr: What kind of drug did you use? Amphetamine. Dr: What was the last time? I used it 10 days ago before the change happened. Go For Delusion: Dr: Do you think anybody want to harm/hurt you? (If yes, ask WHO/WHEN/WHY?) Does anybody want to control you? Dose anybody wants to put thought in to your head? Dose anybody wants to steal thought from your head? Do you believe that other people can read your thought? Do you believe when you watch TV or read newspaper they talk to you or about you? Do you believe that you are special person? Do you have any special mission? Do you have any special power? Do you think any part of your body is (rotting!)? Do you think any body fall in love with you? Here He mentions that want to go to Church Street. Dr: What is the reason and what special at Church Street? I have to go and talk with homosexual persons. Dr: What do your concern about them? I need to purify them. Dr: Why and how? Dr: Do you have any experience? I was gay or I had strong relation with gays but now I am different. Dr: Do you practice safe sex? Dr: Do you have other partner? Now, we know that he has harmful behavior either from the light he wanted to jump or from the purification he harm other people. Dr: Have you seen psychiatrist before? Dr: Have you diagnosed with psychiatric disorder? Dr: Have you ever had the same experience before?

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Then Go To The Mood Dr: How is your mood today? Dr: Are you depressed? Dr: Do you feel low? Then Go To Head Trauma Dr: Have you ever had any head trauma/head injury/headache (Because brain tumor can give that.)? Dr: Do you have fever/lumps and bumps/chill/weight loss/change in your apptit/night sweet? Dr: Have you ever screen for HIV? Social history Dr: Do you smoke? Drink alcohol? Use drug? Dr: How do you support your self? Dr: Do you have any family and friends? Past medical history Dr: Because it is a first time that I see you, I would like to ask you some question about your past medical history. Dr: Do you have any long-term diseases like DM or HTN? (Side effect of antipsychotics typical and atypical) Dr: Do you have any hospitalization and surgery?

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Case3: Patient came to ER and he want to admit because he believes that he contaminated 3 days a go and he want to remove the contamination from his body. (David Green) Case4: Patient came to ER by police that he wanted to kill both his child because he believe that he has a mission like Abraham from the Lord. The checklists of both above cases are similar to case 1&2. If you found delusion in any cases do not forget ask following questions: Do you think anybody want to harm/hurt you? (If yes, ask WHO/WHEN/WHY?) Does anybody want to control you? Dose anybody wants to put thought in to your head? Dose anybody wants to steal thought from your head? Do you believe that other people can read your thought? Do you believe when you watch TV or read newspaper they talk to you or about you? Do you believe that you are special person? Do you have any special mission? Do you have any special power? Do you think any part of your body is (rotting!)? Do you think any body fall in love with you?

If you found Hallucination in any cases do not forget ask following questions: Do you hear any voices? How many voices do you hear? Are they talking to you or about you? Are those voices familiar or not? What they are telling you? Do they ever ask you to harm yourself or anybody else? Do you have any idea about that? If said yes. What do preventing you from doing that? How do you feel about it?

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Case5: Patient came to ER because he believes that RCMP chasing him. (Mr. Walter) Good Afternoon Mr. Walter, I am Dr. Miller doctor in charge at ER. (In this case patient does not sit on the chair and walking around the room.) Would you please come and have a sit.- If he refused - say, as I understand you are here because you believe that RCMP chasing you and you worried about that. This is a safe place and nobody touches you or hurt you here. -If he refused again- say, Mr. Walter I am here to help you and as I said this is a safe place and dont worry about anything. I need to know what is going on. Dr: Could you tell me more about your concern and why are they chasing you? Dr: For how long they are chasing you? Dr: How did it affect in your life? Dr: How do you cope with that? Dr: Did you talk with anybody about that? (The answer always like this: I am not sure, may be, could be, etc.) Dr: Besides the police anybody else chase you? Dr: Do you think anybody want to harm/hurt you? (If yes, ask WHO/WHEN/WHY?) Does anybody want to control you? Dose anybody wants to put thought in to your head? Dose anybody wants to steal thought from your head? Do you believe that other people can read your thought? Do you believe that you are special person? Do you have any special mission? Do you have any special power? Do you see anything that other people cannot see? (In this case you see that he scratching his hand) Dr: I see that you scratching your arm, any reason for that? Dr: Do you feel anything there? I feel ants. Dr: For how long do you feel ants/or any other insects? I am not sure, I dont know. Dr: Do you feel that in any other parts of your body? May be, I am not sure, I dont know. Jump to Cocaine: Dr: Do you smoke? Dr: Do you drink alcohol? Dr: Do you use any recreation drug? Yes, I use Cocaine. Dr: When was the last time you take it?

51 | P s y c h i a t r y I am not sure, I dont know. Dr: How much do you take? I dont know. Dr: Did you exceed the amount previously? Dr: How did you take it? I am not sure. Dr: Do you inject the drug? Dr: Do you have fever/lumps and bumps/chill/weight loss/change in your apptit/night sweet/repeated chest infection/diarrhea/headache/vomiting? Dr: Have you ever had screen for HIV or STD? Then Go To The Mood Dr: How is your mood today? Dr: Are you depressed? Dr: Do you feel low? (Try to rule out Mania and Depression) Dr: Dose any chance to harm yourself or anybody else? (Rule out Suicide and Homicide) If he stand up again and left the room, Look at the examiner and ask I need to fill form number 1.

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Case6: The patient came to ER and would like to be admitted to hospital (Mrs. Bradley is a borderline patient) Good Afternoon Mrs. Bradley, I am Dr. Miller doctor in charge at ER. As I understand you are here because you would like to be admitted. Dr: Could you tell me what is the reason that you want to be admitted? If you admit me I will tell you. Dr: In order to determine if I can admit you or not I need to get more information from you, for that reason I would like to ask you some question to see what is going on in order to help you. So, however there are different ways to help you and admission only one of them. Otherwise, in order to admission the patient, we need to fill the form about the reason of admission. I afraid if you dont admit me something bad would be happened. Dr: What was that? My pressure building up. Dr: When did start? About 6 weeks ago, but last night I felt it very sever. Dr: When so said something bad would be happened what do you mean? I am going to kill myself. Dr: Did it happen before? Yes. Dr: How many times did it happen before? It happened a lot. Dr: What was the first time? Dr: What was the last time? Dr: What was done for you? Dr: Have you ever been admitted to the intensive care unit? Dr: Did you take any medication? Dr: Always when dose it happen to you do you feel some pressure like today? Dr: Have you ever seen by psychiatrist? Dr: What was the diagnosis? Dr: Do you still see him? Dr: What was the last time you saw him? Long time ago. Dr: Why did you stop see him? Dr: In addition to your psychiatrist is there anybody else involved like any social workers or care manager? Dr: In case of crisis do you have anybody to contact? Dr: You told me first build up pressure was 6 months ago. Did anything happen at that time before that? (If she said lost job) Dr: How did you lost your job? Dr: Do you have any financial support?

53 | P s y c h i a t r y (Always if somebody said I lost my job ask:) Dr: What did you do for living? What type of job did you have? Dr: O I am sorry to hear that? Dr: For how long have you been there? Dr: What was happened? Dr: Before that what other job did you have? Dr: Is it difficult for you to keep working in one place? (She always answers because of my boss my coworkers.) Dr: Are you under any financial pressure? Dr: Did you try to find another job? Dr: Did any thing else happen at the last few days? (She may be said that yes my boyfriend left me.) Dr: For how long have you been together? Dr: What was happened? Dr: Before that, did you have any other relation? Dr: Is it difficult for you to stay in relation? Dr: When did your relation started? Dr: For how long did you have your last relation? Dr: Was he supportive or not? Dr: Why did you left your relation? Dr: From the moment that you started your sexual activity how many partners did you have? Dr: Is it difficult for you to stay and maintain relation for the long time? Then Go To The Mood Dr: How is your mood today? Dr: Is there any chance that you are depressed? Dr: Do you feel low? (Try to rule out Mania and Depression) Dr: Do you have any excess fear? Social history Dr: Do you smoke? Drink alcohol? Use drug? Dr: How do you support your self? Dr: Do you have any family and friends? Dr: Do you receive any support from your family? Dr: Could you tell me more about your family? They are jerk. Then look at the examiner: I have done complete work with patient and I need to fill form 1.

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Case7: Patient came to the clinic with diagnosis Bipolar I for last 3 years and would like to discontinue with lithium medication. (Tom Cruse) Good Afternoon Mr. Cruse, I am Dr. Miller doctor in charge at the clinic today. As I understand you are here because you would like to discontinue your medication. During the next few minutes I take a history and I need to ask some questions and at the end hopefully - I can able to help you to make a decision/ we reach a working plan. Dr: Could you tell me more about your decision? About 3 years ago I diagnosed with Bipolar I and from that time till now I am taking Lithium and I think it is the time to stop. Dr: Why do you want to discontinue your medication? It is 3 years and it is long time enough. Dr: Do you have any concern or reason? As a mater of fact yes I am a writer and I could not write anything, I am not sure it is related to Lithium or not. Dr: I am glad that you came today to talk about it. Dr: Let me ask some questions to see how you are doing today. Dr: Could you describe your mood today? I am fine. (You might not accept that but because he already has mood disorder you have to go through all the symptoms.) Dr: Do you feel elevated as high? No (We go through DIG FAST) Dr: Do have a lot of projects recently? Dr: How many projects do you have? Dr: Are you able to finish your projects? Dr: Do you spend more money than before recently? Dr: Are you borrowing money? Dr: Are you buying things that you dont need? Dr: Do you buy more things than before? Dr: Are you spending and buying things that cannot afford? Dr: With whom do you live? Dr: Are you sexually active? Dr: How many partners do you have? Dr: Do you practice safe sex? Dr: Do you smoke? Dr: Do you drink? Dr: Do you use any drugs? Dr: Do you have any problems with the low?

55 | P s y c h i a t r y Dr: Do you drive fast? Dr: Do you take any speeding ticket recently? Dr: Do you have any fight argument recently? Dr: Do you thing you are special? Dr: Do you believe that you have a special mission? Dr: Do you have any special mission? Dr: Do you have any special power? Dr: Do you think that you deserve treat differently? Dr: Do you feel a lot of idea racing in your head? Dr: How much time do you spend in your projects? Dr: How many hours do you sleep every day? Dr: Do anybody tell you are talking faster than before? Dr: Do anybody mention that you talk different than before? (May be the patient is depressed) Dr: How is your mood? Dr: Do you feel low? Dr: What kind of activity do you enjoy? Dr: Are you still doing that? Dr: Do any things bring happiness to your heart? Dr: Do you feel things are getting slower and you need more time to do things like before? Dr: How is your apptit? Dr: Do you have any weight lost? Dr: Do you feel tiered? Dr: How about your concentration? Dr: How did you diagnosed with Bipolar I? Dr: What was done at that time? Dr: Where do you hospitalized at that time? Dr: Was there any serious consequences?(Like HIV from no protective sex or driving problem) Dr: Are you under regular follow up? Dr: What was the last time that you saw your doctor? Dr: Which medication do you take? Lithium. Dr: Do you take any other medication besides Lithium? No. Dr: How much do you take? 1200 mg Dr: Do you measure it on regular bases? Dr: When was the last time did you measure it? Dr: What was the level at that time? Dr: Is there any chance that you take new medication? Dr: Did you increase your dose? Dr: How do you feel about taking Lithium? Dr: Did you notice any side effects? Dr: How do you get your TSH measure?

56 | P s y c h i a t r y Dr: What was the last time you measured it? For Hypothyroid: Dr: Do you feel cold? Dr: Do you have any weight gain? Dr: Do you have any constipation? Dr: Do you have any dry skin? (Give him L-Thyroxin) For Diabetes Insipidus: Dr: Do you drink more ? Dr: Do you go more to the washroom? For Kidney: Dr: Did you do any U/A test? For Neurology: Dr: Do you have any shakiness? Dr: Do you have any difficulty with your balance? Dr: Do you have any seizure? Dr: Do you have any lost of consciousness? (Give B-Blocker) Dr: Do you feel any nausea, vomiting, or abdominal pain? (Because with N/V or abdominal pain you cannot achieve the therapeutic level and you have to change or you have to stop) Dr: Have you ever discontinued Lithium in last 3 years? I know that I have been asked this question before but I have to ask it one more time. Dr: Do you think anybody want to harm/hurt you? (If yes, ask WHO/WHEN/WHY?) Dr: Do you see any thing that other people cannot see? Dr: Do you hear any voices that other people cannot hear that? Dr: Are you person that worried about excessive fear? Past medical history Dr: Because it is a first time that I see you, I would like to ask you some question about your past medical history. Dr: Do you have any long-term diseases like DM or HTN? Dr: Do you have any hospitalization and surgery? Family History Dr: Do any body in your family have diagnosed with depression, Bipolar I or Mood disorder?

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Social history Dr: Do you smoke? Drink alcohol? Use drug? Dr: How do you support your self? Counseling: (We starting by comparing Mania and Depression) What is your understanding of Mania and Bipolar I? It is condition affect our Mood in which people feels elevated and is one of the mood disorders. This is quit common condition, a lot of people have them most of the time, most of the patient have a condition called depression. Patient with depression feel low and start to loss interest and we can treat them by talk therapy or medication and in depression we need to treat for at least 6 months after the improvement of systems. If they discontinue their medication and the patient get relapse then we need to treat for a longer time ever for lifetime and if it happened for more than 2 times we have to treat them forever. This is not a condition of Mania. Mania is a long life disease something similar to diabetes in which, we can control the symptom but we cannot cure it. There is lots of research and hopefully we able to find a cure but not now. If you decide to discontinue your medication and this is the concern you have, your chances of relapse is high about up to 60% of first time, if you discontinue twice your chance increase up to 80% and after third time it reach more than 90% which is very serious and concerning that why better to treat for long time, but there is a trick here (If you find he is taking 1200 mg and his level is 1.2) it looks like your level is highest level of the norm. What can we do? We can decrease a little bit and well see how it is affected you. If you choose it you have to promises me at anytime you start to spend a lot of money, talking fast, not sleep or having racing in your head to contact me immediately or 911 or the Emergency and that is contract. If you accept I change the doze of your lithium. When you are coming to writing, though block is not related to lithium, we need a time to see it improve or not. If you find any trace of depression it looks like you have the other phase of the bipolar I and thats called depression and usually depression in bipolar I treated by psychiatrist and I can refer you to psychiatrist.

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DRUG SEEKER

headache, abdominal pain (vague presentation) or was seen by another doctors, it is not organic, also you need to R/O red flags. in all psychiatric patient always ask about suicide and homicide.

42 years old - headache on Tylenol 3 asking for renew the Tylenol 3 setting= In office and pt. is searching around for Tylenol 3 you should stop the pt. from searching your office - do not let the pt. wave and search the office. When you talk to pt. and pt. is drug seeker use: Habit forming medication - Instead of Addicting In all scenarios - take headache HX R/O cancer--R/O suicide Then start counseling There is a methadone clinic or pain clinic and if pt. cannot stop the painkiller (Tylenol 3) to advise to go step down plan or methadone program

Tylenol 2= 15 mg / Tylenol 3 =30 mg/ Tylenol 4=?

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Case 1: 22 y/o, F- came to the clinic 3 wks Abdominal Pain (or headache for 6 wks) (Somatization)
Knock Knock Knock -as I understanding you are here because you have been having abdominal pain for the last 3 weeks . can you tell me more about your pain? -I was told you were seen by a surgeon 10 days ago .what was the diagnosis? Did he do any investigation? When did your pain start? (OCD PQRST) -did you ever wake up with this pain? (pain during night is organic) Red flag: -Is it associated with fever, chills, wt loss,N/V,night sweat, -any change in your bowel movements? Diarrhea, constipation,bulky, any fat droplet, blood in stool, is it difficult to flush, dose it float in the toilet? -any jaundice? Yellow discoloration? Dark urine, pale stool. -how about heart burn, abdominal distention, bloating, gases? -is it the first time you have this pain? at what age did it start? -how often did you have it? -they were similar? -any surgeries? any investigations before? -How many surgeries? Pt.: ask about MRIWhy do you think MRI is Important? Pt :3-4 times. Pt: yes? Pt: no I had before.

Pt: when I was 17y/o

60 | P s y c h i a t r y -ok in order to determine, whether you need MRI or not I need to have further assessment. (8 somatization ssx) -in addition to abdominal pain do you have any other pain? any headache? neck pain? joint pain? back pain? - with whom do you live? are you sexually active? any pain in Intercourse? -are you interested in having sexual activity? Is that satisfactory? - do you have difficulty swallowing, finding words,any numbness, tingling, jerking movement, LOC? -how did it affect your life? -how are you coping with this? Psychiatric assessment: (MOAPS) -how is your mood? interest? -PMH- do you drink? Do you smoke? Drug? -are you a person who worries a lot? Do you have excessive fears? -can you hear voices or see something that other cant.? -any body wants to hurt you? -any chance you might harm yourself or somebody else? ask about self care) -how do you support yourself financially? -with whom do you live? Is he supportive? -do you feel safe in this relationship? -any FH of depression, psychiatric disease, suicide, drugs

61 | P s y c h i a t r y Counseling: -Based on your symptoms and the fact that you have been seen by a lot of doctors your condition most likely is related to a medical condition called somatization. do you have any idea about somatization? -We dont know exactly why people have somtization .it could be deferent Theory -One of them is decrease threshold of pain, it could be related to the fact people might have low tolerance to pain. -other possibility is difficulty management stress in their life. This stress is presented as pain. -we need to have a treatment plan. -what we need to do is refer you to a psychiatrist to help you to deal with this situation. - in addition to that Its recommended that you see only one physician. -do you have a family physician? Pt: yesgo back to your Dr and discuss with hIm or her the somatization. Pt : no I can be your family physician if you like . we need to set regular F/U visit once every 2-3 wks. -We will look at your condition each time and will see how you are Improving. We review your sx and we make sure that there is no serious underlying condition. the other thing is that we discuss any stress in your life and we will help you to deal with that . -sometimes Amitriptyline can be used for somatization.

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Case 2; 24 y/o come to the clinic because of abdominal pain for last 3 weeks (or headache)ask to renew Tylenol 3. (Drug seeker)

Knock Knock Knock Hello -as I understanding you are here because you have been having abdominal pain for the last 3 weeks . can you tell me more about your pain?

-I was told you were seen by a surgeon 10 days ago .what was the diagnosis? Did he do any investigation? -who prescribe the Tylenol 3 for you? When did your pain start? (OCD PQRST) -did you ever wake up with this pain? (pain during night is organic) Red flag: -Is it associated with fever, chills, wt loss, N/V, night sweat, -any change in your bowel movements? Diarrhea, constipation,bulky, any fat droplet, blood in stool, is it difficult to flush, dose it float in the toilet? -any jaundice? Yellow discoloration? Dark urine, pale stool. -how about heart burn, abdominal distention, bloating, gases? -is it the first time you have this pain? Pt: no I had before.

63 | P s y c h i a t r y at what age did it start? Pt: when I was 17y/o -how often did you have it? -they were sImilar? -any surgeries? Any investigations before? Pt: yes? -How many surgeries? Pt :3-4 times. Pt.: ask about MRIWhy do you think MRI is Important? -ok in order to determine, whether you need MRI or not I need to have further assessment.

Tylenol 3:
-how much do you use? How many times you renewed it? -do you have the container with you? -when did you start it? How many tablets did you take? How about now? -when you take it, beside relieving your pain what do you feel? (Withdrawal sx) -if you dont take it, what will happens to you? Any pain? diarrhea? Runny nose? heart racing? feeling of being on the edge? -do you renew your medical from same doctor or different doctor?

64 | P s y c h i a t r y 8 somatization ssx: -in addition to abdominal pain do you have any other pain? Any headache? Neck pain? Joint pain? Back pain? - with whom do you live? Are you sexually active? any pain in Intercourse? -are you interested in having sexual activity? Is that satisfactory? - do you have difficulty swallowing, finding words, any numbness, tingling, jerking movement, LOC? -how did it affect your life? -how are you coping with this? Psychiatric assessment:( MOAPS) -how is your mood? Interest? -PMH- do you drink? Do you smoke? Drug? -are you a person who worries a lot? Do you have excessive fears? -can you hear voices or see something that other cant.? -any body wants to hurt you? -any chance you might harm yourself or somebody else? Ask about self care) -how do you support yourself financially? -with whom do you live? Is he supportive? -do you feel safe in this relationship? -any FH of depression, psychiatric disease, suicide, drugs _I would not be able to renew your medication.

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Counseling:
-Based on your symptoms and the fact that you have been seen by a lot of doctors your condition most likely is related to a medical condition called somatization. Do you have any idea about somatization We dont know exactly why people have somtization .it could be deferent Theory One of them is decrease threshold of pain, it could be related to the fact people might have low tolerance to pain. -other possibility is difficulty managing stress in their life. This stress is presented as pain. -we usually dont treat somatization with Tylenol 3. -we need to have a treatment plan. -what we need to do is refer you to a psychiatrist to help you to deal with this situation. - in addition to that Its recommended that you see only one physician. -do you have a family physician? Pt: yesgo back to your Dr and discuss with hIm or her somatization. Pt : no I can be your family physician if you like . we need to set regular F/U visit once every 2-3 wks. -We will look at your condition each time and will see how you are Improving. We review your sx and we make sure that there is no serious underlying condition. the other thing is that we discuss any stress in your life and we will help you to deal with that .

66 | P s y c h i a t r y -sometimes Amitriptyline can be used for somatization. -when I cant to renew Tylenol 3, I would like to know what is your understanding of Tylenol 3? Do you know what it is composed of? -it is a good painkiller. It is composed of 2 components, one of them is Tylenol that is the same as to Tylenol that you can find it in pharmacy, even though generally it is safe, we dont recommend it for a long time use unless there is obvious medical reason. But it causes some liver side effects. the other component is called codein .do have any idea what is that? -it is one of the narcotic family and it is a strong, like morphine, very efficient pain killer if it is used in a right way and in a short term. But in long term it is concerning. Do you know why it is concerning? -First, you need to increase the dose to get the same effect, it is called tolerance. -Second, once you start to use it, you cannot stop it suddenly. If you stop it suddenly, you are going through withdrawal sx such as .. -you are hooked to it without being aware of that .by renewing your medication, I would not be helping you . the more you take it, the more you get used to it. -what we need to is, we need to cut it down gradually. Second, we refer you to a detoxification clinic. They can help you .

67 | P s y c h i a t r y

SUICIDE:
Case:16 y/o female- overdose of aspirin last night sow medically Cleared - next 10 min counseling
Memoric for suicidal attempt 10 point : SAD PERSON 4 release 5 admit 1. sex (male) 2. age (> 60 yrs) 3. depression (mood) 4. previous attempt 5. ethanol abuse 6. rational thinking loss( delusion, hallucination, hopelessness) 7. suicide in family 8. organized plan 9. no spouse (no support system) 10. serious illness, Intractable pain

During scenarios, if pt. is preoccupied and playing her cell phone you should address that and ask her to leave that.

68 | P s y c h i a t r y In poisoning scenarios there are charcoal around lips

Suicide:
Knock Knock Knock

_Hello.. - As I understand you are here because you were overdosed on aspirin last night. Iv been told that you were seen by my colleague and my understanding is you are stable right now and I can talk to you and before I proceed I would like to know how do you feel right now about being saved? Pt: fine! - Im glad that you feel better. (happy) -can you describe what happened? (confidentiality) Pt:I took ASA. _ Why did you take it? Pt :I was very frustrated. Why you were frustrated. (If pt. is planning her cell phone I can see you are pre occupied you phone could you please pay attention for a few minassure about confidentiality) Pt: Frustrated because - I had a car accident by mothers car I found my boyfriend cheating on me.

69 | P s y c h i a t r y

(Accident - what happen? how did it happen? were you alone? Driver or passenger? When was that? Did you hurt yourself or somebody else? if he dosent have driver license, it should have been very Important situation for you to decide to drive car without driver license. where were you going?) (cheating -how long have you been together? is that a stable relation ship? that must be difficult to hear something from somebody you love. but sometimes it happens.) -how much ASA did you take? Did you take any other medication with aspirin? Did you take any alcohol with ASA? Or any drug? -did you lose consciousness? - Did you plan to take it or was an act of angry (you saw it and decided to take it ) -did you seek for help or somebody found you? Try to follow SAD PERSONS Did you leave a note? Did you donate your belonging recently? Pt: yes -when did it start? Why? -is it first attempt? -how is your mood? ( if recently depress is not Important ) -do you drink alcohol? With aspirin did you drink alcohol? How about drug? -do you smoke?

70 | P s y c h i a t r y -any suicide in the family? -what do you think your achieve by ending your life? -sometimes people want to end their life, might hear voices or see things other people cant. Have you experienced it? -do you have any long term disease, hospitalization, surgery, liver disease, kidney disease? -with whom do you live? How is your relation? (with your mom/step father ) -Ask about education If we let you go, after you leave the hospital, what do you plan to do? Pt: I have presentation on Saturday. -where do you want to go? Pt: I want to go my grandparents home, can I go? -yes. (If sad persons score 4 let the pt. to go home Pt: would you tell my mom? -why do you want me to tell your mom? - no, It would be better to tell her yourself. (If pt. wants you to tell mom, you can say, we can help you to tell your mom we can arrange a meeting with your mom and social worker to deliver news to her.) In the future, it may happen again and you want to do it again call 911,and seek help., go to ER, tell your family dr. ,>5 admit.)

71 | P s y c h i a t r y

Anorexia Nervosa:
Case : 16 y/o female clinic parents are concerned about their daughters weight.
(Lisa marshal 16 y/o 47 kg/ 173 cm, who was 60 kg before, BMI:15.8) Role play: The girl is here and take Anorexia Nervosa is the only condition, you should inform the parents as pt. has no insight (lack of insight) so may attempt suicide inform parent. In AN first ask about diet .how much you take .they may say that they eat a lot but you should ask how much of each? the Anorexic pt. usually knows how much they take, complications: heart racing, muscle cramps (wake them up at night) and FX are alarm hypokalemia causes heart racing and muscle cramps we ask them of pt Now you should do psychiatry assessment (MOAPS)-HEADS AN - need multidisciplinary approach - doctors, psych. dietitian. Bulimia pt has insight. conditions comorbidity with Bulimia are: borderline, Impulsive behavior Depression, kleptomania (stealing habit) In Bulimia they loss of control eating too much food in a short time(2h) then feel guilty and induce vomit or start heavy exercise.(at least 3 times a we

72 | P s y c h i a t r y

Anorexia nervosa
Knock knock Knock -hello Lisa,Im Dr.. -as I understand you are here because your parents have concern about your wt. they asked you to come here. could you please tell me more about your parents concern? PT: they are worry about my wt. - What do you think? do you agree with them or no? If pt says: yes I lost a lot of wt. - Im glad you are here then we can talk together If pt says: my parents are over reacting - Im glad you are here so we can discuss and address their concern (we can reassure them) (Analyze cc) when did you start to lose wt? Pt: 6 months ago. -how much is your wt today? How about your highest wt.? -why are you losing wt? - what is your target/goal? -when you look at the mirror how do you feel (perceive) yourself? Over wt. or under wt.?

73 | P s y c h i a t r y -Do you like to dress in baggy dress? -why are you doing this? If pt says -I want to be a modal, actress, dancer .(all of them are alarming) -its not easy to lose wt. how did you do that? -how did you achieve that? -lets talk about your diet . how many meals? how about snack? - Lets talk about your breakfast? what do you eat? ( what about the lunch and dinner? ) dont need. -do you calculate how many calories do you take per day? -do you eat alone or with others? Do you like to prepare food?

-how about exercise? how many times a week? How long each time? what do you do? -any other activities beside it like dancing, swimming, walking? -do you take any medication? Laxatives? Water pills? Stool softeners?

(Medication

Zenical - (absorption fat leaving fat down below) Meridia - suppress, appetite centrally - side effect;

tachycardia.

74 | P s y c h i a t r y (-let me see how this wt loss has affected you?) -how did this Impact your life, your health? -(Amenorrhea) When was the first day of your last period? How regular it is? -do you have any chest pain, SOB, heart racing and muscle cramps during night? -Do you feel cold/ constipation/ dry skin? -nail changes, pigmentation in your leg.? -fine hair in your body/ change in hair -any bone pain / fx / (If it is going a long time cheek for fat soluble Vitamins deficiency. - vit. D - Ca)

(Bulimia,3/wk, over 2h, large amount,then feel gilty.) -Did you ever experience to consume a lot of food in a short period of time? -how many times a week? -Did you feel guilty? -What did you do after? exercise? vomiting? (how do you compensate?)

Psychiatrics:(MOAPS) -how is your mood ? any enjoying from before activities?

75 | P s y c h i a t r y (organic- Constitutional sx. and PMH) -any fever,chills,night sweat, ., long term dis. Medication, allergy, -are you a person who worries a lot? Any excessive fears? -do you feel somebody wants to harm you? Do you see or hear things others dont? -(self care ) do HEAADDSSS here -have you ever seen psychiatrist before? -FHx of suicide/ depression / psychiatric dis.

(Bulimia has periods(menstruation),AN no periods) Bulimia - dont tell parents Anorexia - you tell parents.(I will tell your parents) Indication for admission check with the book BMI<85%--> diagnose - 65% of BMI -dehydration _electrolytes Imbalance

1|Respirology

Case 1: 32 y/o male has had an asthma attack 3 days ago that has been managed in ER. Now, he has come to the clinic for follow-up: (Focused Hx 5 min)
General format: Whenever we have an event, we should start with the event (onset, course, duration), then go for before, during and after the event with series of questions. Then we should ask about asthma history to see if there is any increase or not, followup visits and then look for triggers that are divided into three areas: Medication and infection, outdoor activities and indoor activities. Then we should go for past medical Hx, family Hx and social Hx. Event (O,C,D) before, during , after the event Asthma Hx including F/U visits Triggers ( 3 major groups) PMHx FHx social Hx

Knock, knock, knock Hello, Mr. ..., I am Dr. Miller. Im one of the physicians working in the clinic today. P: Nice to meet you D: Nice to meet you too. As I understand, you are here because you have been having asthma for the last 3 years and 3 days ago you have had a severe asthma attack for which you had to go to the ER. Can you tell me more about the situation? ( you also can ask: how do you feel right now?) What were you doing at that time? P: I was in my office and I started to feel SOB. How did you feel at that time? P: I felt SOB. How did it start? Suddenly or gradually?

Questions to determine the severity of attack: Any whizzing? Chest tightness? Were you able to talk? Any excessive sweating? Any heart racing? Did you lose your consciousness?
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2|Respirology

If patient says: yes Did anybody mention you turned blue? How many times did you use your puffer?

How did you go to the ER? Did you call for help or somebody picked you up? P: I was brought by ambulance. What did they do for you in the ER? Were you admitted or did they keep you in the ER? Did they put a tube into your chest? P: They gave me steroid tablets. How long did you stay there? When they release you, which medication did they give you? Asthma history: Lets talk about your asthma history. When you were diagnosed by asthma? How were you diagnosed? Have you ever gone to the ER for asthma attack? P: I was diagnosed 3 years ago. Are you under regular follow-up? When was your last follow-up visit? P: 3 months ago. Before that visit, how often did you have an attack? How often did you have an attack during the last three months? Did you notice recently any increase in the number of attacks? Have you had any attack at rest? How about during the night? P: In the last 2 weeks, I had more SOB. Did your doctor adjust your medications? Which medication did you use? How often do you use your medications? Do you use peak-flow meter regularly? Triggers: Transition: Im going to ask you some q to see why you started to have more severe attacks.

3|Respirology

A.

Medication and infection: Any flu-like symptoms recently? Any chest infection? Can you show me how you use your puffer? Do you store your medication in right way? Do you make sure that your medications are not expired? Did you start to take a new medication recently? Any painkiller, Aspirin or do you take any betablockers? (we should ask specifically and by name about Aspirin and betablockers)

B. Outdoor activities: Have you noticed any relation between your attacks and: excercise? Cold weather? Pollens? Any construction or dust around you?

C. Indoor activities: Do you or anybody around you smoke? Do you or anybody around you have pet? Recently, have you changed any carpet, linen, pillows, rugs or curtains? Any renovation or painting at home? Do you have any basement at your home? (mold) Any relation to any kind of food? Are you exposed to chemicals and fumes and dust at work? (What do you do for living?) Are you under stress? Any perfume? (any new perfume?)

PMHx: Any Hx of long term disease? Diabetes, high blood pressure? Any history of eczema? P: HTN beta-blocker FHx: Any history of allergy or eczema in the family? Social Hx
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Diabetes Metformin

4|Respirology

Case 2: 24 y/o male in the clinic with cough for the last 5 days (5min: Hx)

Knock, knock, knock Hello, I am Dr. Miller. Im one of the doctors working in the clinic today. As I understand you are here because you have been coughing for the last 5 days. Can you tell me more about it from the moment it started? Empathy: would you like me to get you some water? Or offer the tissue to the patient or whenever you want me to stop, please dont hesitate to tell me. How did it start? Suddenly or gradually? P: From 5 days ago I gradually started to cough and from that time my cough is not improving. Anything increases it or decreases it? Is it the first time or have you had it before? P: Increasing. Form that time till now, is it all the time or on and off? Do you cough during the night? Were you able to sleep last night? Empathy: it must have been very hard for you. Im glad you came here today. Hopefully toward the end of the interview, we can reach a working plan. Is this cough dry or do you bring up phlegm?

If phlegm+ COCA+- B:

when did it start ? P: it started 3 days after my cough. could you give me an estimation of how much is the phlegm? What is the color? P: green. Does it have any specific or offensive smell? Have you noticed any blood in it? P: No
4

P: a lot.

5|Respirology

Associated symptoms: Constitutional symptoms: Any fever, chills, lumps, bumps, night sweat? How is your appetite? Any weight loss? Local symptoms: Do you have any chest pain? (OCDPQRST) P: I have pain (unilateral stabbing pain aggravated by breathing ) Is it related to breathing or leaning forward? Respiratory symptoms: Do you have any SOB? Whizzing? Chest tightness?

Cause? Ask about upper respiratory tract infection symptoms: recently, have you had any flu-like symptoms? Any sore throat? Runny nose? PMHx: Any Hx of long term disease? Diabetes? High blood pressure? recent contact with any sick person? Any recent contact with TB patient? Any Hx of asthma? Use of antibiotics? Vaccination for pneumococcus or flu? Any recent travel? FHx: Does anybody in the family have the same cough? Social Hx

6|Respirology

Case 3: 24 y/o male in the clinic with cough for the last 4 days (5min: Hx)

Knock, knock, knock Hello, I am Dr. Miller. Im one of the doctors working in the clinic today. As I understand you are here because you have been coughing for the last 4 days. Can you tell me more about it from the moment it started? Empathy: would you like me to get you some water? Or offer the tissue to the patient or whenever you want me to stop, please dont hesitate to tell me. How did it start? Suddenly or gradually? P: From 4 days ago I started to cough and from that time my cough is not improving. Anything increases it or decreases it? Is it the first time or have you had it before? Form that time till now, is it all the time or on and off? Do you cough during the night? Were you able to sleep last night? Empathy: it must have been very hard for you. Im glad you came here today. Hopefully toward the end of the interview, we can reach a working plan. Is this cough dry or do you bring up phlegm? Associated symptoms: Constitutional symptoms: Any fever, chills, lumps, bumps, night sweat? How is your appetite? Any weight loss? P: I have been having fever for a while. How long have you had it for? When did it start? Which started before? Fever or cough? Did you measure it? How high was it? Do you have any chest pain? (OCDPQRST) P: I have chest pain (bilateral) Is it related to breathing or leaning forward?
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P: No, it is dry.

7|Respirology

Respiratory symptoms: Do you have any SOB? Whizzing? Chest tightness? Any upper respiratory tract infection recently? Have you had any flu-like symptoms? Any sore throat? Runny nose? Risk factors: Any recent travel? Any recent contact with any sick person? Any recent contact with TB patient? Sometimes people having similar kind of cough might have HIV. Have you ever checked your HIV status? Have you ever been screened for HIV? 1. P: No Do you have any reason to be concerned about it? P: what do you mean? Ask about HIV risk factors: tattoo, iv drug, ...) 2. P: yes, I am HIV positive When you were diagnosed? How you were diagnosed? Are you under regular follow up? When was your last follow up visit? Which medication are you taking? Are you still taking them or not? What was your last CD4 count? Then we should look for: chronic diarrhea, skin changes, headache, TB, trush PMHx: Any long term disease, medication, allergy, hospitalization, surgery, ... FHx Social HX Wrap up: Ill do physical exam. I need to admit you to the hospital today. Patient diagnosis: Pneumocyctic Carini pneumonia

8|Respirology

Case 4: 42 y/o male in the clinic with cough for the last 6 weeks (7min: Hx)

Knock, knock, knock Hello, I am Dr. Miller. Im one of the doctors working in the clinic today. As I understand you are here because you have been coughing for the last 6 weeks. Can you tell me more about it from the moment it started? P: Yes doctor. From 6 weeks ago I started to cough and from that time my cough is not improving. Did you seek any medical attention? What made you decide to come here today? Do you have any special concern? No hidden agenda Is it the first time or have you had it before? Empathy: would you like me to get you some water? Or offer the tissue to the patient or whenever you want me to stop, please dont hesitate to tell me. How did it start? Suddenly or gradually? P: suddenly what were you doing at that time? P: gradually continue Anything increases it or decreases it? Form that time till now, is it all the time or on and off? Is this cough dry or do you bring up phlegm? P: it was productive at the beginning. For how long was it productive? P: for a week and then started to become dry. When your cough was productive, did you have any fever, chest pain, flu like symptoms? Did you seek any medical attention for that? Did you use any medication or it improved on its own?
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9|Respirology

Ask about the phlegm at that time COCA+- B: Could you give me an estimation of how much is the phlegm? What is the color? Did it have any offensive smell? Did you noticed any blood in it?

(Whenever we have a change in symptoms, we should split the Hx and clarify before and after the change point. So, in this case we have 2 different entities: productive cough for a week probably caused by a community acquired pneumonia and chronic dry cough afterwards) Now, we should ask about the current symptoms and pattern of the cough: How often do you cough? How many times during a day? Do you have cough all day or attacks of the cough? How long does each attack last? Any special time of the day? Do you cough during the night? Do you wake up by cough? empathy (Differential diagnosis of the chronic cough based on the time of the day: Morning: Sinusitis, GERD Night: CHF, GERD, asthma)

When you cough, do you cough to the extent that you have whizzing, SOB, excessive sweating or chest pain? (In children: does your child vomit?) Associated symptoms: Transition: Im going to ask you some questions to see if you have other symptoms to help me reach the diagnosis. Constitutional symptoms: Any fever, chills, lumps, bumps, night sweat? How is your appetite? Any weight loss? Ask about differential diagnosis: Sinusitis: Do you have any Hx of repeated sinusitis? Do you have any pain in your face? Do you feel that you always need to clear your throat? Any runny nose?

10 | R e s p i r o l o g y

GERD: Do you have any heart burn? Acidic taste in your mouse? Any relation between lying and your cough? How many pillows do you use? If you bend or lean forward, would that increase your cough? Asthma: Any Hx of asthma? Did you notice any relation between your cough and medications or indoor and outdoor activities? (we should ask about all triggers and also ask about his job) Medications: Which medications are you taking? did you recently use any Aspirin, painkiller, beta blockers? How about ACE inhibitors? CHF: Do you have any ankle swelling? SOB? How many pillows do you use? Any recent travel?

PMHx: Any Hx of long term disease? Diabetes? High blood pressure? Have you had any recent contact with TB patient? FHx Social Hx

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11 | R e s p i r o l o g y

Case 5: 67 y/o male in the clinic with coughing blood for the last week (5min: Hx)

DDx: Cancer, TB, infection, CHF, blood thinner, DVT?

Knock, knock, knock Hello, I am Dr. Miller. Im one of the doctors working in the clinic today. As I understand you are here because you have been coughing blood for the last week. Can you tell me more about it from the moment it started? P: Yes doctor, from a week ago I started to cough blood and from that time, my cough is not improving. Empathy: Im glad you came here today. Hopefully toward the end of the session, well reach a working plan. Do you feel it is frank blood or mixed with phlegm? P: No, it is mixed with phlegm. Did you ever brought up clots or only blood? How did it start? Suddenly or gradually? Is it the first time or have you had it before? Anything increases it or decreases it? Form that time till now, is it all the time or on and off? Is it in certain time of the day? Do you cough during the night? CHF How about in the morning? COPD Then go for COCA+- B: Can you estimate the amount of the phlegm? (tea spoon, table spoon, small cup,...)
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12 | R e s p i r o l o g y

What is the color of the phlegm? (if patient has stripes of blood in the sputum) Does it have any specific or offensive smell?

Any chance that you are vomiting this blood or you believe you are coughing it? (If you feel that the bleeding is a lot, you should ask about hemodynamic stability: Do you feel dizzy? Light headedness? Did you lose your consciousness? Heart racing? Tiredness? In this case because he has stripes of blood mixed with phlegm, you can skip hemodynamic questions) Associated symptoms: In addition to that, did you notice any other symptoms? Constitutional symptoms: Any fever, chills, lumps, bumps, night sweat? How is your appetite? Any weight loss? Respiratory symptoms: Do you have any chest pain? (OCDPQRST) Is it related to breathing or leaning forward? Do you have any SOB? Whizzing? Chest tightness? Risk factors: Do you smoke? Have you ever smoked? Do you have any FHx of lung cancer? Any travel outside Canada? Any contact with TB patients? Have you ever been screened for TB? Have you ever been exposed to chemical in the past? (Asbestosis?) Do you have any pain, swelling or redness in your calf? Any history of heart disease? How many pillows do you use? Do you wake up during the nights gasping for air? Do you take any medication or blood thinner? P: yes why? When? How long?

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13 | R e s p i r o l o g y

When was the last time you get your INR measured? What was that? What is your target? From that time till now, did you have any new medication, any increase in the dose, start antibiotics, grape fruit? P: I had a problem and my doctor gave me Erythromycin. Once you realize that warfarin is the cause, you should ask two important questions: Do you have any bleeding from other parts of your body? Nose, gums, vomiting blood, bllody urine, blood in the stool, bruises over the body? Do you have any weakness, numbness, difficulty finding word, tingling?

PMHx: Any Hx of long term disease? Diabetes? High blood pressure? Asthma? FHx: Any family history of lung cancer? Social Hx

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1|Tiredness & difficulty in vision

DM and tiredness:
42 year old male, tired for six weeks, history and counsel: General format for tiredness cases: (Always we should ask about tiredness, sleep and mood together) 1.OCD 2. Relationship to sleep (is it refreshing or not): organic or mood related (MOAPS) 3. Sleep: A. Working in shift B. with whom do you live? Did she ever mention you are snoring or have jerking movements? 4. Organic causes: 1. Rule out red flags, constitutional symptoms, 2. Review of systems, start with heart, lung, GI, liver, renal, anaemia (last period, heavy, regular), autoimmune, endocrine (thyroid, DM), RF of thyroid (living in mountain without salt and fish, radiation, surgery of the neck, recent pregnancy (subacute thyroiditis) RF of DM (FMHx, lifestyle) DM symptoms and presentation: Disaster DKA Hypoglycaemia Fluctuations Eating more, drinking more, peeing more Feeling tired, weight loss, blurry vision ( swelling of the lens because of osmotic) complications Micro: nephropathy, neuropathy, retinopathy In between: impotence, vaginal discharge, joint abnormality, skin manifestations, cataract, intermittent diarrhoea and constipation Macro: cardio vascular (coronary artery disease), CVA, peripheral arterial disease

5. mood 6. Ask about alcohol

2|Tiredness & difficulty in vision

Knock, knock, knock -Introduction, as I understand youre here because you are feeling tired for last six weeks. Im going to ask some questions, hopefully at the end well reach our working plan. - can you tell me more about your tiredness from the moment it started P: Im tired and I began to be concern. - whats your concern? P: Im an airtraffic controller and Im having blurry vision. - what do you mean by being tired? Lack of energy? Some people feel they cannot move their hand , is that the case? P: I feel exhausted. - sometimes people do not feel refreshed after sleep, is this the case? P: Not anymore. - how about before? P: it was good before. - how did it star? -How are you coping with this? How did it affect your life? Do you need sleep more? How many hours of sleep do you get? When do you go to bed? Do you get up at the middle of the night? Which time of the day do you feel more tired? Moring or evening? - how do you support yourself financially? Do you work at night shifts> -with whom do you live? Did your wife mention that you were snoring or is there any jerking movements during the night?

3|Tiredness & difficulty in vision

- Any fever, chills, weight loss, lumps and bumps, - Any history of heart disease, chest pain, heart racing, shortness of breath -any abdominal pain, nausea and vomiting, change in your bowl movemtn, constipation, diarrhoea -any yellow discoloration, itchiness, dark urine, pale stool -change in your amount of urine, is it frothy or cloudy? - anybody told you that you are pale, any bleeding from you gum, nose, coughing blood, bruises, dark urine, tar stool, last period, heavy, regular -any swelling of the joints, join pain, skin rash, warm joint, red eye, and ulcer in mouth, FMHx of autoimmune diseases like RA and lupus - any history of thyroid disease, do you feel hot or cold when everybody feels fine, do you have any dry or moist skin, any constipation, diarrhea? -have you ever had you blood sugar checked? When, what was the result, do you notice that you are eating more recently, drinking more, going more to the washroom? Do you have blurry vision, when, how long? -complications of dm: ( we asked chest pain already), any weakness, numbness in part of you body, difficulty finding words, any vision loss, any pain in you calf, cramps, do you feel you feet cold - sometimes patients having same symptoms may notice change in their desire or sexual function, do you notice any change in you desire or difficulty with you erection? - how did it affect you life? -( assure) it could be related and could be some treatment for that -( if you did not cover micro complications) burning sensation in you hands and feet, frothy urine, vision change, flashes of the light

4|Tiredness & difficulty in vision

-FHx of DM -social: do you have time to exercise, weight , height , do you have a balanced diet? -mood, interest, smoking, alcohol, PMHx ( HTN, hospitalization, Hx of cancer) Counselling: Mr. Doglas, based on what you told me there is a high chance that you symptoms are related to condition called diabetes. Still, I cannot confirm it 100% but im going to do physical exam and do simple blood work at the clinic today. If they are not diagnostic we refer you to the lab to do something called fasting blood sugar. You are going there not eating for 12 hours, fasting, and then we measure your blood sugar. However, if it ended up diabetics then there is a lot of changes we have to do including life style modification, balanced diet, physical activity, we can refer you to dietician. We need to refer you to diabetic clinic, as well. They will give you medication and more information. Well give you some medication base on your blood sugar and other parameters, part of the caring of the diabetic patients is to have referral to different doctors including, eye doctor, kidney specialist, and foot care specialist. What I recommend until we get exact result is you take some time off you job because of safety issue for yourself and others if you refuse I dont have other iption exept to protect others.

5|Tiredness & difficulty in vision

42 years old male with the difficulty of vision for 4 weeks and was seen by an optometrist two days ago. 10 min Hx and counsel:
- introduction - As I understand youve been having difficulty with your vision for 4 weeks - What do you mean by difficulty in vision? (To clarify) P: my vision is not like before. -Is it difficulty in seeing far or in reading (lens problem)? Is it in one eye or both eyes (systemic)? Is it blurry vision? Is it loss of vision? Do you feel any black curtain falling? Do you have double vision? Do you have difficulty seeing sides? Do you drive? Any difficulty in changing lanes? When you are walking, do you bump into objects (Chiasms)? Does it like you are looking into a tunnel? Do you see at night (cataract, vit A)? Do you see any hollow around the objects? Do you see flying objects, dot spots or flashes? (Blurry vision is DM until proven otherwise) - How did it start? P:gradually - What were you doing? P: I was at work - what do you for the living? P: Im a welder - Any injuries? Do you use protection; do you check your eyes on the regular bases? - Is it all the time or on and off? P: fluctuating - Certain time of the day? -how does it affect your life? - Did you seek any medical attention? P: No

6|Tiredness & difficulty in vision

- any redness, pain or discharge? P: No Neurological: - Any headache, numbness and weakness or difficulty finding words? P: numbness ( we have 2 things, numbness+ vision so consider DM) - where, when, how .... P: toes Do you have any history of diabetes or high blood sugar? P: I had it five years ago. - did you seek medical treatment? P: Yes, I took Metformin - do you remember how you were diagnosed? -When was the last time you see a doctor? P: 2 years ago -what is your reason that you are not seeing a doctor anymore? P: I had it before. -What is your understanding of diabetes? P: something about my blood sugar. ( for any chronic disease)yes, it is about blood sugar. As a matter of fact, diabetes is a lifelong disease. Till now we dont have a cure for that. Once somebody is diagnosed with diabetes he has to live with it. We can control the symptoms and prevent complications. On the other hand, there are very studies are going on for the treatment. (transition to make a bridge to history again) because you havent been under any medical care for the last two years, Id like to ask some questions to see if you have other symptoms related to that.

7|Tiredness & difficulty in vision

Symptoms of DM: 1. More drink, eat, go more to the washroom. 2. do you feel tired, any weight loss, have you ever been to emergency room, any high or low blood sugar, 3. any long term complications. Vision, difficulty finding words, any numbness in your body, chest pain, heart racing, shortness of breath, history of heart attack, pain in your calf, frothy urine, with whom do you live then ask impotency, Lifestyle, diet, ulcers in feet, exercise. PMHX, medication, FMHX of DM Counselling (focus on blurry vision, complications and why he needs to correct it) ( include whatever symptoms you have found in counselling) As I told you, DM is a lifelong disease and it is related to high blood sugar. There are important information you need to know to control your blood sugar. Whenever we eat, the food contains different elements including sugar and carbohydrate that is the main source of energy. In order to use this energy our body need a special hormone called insulin produced by a gland called pancreas. In diabetic patient the level of the sugar is not controlled properly and it is more than it should be. And that could be because either our body does not produce enough insulin or sometimes more than needed but it is not effective. Thats why we need to correct this either by medication and lifestyle or diet. And without proper control, the high blood sugar starts to hurt small and large blood vessels and the long term this will lead to heart attacks, strokes and blood vessels in the legs that cause cramps and ulcer in the feet and these are very serious. And without control the chance are getting high. It also affects small arteries so you have numbness in your feet, and it affects your eyes and the swelling of the lens in your eye make you feel blurry vision. The high blood sugar also make you go more to the washroom. For all these reasons you need to start the treatment. Plan to go to diabetic clinic, measure your blood sugar, and check Hb A1C, dietician, and ECG. referral for the follow up.

8|Tiredness & difficulty in vision

40 year female, difficulty vision for 10 days, seen by two doctor and ophthalmologist:(Conversion)

-introduction, as I understand youve been having a loss of vision for ten days, and Ive been told (or my understanding ) also, youve been seen by two doctors. One of them was an eye doctor. - what did the doctors tell you? Which diagnosis he gave you, did he do any investigation? How did it start? What were you doing at that time? At that time, did you have any pain or injury? From that moment till now is it all the time or on and off? Is it increasing or decreasing or the same? Did it happen before or first tiem? -( although we know this is not an organic cause we touch up some local symptoms) - any red eye, pain headache, weakness, numbness, tingling ? -how did this affect you? -with whom do you live? How is the relation? What kind of concern do they have? What concern do you have about it? - give confidentiality -any stress in your life? ( back to the event) can you remember what was the last thing you were doing ? what was the last thing you saw? Whatever information you tell me even you feel it is not significant it might help me to find the cause for you difficulty of vision. PMHx, FHx Psychology, suicide, homicide Counselling: Its looked like this is a difficult and stressful situation for you . sometimes when we face stressful experiences our brain find it difficult to deal with that and this strss is presented as loss of function, in your case because you saw something stressful for you, it caused loss of your vision. This is called conversion and it is not uncommon ( use positive phrase instead of rare) what we can do is, to refer you to psychologist and he will help you to understand the stress in your life adn help you to deal with it. And see if there is any conflict in your life

9|Tiredness & difficulty in vision

35 years old female difficulty vision for four weeks (pituitary tumour): -introduction - (clarify) what do you mean by difficulty of vision? P: Not like before - do you have difficulty for far or difficulty reading? Is it one eye or both, is it vision loss, is it blurry, double vision, difficulty seeing on the sides, when you are walking do you bump to objects, or do you drive? Do you have difficulty changing lanes, hollow objects, flying objects, dark spot? - How did it star? P: I had a car accident, - were you injured? Did you hurt yourself? P: No - good news. - (back to the event) what happened? From that time, were you able to drive? (Even if he didnt bring driving we should ask because this is our obligation.) Any other changes? -Do you have any headache? When does it start? Is it in the morning or evening? How long does it last? Is it increasing or decreasing? Did you seek any medical treatment? Is there any vomiting? Is it forceful? (ICP rising has forceful vomiting usually without nausea) - constitutional - any weakness, numbness,.... - any history of thyroid disease, any cold or warm, shakiness, dry skin, constipation

10 | T i r e d n e s s & d i f f i c u l t y i n v i s i o n

- sometimes people having similar changes in their vision, they may notice engorgement of their breasts, and even sometimes secretion from their breast, did these happen to you? How about any change in you sexual life desire, and erectile dysfunction. - if female ask: any breast engorgement, secretion from the breast, when was your last period - ( acromegaly) ask about ring, shoes and hat -( MEN syndrome) FHx of kidney stones, pancreatic cancer, diarrhoea, foul smell stool PMHx, FHx SHx

1|Urology

General format: whenever we have a patient with urinary symptoms, we should deal with 3 different areas of symptoms: Obstruction: Hesitancy: Do you have difficulty in initiating urine? Do you need to strain? Did you notice any change in the stream? Any dribbling? After passing urine do you feel you have emptied the bladder or do you still need to go again to washroom? Irritation: Frequency: how many times do you go to the washroom? (now & before?) How about during the night? How has it been affecting your life? (empathy) Urgency: do you feel that sometimes you need to rush to the washroom? Are you able to make it all the time? Incontinency: have you ever lost control? Or wet yourself? Dysuria: do you have any burning sensation when you pass urine? Do you have any flank pain? Urine changes: Have you noticed any change in the color of the urine? Have you noticed any change in the amount of urine? Have you noticed any change in the consistency of the urine? o Is it frothy, cloudy or clear? o Have you noticed any stone? Did you notice any blood in the urine? Have you noticed any change in the urine smell?

2|Urology

Case 1: 67 y/o male, inability to pass urine for the last 24 hours. He has been visited by your colleague and after folley catheterization 1.2 lit urine has been collected. Now, you have been asked to visit the patient:

Knock, knock, knock Hello, I am Dr. Miller. Im the doctors in charge in the emergency room today. As I understand you are here because you havent been able to pass urine for the last 24 hours and I have been told that one of my colleagues has inserted a catheter for you and has collected 1.2 lit of urine. How do you feel right now? P: I feel better Im glad to hear that. P: I am still in pain I can see you are in pain. Bare with me for a few minutes. As soon as Im done, Ill try to deal with your pain.

Can you tell me more about it from the beginning? P: I woke up yesterday. I tried to pass urine but I couldnt. How many times did you try? P: 4-5 times. How did it start? Gradually or suddenly? P: gradually. Were you able to pass any urine? Is it the first time or have you had it before? P: I have had it several times before. (Even if he says it is the first time, you should ask the next question) Recently, have you noticed any change in your urination?
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3|Urology

P: what do you mean? Lets say, do you have difficulty initiating urine?

P: yes when did it start?

P: 6 months ago.

From that time till now, is it all the time or on and off? Is it increasing, decreasing or all the time? P: it is increasing.

Then we should ask all urinary symptom questions starting with obstruction questions. When you ask about waking up during the night to go to the washroom and patient says yes, you should ask: how has it been affecting your sleep? (life) and then put Empathy. Associated symptoms: Constitutional symptoms: fever, chills, lumps bumps, appetite, night sweat, weight loss? P: fever, weight loss (how much over how long?) DDx: Do you have back pain? Any trauma on your back? Any weakness, numbness in yout legs? Consequences: Metastasis: 1. Liver: have you noticed any dark urine, pale stool? Any itchiness? 2. Lung: any cough, phlegm, whizzing, coughing blood, SOB? 3. Brain: any headache, vomiting, weakness, numbness? Risk factors: (so far, the most probable diagnosis is the prostatic cancer. So, we ask about prostatic Ca. Risk factors) Have you ever been screened (diagnosed) with any prostate disease? Have you ever done a blood test called PSA? Have you ever had digital rectal exam done before? Do you have any FHx of prostate disease or cancer? Who? In what age? Do you smoke? Do you drink?
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4|Urology

Rest of DDx: Do you have any history of stroke, weakness, numbness in your body? Do you take any medication? Have you seen a psychiatrist? Any history of urethritis? Chronic obstruction renal failure we can ask about any puffiness in the face?, itchiness, ... PMHx: Because it is the first time I see you, Id like to ask you some questions regarding your past medical history. Do you have any history of long term disease? Diabetes? High blood pressure? Do you have any allergy? Any history of hospitalization, surgery? FHx Social Hx

5|Urology

Dark urine scenarios:


We have three dark urine scenarios with 3 different diagnosis: Blood thinner Nephritic syndrome(PSGN) Renal stone

Whenever we have a patient with dark urine, the first step is to make sure that is it blood or not? Then we should ask about urine changes (COCA). The next step is to determine whether it is obstructive or irritative symptoms. Then we should ask about associated symptoms and differential diagnosis. Then PMHx and FHx and Social Hx. Differential diagnosis of hematuria: Trauma, malignancy, stone, bleeding tendency, blood thinner, infection, glumerulonephritis, Ig A nephropathy

Case 2: 67 y/o male with dark urine for the last week

Knock, knock, knock Hello, I am Dr. Miller. Im one of the doctors working in the clinic today. As I understand you are here because you have been having dark urine for the last week. Can you tell me more about it from the moment you noticed it? P: yes doctor, a week ago I noticed my urine is getting darker and it is not improving. Clarification: what exactly do you mean by dark urine? Is it frank? Is it red or dark like tea or coke? How did it start? Suddenly or gradually? P: suddenly. Form that time till now, is it all the time or on and off? P: in the first to days it was on and off and then it became all the time. Did you notice any clots in that? Is it the first time or have you had it before?
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6|Urology

When you pass urine, is it in the beginning of the urine or in the end or whole urine? P: No, it is in the whole urine. (If you feel that the bleeding is a lot, you should ask about hemodynamic stability: Do you feel dizzy? Light headedness? Did you lose your consciousness? Heart racing? Tiredness?) COCA: Did you notice any change in the amount of urine? Did you notice any change in the consistency of the urine? Is your urine frothy or cloudy? Have you ever noticed any stone in your urine? Did you notice any change in the smell of urine?

Associated symptoms: Local symptoms: All obstruction and irritation question Constitutional symptoms: fever, chills, night sweat, lumps bumps, appetite, weight loss Differential diagnosis: 1. Did you have any trauma to your back? 2. Have you had any history of urinary stone before? 3. Recently, did you have any sore throat? Skin infection? 4. Have you ever been screened for prostate disease? 5. Have you ever been diagnosed by any bleeding tendency disease? 6. Do you take any medication? How about blood thinner?

P: yes why? When? How long? When was the last time you get your INR measured? What was that? What is your target? From that time till now, did you have any new medication, any increase in the dose, start antibiotics, grape fruit? P: I am taking Erythromycin for my chest infection. Why? How long? When was the last time? Once you realize that warfarin is the cause, you should ask two important questions:
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7|Urology

Do you have any bleeding from other parts of your body? Nose, gums, vomiting blood, bloody urine, blood in the stool, bruises over the body? Do you have any weakness, numbness, difficulty finding word, tingling?

PMHx FHx Social Hx

Case 3: 67 y/o male with dark urine for the last week (PSGN)
The checklist in this scenario is exactly like the former case with just 2 difference: 1. In PSGN patient has frothy urine. 2. Because the diagnosis is glumerulonephritis, we should always ask about symptos of renal failure: Do you have itchiness in your skin? Have you noticed any puffiness in your face? Have you noticed any leg or ankle swelling?

8|Urology

Case 4: 67 y/o male came to the clinic because his daughter has a concern that he is not himself for the last 3 months (10 min: Hx & counsel)

Knock, knock, knock Hello, I am Dr. Miller. Im one of the doctors in the clinic today. As I understand, you are here because your daughter has a concern about you. (Whenever somebody else besides patient has a concern about the patient, we should ask patient: do you agree with her? P: I agree I am glad you came here. Hopefully, together we will find a working plan. P: I dont agree I appreciate that you took your time to come here to make your daughter feels better. I promise Ill be as fast as I can. It is good to have such a caring daughter).

Do you agree with her? P: She is overreacting. She is worried that I am not going out. Are you staying at home all the time? P: No, I take my dog for walk. But she says that you are not going to see your friends as before. Why dont you go to see your friends? P: Because I used to see them in Oshawa and it is far. When did it happen? P: about 3 months ago.

What is preventing you from going to Oshawa? What made you choose to stop going with your friend suddenly?

9|Urology

Patient doesnt say anything and gives you some body language. Confidentiality: Mr. ..., Id like you to know that our conversation is strictly confidential. Whatever you tell me will be remaining between us and I wouldnt release any information without your permission unless I am requested by the law otherwise. P: I wet myself. I am sorry to hear that. When did it happen? How did you feel? So, we know that he has a urinary problem (most likely prostate problem) and we should go through the same checklist with the previous patient (retention scenario). If we couldnt find anything in this patient, we can ask Geriatric questions: Do you take any medication? Do you have a list of them? How about the over the counter? Do you have any hearing or vision problem? Do you have any problem with your balance? Do you have any history of fall? How is your mood? How is your memory? Do you have any problem with urination?

If this approach also doesnt give us any clue, we should do the review of system (ROS).