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Introduction

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Befor entering the room: Read the scenario. Notice pt last name and the chief complain. Write Pt name, abnormal Vitals, 2DD + (OPDFSC-LIQRAAA+PAMHSFOSS). Knock the door and enter immediately after hear yes. Mr/xxxx (SMILE), Good morning! Shake hands. (Dont shake if the pt in pain situation) Im Dr.,,,,,,,,,,,,,. Im your physician today. Nice to meet you! Look into the eyes! Let me make you slightly more comfortable, put drape. Tell me.how can i help you today? Show Empathy! Im really sorry for this I will do my best to help u and make u feel better. If SP in pain, I can see u in pain, dont worry I am here to help u,, or to say is there is anything I can do to help u feel more comfortable right now. I am going to ask u some Qs,, if the Pt said no doctor I cant talk respond dont worry I am doing most of the talking, I am really sorry? If in examination asked u dont move her,,so dont move the pateint against his well, unless u have to do that? Use phrases, okay, right, thats good, let me help, let us focus now. Dont look shocked, surprised, raise eyebrows or look to your swatch Dont cut off the pt answer. Sensitive issues that may tears up, keep silence for full Second. then say this must have been difficult time for you take your time. let me take care of you. Patient believes should not be denied, even if they seem implausible to the physician. If pt says oh, its only nit b deficiency you can respond this is one of the possibilities. Id like to check some other possibilities. Always reassure the patient if she shocked from your question. Dont be alarmed its just specific question. Rephrase or repeat what the patient saying to you. Use the lay ward, dont use medical terms,is there is any thing coming up with cough instead sputum where the pain moves on instead radiating. Use transitional phrases now I am going to ask you some Qs about ur health in general

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Summarize in brief, significant information in the History, then ask is that correct? Explain initial diagnostic impression (lay terms),clot in lung instead Pulmonary Embolism. Explain the investigation needed, tell the pat some test need to be run blood test instead CBC. FOR THE PSYCHIATRIC CASES, Mr,Smith, I am really consider your complain, Here in our hospital they r running some supporting group they are really good, I am encouraging you to join them, I can arrange this for you. Patient who cant afford the test, offer her social support team.

Example:

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History (O-PDF-SC-LIQR/ABCO-AAA) Tell more about it ?

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Onset: When did this start? Progression: How is it progressing? Or is it getting worse or better? Duration: How long is it last every time? Frequency: How often does it occur? Does it Come & Go or constant? Situation: What were you doing when it start? Cause: Do you notice any cause for this complain? Is it relating to food intake/ recent travel?
PAIN C/O:

Location: Can you show me, where it is? Intensity: How would you grade your pain on a scale of 1-10? Where 10 is most sever pain Show sympathy here, It must be pretty bad I will do my best to make you feel better. Quality: Can you describe the pain?.... Piercing, burning, throbbing, dull/ sharp? Onset: Did it start sudden or gradual? Radiation: Does the pain move anywhere else? Alleviating factors: Is there any factor which makes the pain better? Aggravating factors: Is there any factor which makes the pain worse? Associated problem: Do you have any other associated problem like..? to cover this topic:

TO COVER THE ASSOCIATION SYMPTOMES FOLLOW THIS STRATEGY FOR ALL COMPLAINS & ask on 2 sections: Symptoms related to the same system involved (according to the complaint):
Example: abdominal pain we will ask about vomit, diarrhea, constipation, change in weight. Review of System: as following Constitutional: Constitutional Fever, Chills, sweating, Night Sweats, Fatigue, Muscle Aches Neck: Head & Neck Eye redness/discharge/itching. Ear Pain/discharge/ Fullness/ ringing. Neurological: Neurological Headache, Numbness, Weakness, Spinning, pass out, Fall out, Head Trauma (Hurting your head?). Heart: Chest & Heart SOB, Cough, Chest Pain, Heart racing (Palpitation). GIT GIT: Nausea, Vomiting, Changes of Bowel Habits, Belly Pain, Blood in Stool Urinary: (BPH IS Continuous FUN) Urinary Burning urination any Blood noticed Painful urination (Dysuria) Hesitancy (Do you have to wait for a while before you can start urinating?) Incontinence (Unintentional Dribbling of urine) / Incomplete Emptying of Bladder. Straining urination/ Stream ( Weak or Normal) Continuous or intermittent Stream ( Dribbling on intentional urination) Frequent urination (Polyuria) Urgency (Do you have to rush sometimes to the restroom to urinate?) Nocturia (Do you wake up at night to urinate?).

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Seizures: is there any shaking? During the LOC was there any dribbling of urine, Tongue w . d o c k. c c u -tr a biting & Confusion after regaining consciousness. APPETITE: Is there any change in appetite? WEIGHT: Is there any weight changes? DISCHANGE: DISCHANGE as vomit/diahria/constipation / cough. Amount: Can you estimate roughly the amount of---? A cupful/teaspoon / table spoon Blood: Have you noticed any blood in it? Color: What color was vomit/Discharge/Stool? Consistency: what is the consistency? Is it watery, fatty or bloody? Odor: Did you notice any unusual smell?
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Now you need to summarize what you get from the patient briefly.
Always should use the transition statement between each section in the history: Example, I am going now to ask you some Qs about your health in the past? Is that okay with you.

Past Hx (PAM-HS-FOSS) Previous episode: - Did you have any similar episode in the past?
- What other medical problems do you have? HTN/DM/stroke. Allergy: Do you have any kind of allergy? Medications: Have you taken any Medications? Hospitalization: Have you ever been Hospitalize? Or have you had any Surgeries? Sleep: What about your sleep? Family Hx: Does anybody in your family have similar medical problem? Do they have any medical disease? OBGYN Hx: If Menopausal: just ask about the LMP and move on. If CBP: 1. When was your 1st period? 2. When was your last period? 3. Do you have any problems related to your menstrual periods? 4. Are they regular? 5. How often do you have your period? / What is the length of you cycles? 6. How long do they last? 7. How many pads do you use on a heavy day? 8. Do you have any pain during your period? 9. Do you have any spotting in between your periods? 10. Do you notice any mood changes? 11. Do you have any discharge from the vagina? 12. When was your last pap smear? How was it? 13. Do you have any pain during sex? Any vaginal dryness?

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14. Do you feel you could be pregnant? 15. Have you ever been pregnant, Abortions/stillbirths?

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Social Hx (SAD+STEPl)
MR/smith Now Im going to ask a something very personal! But I assure you, All the information will be kept confidential.
Do you smoke? How many packs /day? How long have you been smoking? Do you drink alcohol? Who much do you drink? What type? if you suspect that this is an alcoholic, just ask her how much you can drink every time? Then proceed to: Have you ever thought to cut down on your drinking? Have you ever felt annoyed by criticism of your drinking habit? Have you ever felt guilty about your drinking habit? Have you ever taken a drink first in the morning as an eye opener? Have you ever use recreational drugs? How do you take it? How frequently do you take it? when was the last time? Is there anyone in close contact have the similar condition? Have you traveled recently? Do you exercise regularly? Do you feel decrease of your energy? Do you have any cats or dogs in your home? Is there any change in your libido?

Sexual Hx
Are you sexually active? How many partners do you have? Male/female or both? Are you using condom? Have you ever diagnosed with STDs? (councel, okay ms.your sexual practice put you at risk of contracting a STD including HIV, every time you doing sex you should insist that your partner use condom. I recommend you to do HIV test? But we will need your permission? What do you use for contraception? Counsel:

The reason, why Im asking you this, because smoking/ drinking of excessive alcohol/ taking drugs puts you at a higher risk to develop many diseases. So being a concerned physician I must advice you to either limit its quantity or ideally quit it absolutely. Do you have any plan to quit? (Yes) excellent! (No) I understand the old habit die hard and it is very difficult to quit it suddenly. In case if make up your mind in future, we have got a very well developed support program. Please feel free to contact me anytime if you need any help-Id feel happy to help you in this regard.
Summarize:

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Just to summarize your history .


Is there anything youd like to tell me or add before I start your physical.

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Closure
All right, Mr._____, thank you for your kind co-operation. First of all, let me summarize. As you told me that you have.is that right? According to the information I got from you and from the examination, I am considering the possibilities like you may have.. But to confirm the diagnosis, I need to run some tests like blood test and scanning of your________ . As soon as I get the results, we will meet again. And at that time I will explain you in the details and we will also discuss the treatment options. ok? ---Have you understand what we discussed today? Do you have any questions for me? No- If you have any question later on, you can call me at any time. Ok, Mr._____It was nice to meet you. Bye. Take care. (shake the hand with smile and leave the room ) MUSTWrapping up or counseling is MUST-Never leave the room without it! IF You didnt finish Questions or PE-proceed to wrapping up: Ive got an emergency call on my pager and Ive to leave within a few minutes. Ill get back to you as soon as I return back. However, before leaving Id like to summarize my findings so ar(Then start counseling)!

How to deal with a silent patient?


Responding nothing or simply yes or no!

Be unhurried and respectful


Im glad you came to see me today. It appears you are not in good mood or you appear upset today. Is there anything I can do for you- to make you more comfortable? It is important for me to know how you are feeling and what are the things worrying you. Im your doctor and Im here to help you. Okay? Tell me how can I help you? Lets do our best to understand each other Id like to know more about your feelings and problems. Would you please share more about it

How to deal with a talkative patient?


Talking too much irrelevant! Im eager to hear about you! But I feel that you are not getting to the facts that I need most now. Could you please tell me more about your complain. I appreciate that you kept such a careful track of yours..but I feel that at present we should concentrate more about . (CC)

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Any pediatric case FEVER IN 1Y OLD CHILD

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(FEVER FEVER) Analysis of the chief complaint (FEVER): When did it start? Did you measure it? What was the reading? Any associated chills/night sweats?

system: Follow review of system: Constitutional: fever, activity, irritable, responding/drowsy?Any depression over the head? Ears: Did you notice any ear discharge? Did you notice your child always pulling his ear? Eyes: Did you notice eye redness or yellow/tearing? Any sunken eyes? Mouth:
Is there any bluish coloration of lip, any redness in the mouth, ulcers, patches, drooling? Any dryness/pallor? What about his crying? Is there any difficulty in swallowing or chocking/regurgitation / any vomiting?

Nose: Is there any cold symptom, rhinorrhea (runny nose), hoarseness? Any noisy breathe?
Chest: Is there any cough? Any braking sounds? Brings up any phlegm? if yes, ABCO.
ABDOMIN: Urinary symptoms: how many diapers of urine changed/day? if < 6 is worrisome of dehydration. Bowel symptoms: how many diapers of stool changed/day? For Diarrhea, constipation. Shaking, Skin Rashes?

PAMHS-Foss: PAMHSHas your child had any past serious illness? Does your child have any type of allergy? Do you give your child any recent medications? Is there any Hospitalization before? Have had any surgery? Is there any sick contact at home? Sleep? Social Hx of MOM (SAD)? Is there any medical problem in the child`s family?

BIG DEAL
Birth history: Any complications during pregnancy/ Full term or preterm? NVD/CS? Any complications during or after delivery? Did you child needed to be incubated? Is your child`s immunizations up to date? Growth: what about his growth is it normal? Or did you notice nay delay? Are you taking your child to a day care center? Ill contact? Eating: can you tell me about your child eating? Do you feed your child from breast or bottle? How is your child`s appetite? When was the last routine check up? Was everything Ok.? Counseling Explain the D.D (fever due to infection of respiratory tract or ear or both, could be due to urinary tract infection, seizure is benign and due to fever) Explain the importance of child being here.

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Explain further work up (Blood tests, urinalysis, stool test) Meanwhile advise her to give fluids and antipyretics

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D.D: - Otitis Media. - Meningitis - Scarlet fever - 5th disease - Varicella. Investigations CBC with differential count and ESR Urinalysis Ear examination Fundoscopy Lumbar puncture Sickle cell scrapings. Varicella antibody titer. In a pediatric phone case of fever we may use CITRUS in modified way: Chest problem/Cough/Pain Insect Bite/Ill contact. Travel /Rash/ Ulcers in mouth Stiffness in any limb? (Septic arthritis?)

29 Yr. O/F known sickle cell anemia pt c/o chest pain


Manage as pain case & add: Ask about the factors that precipitate SK.C. Crisis: dehydration, diarrhea, fever. H/o hematuria H/o blood transfusion H/o Blood clot formation (Personal and family) Examination Inspection of chest (redness and swelling) Palpation of area (minimal attempt to disturb the patient, did not put stethoscope in the area of tenderness) examine fingers and calf. examine abdomen. Counseling Explain the physical findings and diagnosis & work up (blood tests + CXR) Explain the complications of disease (infections, hypoxia can precipitate the pain) and manner of genetic transmission Contact your doctor immediately if you have fever or breathing trouble. Explain might have to take preventive vaccinations for H. influenzae (Flu shot every year). Offer pain medications for time being. Explain the importance of avoiding hypoxemia and maintaining hydration (8 glass of water).

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Newly diagnosed case of Diabetes in a child


When did it diagnose? How was it diagnosed? Which type of DM? Presenting symptoms? Is he taking any medication/Insulin? (Yes Insulin) Tell me about the site of insulin injections? (Thigh: early peak and early fall, chances of hypoglycemia. Abdomen: Preferred) - Whos the injector? Is he compliant with the Insulin or taking it regularly? Is there any side effect of Insulin? Are you measuring blood glucose regularly at your home? When did you measure his blood glucose last time? What was the level? What is his weight and height? How is his growth in whole? Is he following any specific diet? Would you please tell me more about his diet schedule? Does he play? How many hours? At what time? What does he play? DM Associated symptoms: How it has affected the family and child? Does he feel any fatigue? Or Depressed? Is he irritable? Does he have any problem with vision like blurring of vision? Does he have any abnormal thirst or extreme hunger? Has he lost some weight in recent past? Did he vomit before? Does he have any pain in his belly? Does he have any problems with his bowel movement? Any problems with his urination? Does he ever have any hypoglycemia, passed out? Does he have any tingling or numbness in limbs? Does he have frequent infections of skin or gums? Or itchy skin? Any skin lesion? PAMHSF Has he ever been diagnosed with any medical illness before? Does he have any allergies? Is he taking any medications? Has he ever been hospitalized? Does he have any problem with sleeping? Then ask Milestones questions (I use IDIOT mnemonic) Councel Mrs. Xxxx, First let me summarize what you have just told me. You said ... Is that right? yes Mrs. Xxxx , I understand how you might be feeling after the diagnosis of diabetes in your child. Parents are

not the only ones affected by a child's diabetes. Everyone in the whole family is affected. The dynamics of the entire family undergo changes.
Be reassuring You need to stress that the disease can be managed, whether it's through diet reassuring: and exercise or medication. You might tell them that diabetes is a serious disease and our life is going to be a little different now. You can emphasize that diabetes can be managed more precisely than in the old days.

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Be helpful. Provide him written materials I will print out handouts that might answer your Questions whenw . d o c k. c c u -tr a they come up or you can also buy books about diabetes and how to manage it. Be firm: Be sure that the extended family understands the seriousness of the disease and the importance of
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blood-glucose monitoring, carbohydrate counting, and insulin injections. If he is on insulin, it's crucial that you know what to do in case of a low-sugar emergency. You should know that how to recognize hypoglycemia (when you may seem confused, disoriented, or faint) and should also teach your child. You should also know what to give him under such situation and whom to call for help? You may always keep an emergency kit along with child with snacks and juices for such emergencies. You should also inform about it to the teachers and authorities in school. Hope you understood whatever we discussed today? Do you have any concern or question? Alright then, I will see you once you get to the hospital. Take care.

Fatigue
Step-1: Follow the principle of OPD FC AAA Step-2: Follow Head to toe history in a modified manner. Headache/Lightheadedness. Loss of consciousness. Neck (or other parts) glands. Do you snore? Chest pain SOB or cough. Pain anywhere in tummy. Problem with urination or bowel changes Any weight change /appetite. Step-3: Ask hypothyroid history: Cold intolerance. Depression (how is your mood). Hair fall Voice. Step-4: Ask about depression FACE SLIPS+ see or hear anything. Do you hold any idea that others want to control you or harm you? Step-5: Ask about probable Cancer/Bleeding (Anemia) Do you have black stools? Or passed blood in your stool? Have you ever vomited blood? Do you find any difficulty in swallowing food? Step-6: PAMHSFOSS Examination: Examine mucous membranes for pallor Palpate neck for mass or swelling Check memory, orientation and judgment Counseling:

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Explain physical findings and probable diagnosis & work up Offer to talk to the Pt. family Offer to help and support while getting treated Explain the importance of quitting smoking in long term and offered help

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DD: PTSD Anemia Chronic fatigue syndrome Depression Occult medical disease Investigation: CBC Peripheral smear Thyroid function tests Serum electrolytes

RASH
Have you noticed any rash in your body? Tell me more about your rash? Who long have you been in this? Does it start suddenly or gradually? Does it getting worse or better? Is there is any aggravating factors? Is there is any relieving factors? Where is exactly the rash? Was is initially flat or raised? Have it change to new character? Have there any new areas had involved? Is it associated with itching, burning over the rash, any pain or numbness over the rash, bulla formation or oozing? Are there any breathing problems/chest pain, redness of eyes, any joint pains and fever? In Social Hx: - Anyone else in close contact have similar rash. - Ask about recent travel. - Ask about any animal contact.

Painful swollen joint (CITRUS-HPT)


Manage the case as usual pain case and add: LIQORAA + FOLLOWING: ANALYSIS OF THE CHIEF C/O (JOINT PAIN): Is there any recent trauma? Insect pit? Recent travel? Can you work using this joint? Is there any swelling, redness, stiffness? When? How long it last?

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Is there any other joint affected? Review of system: Is there any headache, fever? Is there any visual problem? Weakness in the face? Do you have any ulcers in your mouth? Is there any difficulty in swallowing? Is there any flue like illness, SOB, cough? Do you have any urinary problems? Any discharge from the penis? Vagina? Is there any history of rash? Any numbness or loss of sensation? IS there any weakness or shaking? Did you notice any Change in your skin on sun exposure? (PHOTOSENSETIVITY) Examination: Check knee for full range of motion OR effusion by ballottement or bulge method. Check all other joints for selling and redness (joint above and joint below) Examine sensation motor and DTRs + Peripheral pulses. Auscultate lungs and heart. DD: Inflammatory osteoarthritis Septic arthritis Pseudo gout Mono-articular rheumatoid arthritis Gout Investigation: CBC with differential, ESR Urinalysis Joint aspiration Knee X-ray ANA, Rheumatic Factor Additional: MRI of joint for history of trauma Lyme titers for H/O tick bite and travel to Lyme endemic areas (New England etc) Important points:

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Trauma to knee Hx:


1. 2. 3. 4. 5. 6. 7.

Ask what was he doing at the time the pain began. Ask are there any noises heard at the time of injury (Popping sound indicates anterior cruciate ligament injury) Ask whether the knee was buckling or unstable. Ask about locking and unlocking of joint ( For meniscal injury) Perform Drawers test for cruciate ligament injury. Perform McMurray's maneuver. In the counseling explain that he needs immediate orthopedics consultation for possible meniscal or ligamental injury.

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Evaluation of OA (OPDFAAA + DPS W)

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How long have you been having the osteoarthritis? How is it progressing? Do you know any specific situation where you feel more pain? Is there anything which makes the pain better or worse? Have you noticed any stiffness? When it is seen most of the time? How long did it last? Is it on both sides? Which side is worse? Do you consistently feel pain? Do you feel pain during sleep or resting state? (So advanced stage) Have you noticed any cracking sound during movement? Have you noticed any muscular weakness around knee? Describe your usual activities and exercise routine? What treatment are you taking for it? Did you have any injury of knees anytime? Do you have similar pain anywhere else like hip? Do you feel pain down your calf or leg? Did you have any rash or fever in the recent past? When did you have your last menstrual period/ when did you have your menopause? Are you taking vit-D and calcium? Have you ever tried HRT? Counseling: As you know it is a problem of aging and related to wear & tear of joint. The pillars of management are regular exercise, weight reduction and regular pain killer to relieve pain. We may also try heat and cold therapies, joint protection techniques, and surgery or joint replacement in advanced cases. Regular exercise can help manage pain it act by strengthening muscles around joints, increasing energy, improving sleep, controlling weight and strengthening the heart. You may also try local massage with oils and anti-inflammatory ointments.

COUGH
Do you have cough? Tell more about your cough? Does it start sudden or gradual? How long have you been in this? Does it getting worse or better? Does it constant or comes and go? Did you bring up anything with cough? If yes: go for ABCO. What is alleviating /what is aggravating? Is there is any association with fever, chest pain, chills, night sweet, wt loss, difficulty with breathing? Noisy sounds? Did you notice any relation to a certain season?

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CHEST PAIN (elderly)

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Manage as any pain case do not forget to ask about weither the pt regulary check his BP and Lipid profile and ask what was the last readings? Also ask if he regularly exercise or not, congratulate him about that. Examination Examinee washed hands Performed eye examination with ophthalmoscope Looked for J.V.D Palpated for P.M.I Listened my heart Auscultated all over the lungs Examined without gown not through the gown. Counseling Explained the physical findings and diagnosis Explained further work up [Blood tests, chest X Ray, ECG, cardiac enzymes, angiogram] Explained the importance of lifestyle modifications by quitting smoking , alcohol and exercise program

Sore throat
When did it start? How long have you been in this? Does it getting worse or better? Is there is any fever, cough, chest pain, joint pain/rashes, do u notice any glands in your neck, is there any rashes? pain over sinus areas? nasal discharge? Is there is any abdominal pains, did you notice any change in your eyes color? Ask about bleeding tendencies Ask about contacts with ill persons. Examination Looked inside mouth. Palpate for enlarged neck glands Palpate for spleen (they act like they are having some discomfort when you press your hand for spleen, so everyone must do this test for this case) and liver Palpated abdomen gently and deeply Auscultated heart. Counseling Explain the physical findings and diagnosis Explain further work up (Blood tests, Throat swab, Monospot test)

Shortness of breath (elderly)


When did it start? When did u get SOB, while walking, climbing up stairs? Or at rest? Is there is anything that may aggravate it/ or alleviate it? Is there is nocturnal attacks, what do you do to relieve it?

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Is there is any swelling in your feet, chest pain, cough, racing of your heart, fainting attacks or dizzy? - Have you checked your cholesterol regularly? What was the last result? Examination Perform eye examination with ophthalmoscope Look for JVD Palpate for PMI Auscultat all over the heart and lungs Percuss for liver span. Check for pedal edema. Check peripheral pulses Counseling Explain the physical findings and diagnosis Explain further work up (Blood tests, chest x ray, EKG and Echocardiogram) Explain the importance of lifestyle modifications by quitting smoking, alcohol, exercise program and dietary modification it decrease hyperlipidemia. -

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LEG CRAMPS (DVT)


LIQRAAA (association: hair loss, sensory changes, weakness, color changes, unilateral swelling, chest pain, back pain). Examination Examine calf tenderness. Elicit Homan's sign. Check pulses in both legs and arms. Check sensation in both legs. Check reflexes in both the legs. Counseling Explain the physical findings and diagnosis Explain further work up [Blood tests, duplex ultrasound, x ray of the spine, blood sugar] Explain the importance of lifestyle modifications by quitting smoking, alcohol and importance regular exercise and strict diabetic control] D.D for this Case Thromboangitis Obliterans Atherosclerotic vascular disease Lumbar spinal stenosis Diabetic Polyneuropathy Deep vein thrombosis Investigations CBC with differential count Duplex ultrasound of lower limbs X- ray of spine Blood sugar

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Lipid profile Angiography.

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ABDOMENAL PAIN
Tell me more about your pain? How long have you been in this? Does it start suddenly or gradually? Does it get worse or better? Tell me exactly where is your pain? From 1 to 10, how could you scale your pain? How does it feel like? Does it move anywhere? Did you notice anything that may aggravate it or may alleviate it? Is there any associated fever, chills, vaginal discharge? What is your LMP? Is your pain related to any kind of food? Is it increase by eating or after a while of eating? Is there any associated vomiting, jaundice, change in bowel movement or color of stool? Have you notice any change in caliber of stool? Any blood in it? Is there is any change in weight or appetite? Did you notice any glands anywhere in your body? Examination Auscultate abdomen prior to palpation Palpate abdomen superficially Palpate abdomen deeply Checke rebound tenderness Looked for CVA tenderness Percuss for liver span Performed Psoas sign and Obturator sign Counseling Explain the physical findings and diagnosis Explain further work up (Blood tests, ultrasound, abdomen x ray) Explain the importance of lifestyle modifications by quitting smoking, alcohol. D.D for this Case Appendicitis Meckel's diverticulitis Perforated Peptic Ulcer Intestinal Obstruction Pancreatitis Urolithiasis PID Investigations CBC with Differential Count Abdomen X-Ray Ultrasound Abdomen

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Pancreatic Enzymes Upper G.I Endoscopy

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JAUNDICE

When did it start? Does it getting better or worse? How long have u had this jaundice? Did u notice any factors that alleviate / or aggravate it? Are there any changes in the color of stools and urine? Is there any associated itching, abdominal pain, fever with chills? Do you feel tired? Do you have any blood transfusion?

GIT cases: ask always on relation to type of food, bowel movement changes, change in

color of the stool, notice in blood in stool, vomiting any blood, change in caliber of the stool, any loss of weight or change in appetite. Do you have any bleeding tendencies? Did you notice any enlarged glands? Have you traveled recently? Examination: examine the abdomen as usual. D.D for this Case Infectious hepatitis Alcoholic hepatitis Drug induced hepatitis Primary biliary cirrhosis Malignancy Investigations CBC with differential Urine for bile salts Anti mitochondrial antibodies LFTs Hepatitis screen

Diaharea

How long have you had this diarrhea? Does it getting better or worse? Is there is any causing factors? Did you notice any factors that increase it / decrease it? Can you estimate roughly the amount? What does it contain/whats it color/what does it look like watery /fatty? Is it smell bad? Is there is any blood or mucus in it? Is it associated with pain? Vomiting? Fever? Rashes? Do u feel every time that u didnt complete the evacuation? (Tenesmus) Have you traveled recently?

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w Do u remember that you exposed to any pet or pet droppings? .c .d o c u -tr a c k Is there is any urinary problems? Examination abdomen examination + Examination of skin for any rashes (face) Examination of oral cavity Respiratory examination Cardiac auscultation Counseling Explain the physical findings and diagnosis (infective diarrhea, like similar in past or due to some different organism). Explain further work up (Blood tests, stool examination) explained the importance of safe sexual practices and use of condoms. Ask to perform rectal examination Advise to take increased fluids. D.D for this Case Gastroenteritis Giardiasis Iso-spora infection Drug induced diarrhea Investigations CBC with differential count Stool for culture and sensitivity Stool examination for cyst and ova CD 4 count P24 load

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Constipation
How long have you been in this? Does it getting worse or better? Is it complete or partial? Can you estimate roughly the amount of stool passed? What is the consistency of stool? Did u notice any blood in it? Do you feel urge to defecate? Do you feel after the evacuation that u didnt complete it? tenesmus Is there any associated pain? Vomiting? Abd. Pains? Fever? Jaundice? Is there is any swellings in your neck? Is there is an episodes of diarrhea in-between? Is there any urinary problem? Do you feel depressed, fatigue and loss of interest in life? Do you have thyroid problems, or do u have cold intolerance, weight. Examination: abdomen Counseling

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Explain the physical findings and diagnosis (functional constipation, due to colon disease (could be due to colon cancer, hypothyroidism) Explain further work up (Blood tests, Stool examination, and Colonoscopy) Ask to perform rectal examination. D.D for this Case Functional constipation Carcinoma of colon Hypothyroidism Diabetic autonomic neuropathy Bowel obstruction Investigations CBC with differential Rectal examination and Stool for occult blood Colonoscopy Thyroid screen Blood sugar and Hb A1c

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Difficulty in swallow
Ask about onset, intensity, location? Progression? Do you have difficulty to swallow solid foods or liquids? Which started first? Is there any relieving factors or any aggravating factors? Is there any vomiting or nausea, pain, fever or change in urinary or bowel habits? Have you had heartburn? Do you notice any change in voice? Have you ever had accidental corrosive swallow before? Do you have any difficulty in breathing? Do you notice any swelling or masses in neck? Do you notice any changes in skin or nails (scleroderma)? Examination: Palpate neck for swelling Examine mouth and throat Give the Pt water and ask him to swallow. Palpate axilla and above clavicles. Examine the abdomen. Ascultate lungs & heart. Counseling: Explain about physical findings & possible diagnosis Explain further work up Explain probable modalities of treatment Explain importance of quitting smoking Offer help in trying to quit smoking Offer continuous support during treatment

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D.D: Cancer esophagus Achalasia cardia Reflux esophagitis Scleroderma Investigations: CBC Barium swallow Esophagoscopy Chest X-Ray Rheumatoid factor and Scl antibodies

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ANC(1st BOOKING)
What is your LMP? Calculate GA, if it wasnt given. How do you know about your pregnancy? Obstetrical history. Menstrual history (Menarche, regular periods) D you know your Rh type of your blood, have you taken any blood before? Contraception history before getting pregnant. Is there is any problems of pregnancy (vomiting, fever, abdominal pain, vaginal bleeding) Past History: as usual PAMHUGS - FOSS but add Ask about history of exposure to cats. Ask about rubella immunization in the past. Ask about families health ( Congenital/ birth problem in the family ) Examination Examine my eyes ( for pallor ) Examine Oral cavity (For general hygiene ) Examine Legs (for edema & varicose veins ) Auscultate Heart and Lungs Examine and Auscultate abdomen ( If less than 28 weeks just do Fundal grip; If more than 28 weeks do all the Leopolds maneuvers) Measure the BP. Counseling Explain the findings and further work up ( Blood for Hb, TORCH screen, HIV ( took the consent) , Hepatitis Screen, U/A, abdominal Sonogram ) Advise to stop usage of tobacco and alcohol consumption. Advise for safe sexual practices. Explain the need for vitamins, Iron supplementations and nutritious diet. Explain the importance of avoiding sick contact (if Rubella ve titre) Explain the importance of regular ANC visits. Investigations CBC with differential count, Blood grouping and typing.

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Urine Analysis. Ultrasound of Abdomen TORCH Screening Hepatitis B Screening HIV Screening

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Amenorrhea
When was that? When was your LMP? Do you have a period every month? How many days it last? How many pads do you use every time? When was your 1st period? Do you have any associated pain? Do you have any bleeding in between the period? Do u experienced problems with PMS? Feel some nervous? Do you use any kind of contraception? Asked about sexual practices Do you notice any loss of weight, change in the appetite? Have you ever got any fever for long duration? Are there any swellings or masses in neck? Asked about any urinary problems or bowel changes? Do you feel depressed or lonely? Do you suffer any decrease in your performance at school? Do u have a nice family? (Family support) Examination: Examine the abdomen Palpate neck for masses, Ask SP to swallow. Examine eye movements. Examine hands for tremor. Auscultate heart & lungs Counseling: Explain physical findings and probable diagnosis Explain further work up Ask to perform P/V Explain about treatment Ask about family support Offer support Psychiatric counseling for depression DD: Pregnancy Anorexia nervosa Hyperthyroidism Hyperprolactinemia Hypothalamic-pituitary-ovarian problems

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Investigation: Pregnancy test and pelvic examination CBC Urinalysis USG abdomen Thyroid function tests and serum prolactin

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DIFICULTY IN MICTURATION
HPI: Does it start suddenly or gradual? How long have you been in this? Does it getting better or getting worse? How frequent do you need to urinate? What about night? If I asked you about the flow of your urine, is it continuous or interrupted? Do you notice any blood in it? When at the beginning or last or all through your urination? How difficult is it initiating or maintaining the flow? Do you feel rush to urinate, burning sensation, fever or chills? Have you got any trauma to spine? Or accidents? Is there any weakness in legs? Is there any change in bowel movements? Are you taking any recent medicines? Examination: Auscultate abdomen Palpate abdomen Suprapubic area (superficial and deep) Palpate back (costovertebral angle) Test reflexes in legs Ask to perform rectal examination Counseling: Explain physical findings and probable diagnosis & the work up Explain the importance of rectal examination Explain how the beer intake may increase the frequency DD: Benign Prostatic hyperplasia Prostatic carcinoma Stone in urinary tract Infection Sphincter dysfunction Investigations: Per rectal examination CBC Urinalysis Renal function tests and IVP Prostate specific antigen (PSA)

INCREASED URINATION

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w Does it start suddenly or gradual? .c .d o c u -tr a c k How often you go to urinate every day and night? What about the volume, can you roughly estimate it? Is there any burning with micturation, urgency or hesitancy? Is there associated thirst? Do you drink a lot of water or eat a lot recently?? Is there is any weight changes? Do you have any history of head trauma? Any lung complains before? Do you have any psychiatric problems? Do you have any of (heat/cold intolerance, hair loss, constipation/diarrhea)? (thyroid) Examination Palpate thyroid Auscultate heart Test muscle power in both upper and lower limbs Test sensations in both upper and lower limbs Test reflexes in both upper and lower limbs Test for CVA tenderness Test visual fields and examined fundus Counseling Explain the diagnosis, physical findings& work up (Blood tests, blood sugar, thyroid profile) Explain the importance of lifestyle modifications and exercise program D.D for this Case D. Mellitus Hyperthyroidism Diabetes Insipidus Psychogenic Polydypsia Investigation CBC and differentials Screening blood Sugar Urinalysis Thyroid profile Serum electrolytes

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Confusion
ask about daily activities which are: Do you need any help getting dressed? Do you need any help feeding yourself? Do you need any help going to the toilet? Do you need any help cleaning your house? Do you need any help shopping? Do you need any help bathing? Do you need any help accounting?

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Do you need any help preparing food? Do you need any help getting up from a chair to bed? Does anyone help u with these activities?

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Depression (FACE SLIPS)


Do you feel guilty about anything? Has your appetite/weight changed lately? Do you have difficulty concentrating? How is your energy level? Do you ever have elated feeling of well-being? Do you have any problems falling asleep/staying a sleep/waking up early in morning? Do you experienced any decrease in your libido? Or loneliness Do you take interest in daily activities? Can you still perform your daily functions or activities? Suicide: Have you ever thought about hurting yourself? Ok what is this plan?

Hallucinations/Psychosis
Just like a case of depression & add: When did hallucinations 1st appear? Would you plz tell me more about it? What are these voices telling you? Was it sudden in onset? How long have you been having this problem? How frequent does it occur? Do you see something? Feel something or being touched? Bugs crawling on body? Do you feel as if other people are trying to harm or control you? Are you taking any illegal drugs? If yes: How long have you been taking this? How frequent? have you ever taken IV drugs also? Do you know your HIV status? Have you had any recent stressful event in your family or work? Have you ever been diagnosed with mental illness? Would you like to meet with a counselor to help u with your problem?

PANIC ATTACK (Breathlessness & anxiety)


When did it start? Suddenly or gradually? How long did it last? How long have u been in this? Is there is any noticed trigger? What may increase/decrease it? Are there any other associated respiratory symptoms? chest pain? Are there feelings of fright, fear of death? Is there any palpitations, dizziness, sweating? Did this make you take any restriction of activities? Did you notice any recent trembling of hands? Is there any family stress, have u had a good supporting family? Did you notice any swelling or mass in the neck?

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Is there any change in menstrual periods noticed? Have you had hot flashes? Asked about occupation? Examination: Palpate neck for swelling Look at hands for tremor Auscultate heart & lungs Counseling: Explain about probably diagnosis & workup Explain about relaxation techniques Explain about treatment Advise not to limit his activities Explain about the importance of family support. DD: Panic disorder Anxiety Hypochondriasis Hyperthyroidism Approaching menopause Investigation: CBC Thyroid function tests Urinalysis Serum LH, FSH NB. IN EPIGASTIC PAIN CASE, handle it normaly any any case of pain but in examination of abdomen dont forget to palpate the axilla and supraclavicular LN.

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Insomnia
History: Since when you have this problem? How many hours do you use to sleep? Do you have any difficulty falling asleep or staying asleep? Is there any nightmares? Ask about any recent traumatic events Ask if having feeling of guilt, lonely or depressed Ask if feeling anxious about any thing Ask if having any associated palpitation, sweating or dizziness Ask if I have pain anywhere in the body Ask about having any fears Ask about suicidal intentions, and plans Ask about daily activities Ask about any medication use Ask about illicit drug use

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Ask about appetite and weight Ask about family support Ask about family problems Examination: You do not require MMS examination for depression unless it is associated with memory problems Palpate neck for masses or swellings Test reflexes and muscle strength Auscultate my heart and lungs Palpate abdomen superficially and deeply Test for lymph nodes enlargement Counseling: Explain the findings and probable diagnosis and the workup. Explain the importance of keeping to a particular sleep schedule Explain the importance of quitting smoking and offer help. Explain about treatment and side effects. DD: Depression Anxiety disorder Drug induced Hypothyroidism Occult medical illness (ca. pancreas) Investigation: CBC Thyroid function tests Urinalysis B12 level Upper G.I endoscopy and ultrasound abdomen

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PASSING OUT (ELDERLY)


When this happened? Is this the 1st time? How often do you have it? How long it last? Tell me more about you passing out: what happened before you pass out? Was there any witness describe to you what happened during it? Do you remember what happened after it? Is there any shaking? Did you bit your tongue? Have you passed any urine or stool? Do you have headache? Do you have any problems with memory or calculations? Is there any head trauma? Any associated limbs weakness. Do you feel dizzy when you stand suddenly? Is there any recently add or change in you drugs? Examination: CNS D.D.: .: Convulsive syncope Vasovagal syncope.

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Cardiac arrhythmia Drug induced othostatic hypotension Seizure AS.

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FREQUENT FALL (in elderly)


HPI When did it start? How often you fall? Does it getting better or worse? Did you notice any difference in the way you walk? Is there any injury caused with fall? Neither a head truma? Did you lose consciousness before or after your fall? Do you have headache/ dizziness/ speech problem, problem with memory or calculation? Don you have /nausea or vomiting/ fever/ chest pain/SOB any racing in your heart? Do you get tremors, I mean any shaking of your hands? Does it improved by alcohol? Also, are there any urinary problems or bowel problems? Inquire about ADLs (active daily living): Dressing, Eating, moving about, Toileting. Ask about IADLs (Instrumental activities of daily living): Shopping, housekeeping, accounting, food preparation, transportation-driving. Could you tell me about your living conditions briefly? Do you have any one to help you? Is there any heat intolerance, voice change, hair loss (thyroid). Are you feel sadness and loneliness? Have you ever felt like ending your life? Examination Examine eyes & neck Examine heart and lungs Examine MMS. Examine touch, pain and temperature sensations in legs and hands Test muscle power in limbs: rigidity, reflexes. Ask me to get up and walk and turn around and sit again Do finger nose test Do alternating movements test Do Romberg's test Check jerks in limbs including planters. Would you plz move your arms. (to see if the tremor disappeared with movement) Counseling Explain the physical findings and diagnosis Explain further work up [Blood tests, blood sugar, MRI] . D.D for this Case Cerebellar disease [Alcoholic/Tumor] Parkinsons disease (idiopathic/drug induced) Diabetic neuropathy [Sensory ataxia] Brain tumors Hyperthyroidism

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Investigations CBC with differential CT or MRI [ posterior Fossa] Serum electrolytes TSH, T3, and T4. ECG

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A 50 year-old man with blurred vision


HPI

When did it start? Does it start suddenly or gradually? Does it getting better or worse? Does it constant or comes & goes? Is there is anything that may aggravate it or alleviate it? Do you have any H/O fits, loss of consciousness, complete loss of vision, eye problems and high blood pressure? Do you experiencing any thirst lately? Do you eating more than you usually do over the past few months? Is there is any change of weight? Do you have problems attaining and maintaining erections while having sex? Do you have problems while walking? You feel pain while walking. Is there is any numbness and tingling in a glove and stocking distribution? Is there any associated headache or nauseating? When was that?

Examination
Check eyes with an ophthalmoscope Did a focus neurological exam with special emphasis on Sensory examination of the extremities Test for vibration sensations on bony prominences proceeding from distal to the proximal Listen to my carotid arteries Do Heart exam (PMI palpation, Auscultation) Felt for pulses in the lower limbs Counseling Explain the possibility of being afflicted with Diabetes Explain the importance of weight reduction Explain that diet would be a major part of my treatment regimen. Medications would be secondary. Explain the various precautions that I need to be taking to avoid injury to my feet Show understanding of the SP problems with erectile dysfunction and discuss treatment options. Ask about family support systems. Explain that regular follow-up would be necessary for my vision and other problems. Explain that the SP can monitor his own blood sugar. Motivate towards a better lifestyle.

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Use appropriate transitions sentences while asking about sexual history (Mr. Jones. I w . d o c k. c am c u -tr a now going to ask you some questions regarding your personal life. I assure you that they will be kept confidential. Please do not feel embarrassed.) D.D for this case Diabetic retinopathy Hypertensive retinopathy Macular degeneration Cataracts Open angle glaucoma Workup CBC with differential count Diabetic screening--Fasting blood glucose and Standard GTT Urinalysis for microscopic proteinuria Lipid profile Doppler of carotids and lower limb vessels
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Dizziness
HPI
When did it start? How long have you had this? Did this related to posture? What brings it and what relieve it? Have you ever lost consciousness? Are there any associated symptoms: chest pain, rings in ears, dripping of urine, did you notice any weakness in limbs? Are you taking any drugs for BP control? From the vitals given? Was there any recent change in medication or dosage? Asked if there is any change in bowel or bladder habits? Examination: Check BP on both hands in sitting, standing and lying position. Check motor power and sensations in all limbs Check reflexes Examine cranial nerves Auscultate heart & lungs Counseling: Tell that you need to record BP in all limbs. Explain physical findings and probable diagnosis. Explain further work up & the treatment. Explain the importance of quitting smoking and offered help Explain the effects of medication change Congratulate the pt for doing regular exercise and ask him to continue doing it regularly. Explain the import of changing dietary habits (less salt). DD: Drug induced hypotension

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Postural hypotension TIA Arrhythmias Coronary artery disease Investigations: CBC Doppler carotid study Blood Glucose Serum Electrolytes EKG and Holter monitoring.

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Loss of hearing in elderly


HPI When this is start/ suddenly or gradually? How long have you been in this? Does it getting better or worse? Is there is anything that may aggravate or alleviate this proble? Have you had any earache, fever, discharge and there is no any of these currently? Have you any sensation of ringing in your ear? Do you feel that the world is spinning around you? Have you feel any episode of dizziness feeling of imbalance? Is there a kind of exposure to a noisy environment for a long time? (work) Do you have weakness with any of your facial muscles? Have you had any other neurological problems like loss of sensation , numbness, tingling anywhere in the body Are you under any medication currently? Examination Check for vision & eye movements Check for jaw muscles and sensations on the face Ask to show his teeth & Ask to puff out cheeks Ask close his eyes and then close one ear while checking the other ear for hearing

Do an Otoscopy by pulling back the pinna Perform the Rinne test (AC>BC) in both ears

Perform the Weber test (Localized to the right ear) Ask to swallow Ask to put his tongue out and move it from side to side Ask to shrug his shoulder. Check position sense Do most of the neurological exam. Counseling Explain the physical findings & the work up (audiometry) Explain that I might need to wear a hearing aid. Address the pt concerns about cosmetic problems of hearing aids and my concerns about looking old with a hearing aid

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Advise that he need to get a periodic Sigmoidoscopy and FOBT tests.

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D.D. Presbyacusis Cerumen impaction Ear drum damage Infections of the ear Otosclerosis VIII Nerve lesions (CNS tumors) Meniere's disease Trauma to the ear Drugs Investigations CBC & ESR Audiometry FOBT and sigmoidoscopy as a screening for his age Lipid profile as a screening for his age

Seizure
HPI When did it start? Does it start suddenly or gradually? How long did it last? How long have you been in that? Did you notice any trigger to this seizure? Anything make it go away? Have you lost your conscious during the attack? Have you Had a vague feeling of dizziness 10 min before each episode (Aura) Tell me about the seizure was it jerking or thrashing movements of limbs? Was there any biting of tongue? Have you passed urine or feces? Tell me what happened after the attack, did you vomit, or did you feel any weakness in your limbs? Do you have or had any headache? Have you had any recent trauma to your head? Do you have fever? Pain in neck? Examination: Try to bend the pt neck Check motor power in all limbs Check reflexes of all the limbs Check sensations in all limbs Examine all the cranial nerves Examine eyes with ophthalmoscope Examine ears with otoscope Auscultate heart & lungs Counseling: Explaine physical findings and probable diagnosis & work up Inform the pt as to how long the treatment is necessary

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Offer support to cope up with the situation

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DD: Epilepsy Tumor Encephalitis Meningitis Trauma Investigation: CBC and electrolytes CT Scan of head Lumbar puncture Blood and urine glucose levels Serum electrolytes

65 Yr Old Lady with arm and leg weakness


HPI
When did your weakness start/ does it start suddenly or gradually? Does it getting worse or better? Are there any aggravating and alleviating factors? Is it affecting the whole leg and whole arm? Which side? Are able to talk? Is there any visual changes? Any sensory changes? How did you feel most of the days before the weakness? Are there any associated factors fever, chills, ear discharge, nasal discharge (sinusitis) neck pain, vomit, jerking movement or dizziness? Do you have problem with frequent falls? Is there any recent trauma Are you has a good supporting family? Examination Check for pulses at two places Check cranial nerves 2-12 B/L Test motor function B/L Check for sensory modalities proximally and distally Check Coordination and gait Check balance Do the Romberg's test Do the tests for cerebellar functions Check for special sensations like proprioception. Do a cursory heart and lung exam. Counseling Tell to pt the probable diagnosis & tests. Discuss smoking cessation and drug compliance. Discuss prognosis. Discuss home situation Inquire if he need any help

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D.D for this Case Stroke Evolving stroke Transient Ischemic attack Subarachnoid Hemorrhage Conversion disorder Work Up Periodic monitoring of Vitals CBC with differentials CT scan of the head Doppler of the carotids Lumbar puncture VDRL (or) syphilis serology

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BL00d PRESSURE CHECK AND REFILL


History: Ask about onset Ask about associated symptoms (Headache, Dizziness, Blurring of vision, chest pain, palpitations) Any recent aggravation in symptoms Ask about self checking of BP regularly Ask about diet control Ask about exercise Ask about occupation & related stress Ask about stress at home Ask about medications Ask if using as prescribed regularly Ask when he had my urinalysis done last Ask about bowel and bladed habits When you last had your cholesterol level checked? Do you have any strokes before or DM? Investigation: CBC Urinalysis Lipid profile EKG Serum electrolytes

HIV AND REFILL


What is the medication you are taking? Are you taking it regularly? Do you have any side effects of drugs (any stomach pain, muscle weakness)? Do you have any breathing problems (cough, SOB)?

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w Have ever had a fever? .c .d o c u -tr a c k Do you have headache and vomiting Is there any eye problems? Do you have oral ulcers or white patches? Do you have any problems with swallowing? Do you have any associated skin problems and rash You dont have weakness and sensory problems in limbs Is there any bowel problems (loose motions) Is there any urinary problems Do you notice any genital problems (ulcers, discharge) Are you joiing any of the support systems, I can help you to join our system if you need? Do you feel sadness or lonely? Any ideas to harm yourself? Do you have any plans? Examination Palpate abdomen gently Auscultate lungs and heart Examine eyes with ophthalmoscope. Check sensory system in hands and legs Examine oral cavity Examine without gown not through the gown Counseling Explain the physical findings & further work up (Blood tests, viral titers, chest x ray) Explain the importance of safe sexual practices and use of condoms to protect others Explained the complications and how to deal with them Explain the importance of vaccinations Explain the availability of support systems D.D for this Case HIV refill Depending upon case (not here - PCP, Candida infection, CMV Retinitis, esophagitis) Investigations CBC with differential count CD 4 count P24 antigen quantification. Chest X-ray LFTs (Zidovudine Toxicity)

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65 Yr. O/M requesting pain medication


A 65 year old man have pancreatic cancer It was diagnosed 7months ago, known to be died. This is not the regular physician you are about to talk to He has steadily been losing weight. Your weight is 10 pounds less than what your weight was 1 month ago He has severe pain in your back.

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w He has an enlarged gall bladder as found by an USG .c .d o c u -tr a c k He has jaundice. It is 9 on a scale of 1 to 10 It doesnt seem to go anywhere It doesnt get better or worse with anything He has decreased appetite. You dont feel like eating anything His bowel habits are normal. He cant fall asleep He is depressed most of the time He was a smoker and drinker before you got the cancer He has a wife and two estranged kids. He has been given morphine by your regular physician ,but it doesnt seem to be working any more for the pain He wants to die comfortably in his home. He has accepted his fate and are not angry or denying the fact that he are dying. He has no interest in sexual life any more. He has no Drug allergies or for that matter any kind of allergies History Taking [General Proforma] Ask if pain was progressive Ask about aggravating factors Ask about the pain going any where Ask about alleviating factors Ask about associated problems Ask about recent fevers Ask about gastrointestinal problems. Ask about shortness of breath or chest pain Ask about problems with urinary tract. Ask about diet and weight Inquire if I had any other problems Ask about any other problems I was having with other systems. Ask about sexual history. Ask about my mood. (This is very important in any terminally ill pt as well especially so in the Pancreatic cancer) Examination: abdomen. Counseling Respect my decision that I wanted to die peacefully and at home Discuss options of hospice care and voluntary health care workers who come home. Agree to increase the pain medication to make me feel comfortable Ask him about advance directives like a living will. Create an atmosphere of trust and respect. Ask about home situation. Ask him about the financial situation Ask how his wife was taking the whole situation.

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Pain in pancreatic carcinoma can be due to the involvement of celiac plexus.

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32 yr old female with multiple bruises


Mental Checklist of DD: Accident Physical assault Spousal abuse Bleeding disorders Collagen vascular disorders S.P's notes: a 30 year old woman, have a bruise on the right arm between your shoulder and the elbow She is accompanied by her husband. When the doctor asks her how she sustained the injury? She told that My husband told me that I fell down the stairs. On further questioning by the doctor she said that, she has been hit by her husband. They have been married for 7 years. Her husband is a truck driver. Her husband hits you whenever he has his rage episodes-usually once a week. They have 2 children, a boy aged 6 and a girl-aged 5. He doesnt hit them. He loves them but they are afraid to go near him when he has his rage episodes. Her husband is an alcoholic and he almost always has a bottle of bourbon by his side. Both her parents are living in the same town and neither of them is aware of the abuse. She loves her husband, but she is always on the edge when he is around. She feels that it is very difficult for her to leave him. She has never reported the matter to any agency. She dont feel safe at home especially when he is around. She has felt at least on two occasions- that he might kill her. She dont have an emergency plan to leave home if the need arises. She dont wish the matter to be reported to the authorities. She has a satisfying sexual relationship with him and you are monogamous. She dont smoke, drink or use recreational drugs. There is a shotgun at her house. She thinks her husband might use it. When the doctor persuades her that she need not endure such a relationship in which she are always in mortal fear- she said that she are going to think about reporting it to the social welfare agencies. If she has been persuaded enough by the doctor- take his phone number and tell him that she are going to call him if the need arises. HPI: Ask how the injuries have occurred Ask about any other injuries that she had Ask about family history of bleeding disorders Ask about use of any medications Ask about child abuse at the house Ask if her family was aware that she was being abused. Ask about his profession Ask about her husbands alcoholism Ask if this happens regularly Ask about how she feels about her husband & how her husband feels towards her Ask about her sexual relationships with her husband Ask if there were any weapons at her home

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Ask about her feeling of safety at home Ask if she had an emergency plan to leave the house if the need arises. Examination Do not neglect the physical exam Ask to touch the opposite shoulder Check if she had any other injuries. Check her arm to see if it was broken Closure Inform the pt that she might have a broken upper arm Inform that you was ordering an X-ray to rule out a fracture. Give her your office phone number and offer ongoing support. Diagnosis: Spousal abuse Investigations: CBC and the others depending on the type of injury

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IMPOTANCE
When did it start? Does it getting worse or better? Does it comes and goes or constant? Does there any factor increase it or any factor that may decrease it? Would you grade your impotence on scale from 1 to 10 where 1 is flaccid and 6 is adequate for penetration? Do you have any problems of sexual desire? ejaculation? Do you have any pain in the legs (claudication) Is there any anxiety or depression? Do you feel that u became intolerant the heat or cold wither, weight changed, any racing of your heart? Examination: Palpate abdomen gently & Examine pulsations in lower limbs Counseling Advise home glucose monitoring & Advise to strict to diabetic diet Advise about the importance of exercise program and quitting alcohol and smoking Advise and explain some relaxation techniques D.D for this Case Diabetic neuropathy Chronic alcoholism Anxiety Head injury with endocrine dysfunction Spinal cord dysfunction Investigations Blood sugar Postage stamp test X-Ray spine MRI of brain Rectal examination

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PATEINT NOTES FORUM

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History 66 yo M c/o right hand tremor for 6 months. It occurs at rest and seems to be getting worse recently. The tremor is exacerbated by fatigue, and there are no alleviating factors (he does not drink alcohol). Reducing his caffeine intake to 1 cup of coffee daily did not seem to help. He denies associated symptoms but does say that his wife complains that he has slowed down since retiring last year. Specifically, he seems to be walking more slowly recently (time course unspecified, but within the past year). He had a hand tremor when very fatigued back in college, but it was bilateral and faster than his present tremor. ROS: Negative except as above. Allergies: NKDA. Medications: HCTZ, Albuterol MDI pm (no use in past year). PMH: High cholesterol, treated with diet. Mild asthma. SH: No smoking, no EtOH, no illicit drugs. If you done CAGE (No for all 4) He is a retired chemistry professor, married and lives with his wife. FH: Noncontributory

NORMAL PHY.EXAMIN REPORTS IN Pt NOTES


Vitals: NWL, no orthostatic changes. HEART: Regular Rhythm Rate (RRR), Normal S1 S2, no rubs, gallops or murmurs. HEENT: - NC/AT, non tender to palpate. - No JVD, No Bruises - PERLA (pupil, equal, reactive to light & accommodation) - EOMI without Nystagmos, no papilleadema - Nose: no external abnormality, turbinate anr not congested and no masses. - Throat: no ulcers, erythema, patches, or exudates. Tonsils are normal no denta or gum abn. - No cerumen, TMs normal, No redness or discharge, No tender auricle. - Neck: Supple, Thyroid is not palpable, No palpable lymph nodes. CHEST: Clear breath sounds bilaterally. Abdominal: soft non distended, + BS, no tenderness, no rebound or guarding, no organomegaly. CNS: alert oriented 3, good concentration. CNs 2-12 intact. Rinne test , tilt, Webber (no lateralization). Motor: sensory= 5/5. DTRs: 2 + intact, symmetrical, Babiniski. Rombergs sign , finger to nose normal. Normal gait.

Back: NROM, No para-spinal tenderness, No warmth or erythema


Examination of extremities: Locate the pain & tenderness.

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Test ROM on extension, flexion, adduction, abduction and external rotation. Examine all the joints. Pulse: intact, symmetric. Sensation if intact to pinprick and soft touch.

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Investigations
HEENT: 1. X-ray, CT, MRI of head 2. Eye- Snellens chart, Visual acuity 3. Ear- Complete audiometry and tympanometry, Culture/Sensitivity for any discharge 4. Routine CBC with diff, ESR CNS: 1. Routine CBC with diff, ESR 2. X-ray, CT, MRI 3. Lumbar puncture 4. Carotid Doppler study 5. EEG 6. EMG & Nerve conduction studies. 7. ECG Musculoskeletal: 1. Routine CBC with diff, ESR 2. X-ray 3. Joint aspiration for culture/ sensitive, cytology, crystals 4. Rheumatic factor, HLA-B27. 5. Serum uric acid levels 6. Antinuclear antibodies, anti dsDNA 7. Muscle biopsy CVS: 1. EKG and echocardiogram 2. Cardiac enzymes (CPK-MB, Troponin, LDH) 3. Chest X-ray 4. Lipid profile 5. Thyroid screen 6. Serum electrolytes Respiratory: 1. Routine CBC with diff, ESR 2. Chest X-ray & PPD 3. Sputum studies (culture/sensitivity, gram stain, AFB) 4. Pulmonary function tests and spirometry 6. ABG and pulse oximetry Abdominal: 1. Routine CBC with diff, ESR 2. Abdominal X-ray & Ultrasound

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4. LFTs 5. CT abdomen/pelvis 6. Upper GI series-Barium swallow, endoscopy, ERCP 7. Lower GI series- enema, Colonoscopy 8. Test for fecal occult blood/rectal examination 9. Pancreatic enzymes (amylase, lipase) 10. Renal function tests Endocrine: 1. Routine CBC with diff, ESR 2. Blood sugar 3. Serum electrolytes & calcium 5. Thyroid screen T4/T3/TSH 6. 24hr urinary catecholamines and metabolites 7. Urine for ketones and sugar. Psychiatry: 1. CBC and ESR 2. CT and MRI of brain 3. Thyroid screen 4. Electrolytes 5. Urine analysis 6. Drug screen / HIV

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CHALLENGING QUESTION
Tremor case: Do you think I will get better? I think your tremor will improve with medication, but I dont know how long the improvement will last. The tremor may be a sign of a larger movement disorder called Parkinsons disease, and we need to do more evaluation to explore that possibility. Passing out case: Do you think I have a brain tumor? I think its unlikely. To make absolutely sure, however, we will do a CT scan, which is a special x-ray test of the brain. That will help us see the structure of the brain and rule out any bleeding or tumor. Weight gain: I want to go back to smoking because I believe that I have started gaining weight since I quit. I understand that your weight is very important to you, but its clear that the health consequences of smoking far outweigh those associated with weight gain. We also need to determine what else might be contributing to your weight gain and then discuss strategies to deal with it. 2ry amenorrhea in 35 age: Am I going through menopause? I doubt it. It would be extremely unusual at your age. I need to learn more by asking you about other symptoms and examining you, and then we can discuss possible reasons you are not having periods.

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Vaginal discharge case: When asked about vaginal discharge, ask, Do you think I have aw . d o c k. c c u -tr a sexually transmitted disease? There are many causes of vaginal discharge, only some of which are due to STD infections. I will try to look for clues by asking you more questions and examining you, and we will definitely send a sample of the discharge to the lab to check for infection.
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Back Pain case: I dont think I can go to work, doctor. Can you write a letter to my boss so that I can have some days off? Youre right; heavy construction work can worsen your back pain or cause it to heal more slowly. I will ask your boss to reassign you to light duty for a while. Call encounter for mother c/o her baby has a diahrrea: How sick is my baby? It is hard for me to give you an accurate answer over the phone. I would like you to bring your baby here so that I can examine her and perhaps run some tests. After that, I should be able to give you a more accurate assessment. Hearing loss in elderly case: Do you think I am going deaf? It is obvious from your symptoms and from the results of my exam that you do have some kind of hearing deficit. We need to perform more complicated tests to fi gure out the cause of the problem, to determine whether it is going to get worse, and to ascertain whether we can halt its progression or improve your hearing. For the time being, I would like you to stop taking aspirin. Bed wetting case: Did I do something wrong to cause this problem? or Is my child going to get better? There are a few medical problems that can lead to your childs condition, but its just as likely to be an isolated symptom. Bed-wetting is much more common than most people believe, and there is no reason for you or your child to feel embarrassed or guilty. There are a number of treatment options available for this condition, and after we have run a few tests to rule out any physiologic abnormalities, I will discuss them with you. Motor vheical accident case: Do you think I am going to die? Your condition raises concern and is obviously urgent. We will start by taking some images of your chest. Then, once we have a better idea of what might be wrong with you, we can give you some medication to help you with your pain. If there is air or blood around your lungs, there is a procedure we can perform that may release the pressure. We will be monitoring you very closely from this point on, and if you have any signifi cant problems, we will be available to make sure you keep breathing. Old women with knee pain: Do you think I will be able to walk on my knee like before? Most likely, but that depends on the underlying problem and your response to treatment. HTN follow up case: I think it is my age. Isnt that right, doctor?

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w No, I dont think its because of your age. I worry more about your medications. However, c k. c .d o c u -tr a testosterone levels can decrease with age, and we will check for that.

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Hematuria case They told me this is because of my old age. Is that true? case: No. Bloody urine is rarely normal. HEADACHE in 35 yrs old women Do you have anything that will make me feel women: better? Please, doctor, I am in pain. Yes, we have many options for medicines to relieve your pain, but first I need to learn as much as I can about your pain so that I can recommend the best medicine. Fatigue: either Domestic violent: I want to go on a trip with my wife. Can we do the tests after I come back? It doesnt sound as if youre feeling well enough to be able to enjoy a trip. Lets do some initial blood tests, and then we can see how youre feeling and decide whether were comfortable letting you go away. AIDS: I think that life is full of misery. Why do we have to live? I am afraid that I might have AIDS. This patient clearly has more to say. Silence is appropriate here, or some small encouragement for the patient to continue talking. Alternatively, say, It sounds as if youre losing hope. Have you thought about hurting yourself or tried to do so? Or Tell me more about your concern about AIDS. DM follow up case: Will I lose my feet, doctor? Not if we continue to keep your blood sugars and cholesterol well controlled. The nerve damage to your feet is uncomfortable but alone will not lead to amputation as long as you take the proper measures to protect your feet from injury. Well discuss how to do that later in the visit. case: Alzheimer case Do you think I have Alzheimers disease? I dont know; we still need to do more testing. Tell me what you know about Alzheimers disease. cases: Jaundice in elderly cases My father had pancreatic cancer. Could I have it too? Its possible; thats why we always rule it out in patients with yellow eyes or skin. Your family history does put you at slightly increased risk, and we will keep that in mind. cough: Persistent cough Will I get better if I stop smoking? Well, we still have to sort out exactly whats making you sick. Stopping smoking should help your chronic cough, and over the long term it will significantly decrease your cancer risk. Young with Cough: Do I need antibiotics to get better?

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w Possibly. Antibiotics dont help with bronchitis because this condition is primarily caused. d o c k. c c u -tr a by viruses that are not sensitive to antibiotics. However, if we find that you have pneumonia, antibiotics will be needed.

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Child with a fever: Do you think that I did the right thing by coming here and telling you about my childs fever? or Is my child going to be okay? You absolutely did the right thing. Maria may have an infection that needs antibiotics; we need to examine her here in the office and then decide whether she needs any more testing or treatment. Infant with fever: Is my child going to be okay? or Do you think I need to bring my child to the hospital? Well, I will need to examine your child first. Although I suspect that he has a viral infection, I still need to make sure he does not have anything else. elderly: Chest pain in elderly Is this a heart attack? Am I going to die? As you suspect, your symptoms are of considerable concern. We need to learn more about whats going on to know if your pain is life threatening. stool: Blood in stool My father had colon cancer. Could I have it too? It is a possibility. Tell me more about the symptoms youre having that concern you with regard to cancer. Sore through: Do you think I have AIDS? Thats a difficult question. Do you believe you have been exposed to HIV? Elderly with arm pain: Doctor, do you think I will be able to move my arm again like before? I hope so, but first we need to find out exactly what is causing your problem. pain: Young women with abdominal pain My child is in the house alone. I must leave now. I cant afford to stay in the hospital. Please give me a prescription for antibiotics so that I can leave. First we have to make sure that your illness isnt life threatening. Our social worker would be happy to work with you to ensure that your child is taken care of, as well as to address any financial concerns you may have. Patient moving with extreme pain on the bed the moment you enter the room!
1. Introduce Yourself with appropriate soberness. 2. Say "I am sorry that you are in so much pain - I shall go through some quick questions and physical examination - as soon as I am done, I shall promptly have my nurse give you something for your pain. I only ask you to bear with me for a few minutes - Is that ok Mr. Clinton?" 3. Drape the SP 4. Start

Patient refuses to answer questions about his/her sexual history?

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"Dear Mrs. Bush, I understand the sensitive nature of this question, but be assured that this will not go out w .c .d o c ack of this room. The way clinical medicine works, there may be important clues hidden in this kind of information u - t r and I want to do my best to help you. So shall we try answering these questions again ?"
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