Patient History

opening

Miss/Mr ___ ? Good morning Mr___

My name is .… I’m the attending physician here today I will take care of
you .nice to meet you (shake)
How would you like me to address you…..
Is there anything I can do to make you comfortable here ?

ok Mr____I will ask you some Qs regarding your health & I will follow it by a
an [Link] I will share my impression with you. is that ok with you?
may I take some notes while we talk ?
_______________________________

- how can I help you today?

- how did this start?
- do you have the pain all the time or does it come & go?
- (if episodic what is the duration of each episode? when was the last one?
- since this started has it been the same or getting worse ?
- can you please locate the pain with your finger?
-how would you grade your pain from a scale 1-10 where 10 represent the
most sever pain of your life ?
- how would you describe your pain. is it …..?
- does the pain travel anywhere else ?
- does anything make it better ? anything make it worse?
- do you have any other symptoms associated with your pain like N/V ?

Differential dx Qs : now I will ask you some Qs about your general health

- do you have any fever / sweating/ chills / travel hx ?

- do you have any changes in your urinary habits? bowel habits ?
- any rashes recently ? any skin/ hair changes ? eye color changes ?
- any headaches , N/V , vision changes, weakness, numbness ?
- how is your sleep / mood / do you think you are under more stress
recently?
- any changes in your weight recently ? what about your appetite?
- do you exercise regularly ?

Now I will ask you some Qs about you health in the past :

- have you had any similar complaints in the past ? do you have any medical
condition ,like high BP or high blood sugar ? for how long ? any meds
compliant? do you visit your Dr regularly? when was your last visit? what
was the last reading ?
- are you allergic to anything ?
(if yes ) when was the last time you took it ? what happened ?
- are you taking any medications right now ?
- have you had any surgery before ? when?

now I want to ask you about your women’s health : (from Gyne section)

now I will ask you Qs about your family health ?

- anyone with similar problem ?any medical condition runs in your family?

I will ask you Qs about your day to day activity and also about your sexual
health , and let me assure you that everything you gonna tell me will be kept
confidential is that ok ?

- do you smoke?
(No) have you ever smoked ? how many backs/ day you used to smoke? for
how long?
- do you drink alcohol?
(No) have you ever drunk alcohol ? how many glasses/ day you used to drink
?for how long?
C: Have you ever tried to cut down your drinking?

A: Do you feel annoyed when others talk about your drinking?

G: do you feel guilty about your drinking?
E: Do you need a glass of drink as an eye-opener?
- do you use any recreational drugs ? what type ? how much? how often do
you take it ? when was the last time ?
- are you sexually active? can I ask you with whom ?
(if GF)

- how many partners did you have in the last year

- men or women or both ?
- do you use condoms or do you practice safe sex ? if no ask why?
Counsel
- have you been dx with any STDs?
- have you been tested for HIV before? when was it ? what was the result?

Now let me rephrase what you have told me so far

thank you for sharing your problem with me , is there anything else you want
to add

now I would like to start my physical examination , is that ok ?

excuse me I will put my gloves on
how is your day ? study

__________________________
Thank you for your cooperation .
now according to your history and the examination , your problem could be
related to a variety of conditions. it could be…….or ………( explain the d.d. ex
if you suspect cholecystitis say it is an inflammation of your gallbladder and
so on )
right now I’m not sure what is the cause of what you are dealing with so I
need to run some tests including some blood workup like a Complete Blood
Count (CBC) and some imaging studies like X-ray and CT scan ( explain any
tests meaning ) .
Once the results are available, we will meet again to discuss the final dx & the
prober management .
Meanwhile ( depends on the case):

1- (severe pain or ER ) I will keep you under observation and my nurse is

going to give you some pain medications etc.
2- counsel about weight, diet , stress management and so on depending on
the case

Do you have any questions/concerns?

feel free to contact me whenever you have any Qs , it was a pleasure
meeting you, bye( shake)
( Patient Notes )

HISTORY

HPI:____ yo M/F c/o _____ for_____ started ____The pain is _____ and ____ on severity.
The pain ↑ with ___and↓ with_______
pt reports ( all the positive)
Pt denies ( all the negatives which misrelated to the system)

ROS: negative except as above

Allergy:NKDA
Medication:HCTZ , atenolol ( compliant )
PMH:HTN x 2 yrs
PSH: cholecystectomy x 20 yrs
SH:CIGGA 1 PPD x 20 yrs. ETOH occasionally or ( 1/4 CAGE) . no illicit drugs use.
sexually active with wife. no hx of STIs
FH:Mother has breast Ca. Father had DM and died of MI

PE

General:A&O x 3, NAD
VS: T 100.2 , or WNL
HEENT: EOMI (extra-ocular movements intact) .PERRLA (pupils were equal, round and
reactive to light and accommodation).no visual field loss. MMM (moist mucus membrane )
wo any visible lesions or pharyngeal erythema . neck was supple. nl thyroid . no LAD.
external ears appeared [Link] intact
CVS: RRR, S1 S2 audible, no S3, S4, no GRM . PMI not displaced. no JVD, no carotid
bruits
Lungs:CTAB, no RRW, no tenderness on palpation, tactile fremitus WNL
Abd: Soft. NT. ND. tympanic x 4. BS x 4, no organomegaly
Back: no kyphosis midline spine, no CVA tenderness
Ext: no cyanosis, clubbing or edema. . no tenderness . b/l symmetric +2 pulse intact
sensation to LT in all ex .full ROM
CNS: cranial nerves 2-12 intact grossly. 5/5 strength x 4 b/l w/ good tone throughout (or
down-going toes bilaterally). intact ROM . symmetrical and b/l intact sensation to LT.
DTRs: 2+ and symmetric in all Ext (Recruitment utilized for lower extremity DTRs) .intact
finger-to-nose test. intact proprioception. negative Romberg’s . nl gait ( disequilibrium
noted ). Speech was fluent and appropriate.
workup:

1: physical exams which cannot be performed like rectal and pelvic examination, breast
2: Rule in investigation for DD1
3: Rule in investigation for DD2
4: Baseline investigation (CBC w diff, UA, S/E, BUN, Cr etc.
( counseling )

SMOKING

YES: I would be happy to help you to quit; we have many tools to help you. Let's
arrange for an appointment in 2 weeks from now and we can get started from there, is
that OK?”
No: Well I strongly recommend that you quit smoking. Because it is a major cause of
cancer and heart diseases. Are you interested in trying to quit? If yes (see above). If
No If you ever decide to quit smoking, we have a great team of professionals that can
help you with that, whenever you feel ready, I will be here to help you, feel free to
contact me at any time

ALCOHOL

CAGE: if one is yes do counseling as following: “I am concerned about your

drinking, it can lead to liver disease, bleeding problems, heart disease and brain
disease”. If a women in childbearing age: “If you get pregnant, alcohol, can cause
serious problems to the baby like mental retardation.” Are you interested in cutting
down your drinking?

NO: “If you ever decide to cut down your drinking, we have a great team of
professionals that can help you, whenever you feel ready, I will be here to help you, if
you have any questions in this regard, please feel free to contact me at any time”

YES: “I am glad you want to cut down your drinking. We have many tools to help you
to do that, and I will be with you in every step of the process. Let's arrange for an
appointment late this week and we can get started on that, is that OK?.”

PATIENT with many sexual partners but not using protection [Link]

Condoms reduce the risk of sexually transmitted infections, Do you think you could
try to use condoms?
NO: I understand that you may not like to use condoms, but I am concerned that you
may risking yourself for sexual transmitted diseases, you could get HIV, herpes,
chlamydia, gonorrhea, syphilis and any other sexual infections. The complications of
theses diseases include infertility, painful infections .

YES: “I am glad to hear that you use protection that will help you prevent from getting
sexual transmitted diseases.

MEMORY LOSS
- Until we get the test results back, I want to ask your permission to talk to one of your
family members about family and social support and safety at home, Is that OK with
you? We have excellent team of social workers that can help you in manage your daily
activities and future living plans in case you need it

-name ID
- don't go out alone
- don't drive or use stove
- use a diary

DEPRESSION

Mr./Ms.__I believe that you might have depression, it is a common disease due to a
chemical imbalance in the brain.” “I know that dealing with depression can be
extremely difficult. Depression cause physical and emotional stress, but we can deal it,
we have a number of techniques and medications that help with depression.” “Also we
need you do some lab test including: blood cell count, electrolytes that are compounds
that are in the blood and in the cells that help the correct functioning of the body, and
also we need to measure the thyroid hormones, that are substances release by the
thyroid that is a gland located in the neck, this substances help in the correct
functioning of the body; when we get back the results of these test we will discuss the
proper treatment.”. “If we decide to use antidepressants, you should be aware that this
drugs can take up to 4 to 6 weeks to show effects.”

LOSS OF CONSCIOUSNESS

“At this time I must ask you not to drive again or use any other kind of machinery, until
we are sure what caused you to loss consciousness.” “I understand that this is an
inconvenient, but you might hurt yourself or others. I assure you that I will do all I can
to find out the cause of this and find the best way to help you, so you can go back to
your daily activities.”

DIABETES

Are you taking your medications as your doctor prescribed? (compliant?)

YES: I am glad to know that you take your medications as it should, I want to let
you know that beside these medications

there are simple but important measures that gonna help you maintaining your
health, First do regular exercise and follow the diet instructions that my nurse will
provide to you before you leave. Also you should make a habit of using soft
footwear when you walk, because diabetes can lead to injury-induce ulcers on the
foot. You also should regular monitor your blood sugar, so I can adjust the dose of
your medications if needed

NO: I strongly recommend you to take your medications regularly because

diabetes can lead a lot of complications, it may cause vision problems, kidney
disease, nerves damage that can affect your legs, feet and arms and hands; also
can affect the arteries and vessels causing problems in your legs and arms that
may end in amputation. Additionally you will be a higher risk for developing
infections, strokes and heart attacks. If you want I can help you to remember how
to take your medications. Do you have someone who could help you take your
medications? If No We have a social worker who might be able to arrange for a
nurse to come to your home, are you interested in that? Also you should follow
diet instructions that my nurse will give to you before you leave, and do exercise
regularly.

Q:Will I lose my feet, doctor?

Amputation is a last resort in patients with diabetes as a result of

infection . The nerve damage to your feet will not lead to amputation as
long as you protect your feet from injury and as long as you keep your
blood sugar under control

HYPERTENSION

Are you taking your medications as your doctor prescribed? (compliant?)

YES: “I am glad to know that you take your medications as it should. I want you
to know that besides the medications,

there are other simple but important measures that help to control your blood
pressure. First do exercise regularly and modifying your diet will help us to
manage your hypertension, my nurse will give you some diet instructions that you
can follow. Also you should regular monitor your blood pressure everyday, and
write it down, the next time we have an appointment I can look at it and adjust
your medications if necessary.”

NO: “I strongly recommend you to take your medications regularly, because

hypertension is a silent disease that can lead to a lot of complications, it can affect
your heart, your kidneys and your eyes; also it can lead to strokes, heart attacks
and heart failure. I can help you to remember how to take your medications. Do
you have someone who could help you take your medications? If NO We have
a social worker who might be able to arrange for a nurse to come to your home,
are you interested in that? Also you should follow diet instructions that my nurse
will give to you before you leave, and do exercise regularly.

-The palpitations and sweating you have experienced are most likely due to
episodes of low blood sugar, which may have resulted from a higher than normal
dose of insulin or from skipping or delaying meals. The numbness you describe
in your feet is probably related to the effect of diabetes on your nervous system.
Better control of your blood sugar may help improve this problem.

Do you think I have serious problem ?

I understand your concerns but let’s not jump into conclusions . for now

child with DM
it sounds like it has been a tough adjustment for you and your family since your
daughter was diagnosed with diabetes, so your life is going to be a little different
now. We can manage this disease very well through a combination of insulin, a
balanced diet, and regular exercise. I encourage you to attend diabetes classes
with your daughter. Second, everyone in your family, including your daughter,
should learn to recognize signs of low glucose levels, such as confusion,
disorientation, or fainting. Your daughter should always carry a snack or juices
as an "emergency kit. we can also discuss her condition further when you bring
her into the office for an exam.

Challenging Questions to Ask

Your daughter probably developed diabetes due to multiple reasons. She may
have had a genetic tendency to develop diabetes and then certain environmental
factors lead her to get diabetes. Your daughter may have either type 1 or type 2
diabetes. In type 1 diabetes, the immune system attacks the pancreas and destroys
the cells that make insulin. On the other hand, if your child is overweight and is
not physically active, she may have type 2 diabetes, which is a combination of
low insulin and resistance to the action of insulin. In either case, it is not
necessary to have a family history of diabetes. In fact, your daughter can still eat
sweets but in moderation, if you would likeI can arrange a referral to a dietitian to
guide you for healthy meal plans and to learn more about the effect of different
foods on sugar level
+ve pregnancy test

I will repeat a urine pregnancy test to confirm your home pregnancy test. Your
last period may not have been a real menstrual period, as spotting can frequently
occur in the first [Link] you are pregnant, I would like to speak with you
about your options with this pregnancy, including carrying the pregnancy to term,
adoption, or termination. After you have some time to think about that,. We will
need to perform a pelvic ultrasound to estimate the dates of the fetus and the
expected date of the delivery. we will check some more blood tests, a Pap smear.
and some vaginal cultures that we routinely perform in every pregnancy.
meanwhile I recommend that you stop drinking alcohol and avoid intense exercise
and excess caffeine. I will be giving you some prenatal multivitamins to take
orally, and we win schedule your future visits.

Q:I’m not married. and didn't plan to have this baby. What should. I do doctor?

I understand your anxiety about this unplanned pregnancy. As your physician, I

want to assure you that I am here to support and advise you in whatever decision
you [Link] you wish, I would be happy to discuss your options with you

Q: am I going to die ?

your condition raises concern & is obviously urgent. We will start by taking some
images of your chest. Then, once we have a better idea of what is wrong, we can
give you some medication to help you with your pain. if there is air or blood
around your lungs ,there a procedure we can perform to release the [Link]
We will be monitoring you very closely

Q: I don't have any insurance. How much will this visit cost?
We have several financial assistance programs that are offered to people
with low income or with no insurance.
after I finish speaking with you and examining you, I will. have our social
worker come to help you sort out the insurance issues
Difficulty at home

Your safety is my primary concern, and I am here to help and support you.
Sometimes, living with family members can be stressful for the whole household. Have
you ever considered moving to an assisted living community or to an apartment
complex for seniors?if you are interested, I can arrange a meeting with our social
worker, who can assess your social situation and help you find the resources you need

Crying
stand, hand over the shoulder, tissue or water to the pt

I know it’s a very hard thing to deal with, I’m so sorry about ….., I want to tell you
that I will be here to help you as much as I can and I will listen if you want to talk
about anything
PAEDIATRICS
1-HPI
OCDP ⬆ ⬇ &D.D
3-FEVER CUDDS
4- PAMH
5-BIG DEALS
__________________________________________________

FEVER CUDDS

•Fever:
What do you mean by burning up ? For how long? Continuous or intermittent? High grade or
low grade? What is the reading? Oral or rectal? How high is the fever ?Does he/she have
chills? night sweats?

•Ear pulling & discharge

Does he/she seems to pull his/her ear frequently?
Does _______ have any ear discharge?How is it?

•Vomit:
Has ______ throw up?
color of vomit?
Did you see any blood in it? food in it?

• Eye discharge:
Does he/she have any eye discharge?

•Rash:
Does he/she have any rash?
Does _____ have itching?
Where does he/she have it?
When did the rash start?
Where did the rash start?
Has the rash moved to somewhere else?

•Chest symptoms:
Runny nose/chest pain/ difficult breathing?
Does he/she have cough?
How often does he/she cough?
Does he/she cough up phlegm?
How is the phlegm?
Is there any blood in the phlegm?

•Urinary:
Has _______ increase or decrease the amount of urine?
How many diapers does he/she use?
Has been any change in the color/odor of the urine?
Does _____ have pain when he/she urinates?

•Diarrhea:
Has been any change in his/her bowel habits?
Does ______ have diarrhea?
How many times did he/she have diarrhea?
Have you seen blood in the diarrhea?
Does the diarrhea have mucus on it?
Does he/she have pain or cries during defecation?

•Dehydration:
Does ______ have dry mouth?
How long since his/her last wet diaper?
When ____ cries can you see any tears?
How is his/her energy?

•Seizures:
Does he have any jerk movements?
Has he/she been shaking?
Is any leakage of urine/stools during/after the shaking?
How is his/her level of consciousness?
How is _____ after the seizure?”

***************************************************************************
BIG DEALS
•Birth
history:
Was that pregnancy full term?
Was it a vaginal delivery or a C-section?
Was any complications?

•Immunization:
Is he/she up to date on his/her vaccines?

•Growth and development:

A-Prenata:
Did you have routine checkups during the pregnancy?
Was there any complications during the pregnancy?
Did you take vitamins during the pregnancy?
Did you smoke/drink/use drugs during the pregnancy?

B- Neonatal:
How long did he stay in the hospital after birth?
Did he require oxygen after birth?
Did he need any medication after birth?
Did you start feeding him/her after birth?

C-Infancy:
Is he/she growing well?
Has his/her pediatrician told you that he/she is achieving the milestones for his age?
When did he/she first smile (2mo)/sit up (6-7mo)/start crawling (9mo)/talking (10-12mo)/
walking (1yo)/to dress him/her self/start using short sentences?
How is his/her weight?

•Day care:
Does he/she go to a day care?
Do you know of any other child with the symptoms?

•Eating:
Did you breastfeed him?
Is the formula fortified with iron and vitamin D?
How long did you breastfeed him/her?
When did he/she start to eat solid foods?
How is he/she eating?
Has ______ ever had any problem with any food?

•Appetite:
any change in his/her appetite lately?

•Last checkup & look :

Do you take him/her to the pediatrician?
When was the last routine checkup?
Was everything fine?

•Sleep:
How is _______ sleeping?
Has his/her sleep change lately?
(Picky Eater)
Differential Diagnosis: AT OHIO

Organic disorder, Habitual Eating Disorder, Iron Deficiency, Oppositional

Defiant disorder, Autism/Adjustment disorder, Thyroid (low)

*How is the child growing? Did he gain any weight? Milestones achieved?

1. For Organic dx:

a. Have you noticed any change in bowel habits?

b. Have you noticed any blood in stools?

c. Have you noticed crying discomfort on passing stools?

2. For Habitual Eating Disorder:

a. Do you follow a set schedule of meals?

b. Does he drink a lot of high-calorie drinks?

3. For Iron Deficiency:

a. Have you noticed a change in skin color?

b. Have you noticed a bleeding from any site?

4. For Oppositional Defiant disorder / Depression:

a. How is his behavior towards others?

5. For Autism:
a. Does the child have problems playing with others?

6. For Hypothyroidism

Have you noticed a change in bowel habits/energy/weight?

7. For Adjustment disorder:

a. Have you recently moved?

b. Has the child suffered any trauma recently

Workup: CBC with differential, S/E (K+

________________________________________________________________________________________

(FEVER)

Differential Diagnosis: Viral illness, Otitis Media, Meningitis, URI, LRI,

Gastroenteritis, UTI.

1. For Viral illness:

a. Have you noticed any rash on the body?

b. Have you noticed any swelling of the body?

2. For Otitis Media:

a. Does he/she pull the ear?

b. Have you noticed runny nose or redness of eyes?

c. Have you noticed any discharge from the ear? If yes, then ABCO

3. For Meningitis/Encephalitis:

a. Have you noticed any stiffness in the neck?

b. Did he/she lose consciousness?

c. Have you noticed any shaky movements?

d. Have you noticed bulging of fontanels?

5. For LRI:
*Croup:

i. Have you noticed any a cough?

ii. [Link] you noticed any sound accompanying? (stridor)

*Epiglottitis:

i. Have you noticed any difficulty swallowing?

ii. Have you noticed drooling of saliva?

*Bronchiolitis : Have you noticed any difficulty breathing?

6. For Gastroenteritis:

a. Have you noticed any change in bowel habits?

b. Have you noticed nausea or vomiting?

c. Have you noticed any distension of the belly?

d. Do you have to use more diapers than usual?

7. For UTI:

a. Have you noticed any change in urinary habits?

b. Does the baby cry while urinating?

Workup:

1. CBC with differential, S/E (K+)

2. CXR

3. Blood Culture

4. Lumbar puncture & CSF analysis

5. Urinalysis

_________________________________________________________________

(Seizures)

Please tell me more about that? Describe the event in

detail? What was the child doing before that?
Have you noticed any LOC? Tongue biting or frothing? Passed urine or stools
without knowledge? What happened after the episode?

Differential Diagnosis: FM TE
Febrile, Meningitis, Trauma/hemorrhage, Hypo/Hypernatremia.

1. For Febrile seizure: (Fever, Family Hx)

a. Do you have a Hx of recent illness?

[Link] Meningitis:

a. Have you noticed any stiffness in the neck?

b. Did he/she lose consciousness?

c. Have you noticed any shaky movements?

d. Have you noticed bulging of fontanels?

3. For Trauma/hemorrhage:

4. For Hypo/Hypernatremia:

a. Have you noticed any change in bowel habits?

b. Have you noticed nausea or vomiting?

c. Have you diluted the formula feed?

PE: HEENT /CVS Exam.

Workup:

1. CBC with differential, S/E (K+)

2. CXR

3. Lumbar puncture & CSF analysis

4. CT scan brain

5. Urinalysis

_________________________________________________________________

(Diarrhea)

Differential Diagnosis: Infection, Malabsorption, Intussusception, Overfeeding

1. For Infection:

a. Do you have to use more diapers than usual?

b. Have you noticed any dryness of mouth or tongue?

c. Have you noticed any dryness of skin?

d. Have you noticed sunken eyes?

2. For Malabsorption:

a. Have you noticed any abnormal smell from stools?

3. For Intussception:
a. Have you noticed crying spells or episodes relieved by bending?

4. For Overfeeding:
a. How much and how frequently do you feed the child?

CBC with differential, S/E (K+)/Stool examination

Counseling
Mr./Ms.___, your child has diarrhea, we need to find out the cause of the diarrhea, I
need to see him/her in order to perform a physical exam and some lab tests, so please I
will ask you to bring him/her to my office today, so we can take care of him/her.“In the
meanwhile you can do some measures that will help your son . “First stop giving him/
her cow milk.“Do you know what an oral rehydration solution is? “Give your child as
much of the liquid as he/she requests in small amounts, frequently and continue feeding
him/her the usually food. If he/she vomits wait 10 minutes and give the solution again.

_________________________________________________________________

(Cough)
Differential Diagnosis: LPC FERA.

Laryngitis, Pertussis, Croup, Foreign Body, Epiglottitis, Retropharyngeal

Abscess, Asthma

1. For Laryngitis: Have you noticed any change in the voice?

2. For Pertussis:

a. Have you noticed a runny nose or watering from eyes before a cough
appeared?

b. Have you noticed any additional sound along with the cough?

c. Did the baby throw up?

3. For Croup:

a. Have you noticed any cough?

b. Have you noticed any sound accompanying? (stridor)

4. For Foreign Body:

What was he doing when a cough started?

5. For Epiglottitis:

a. Have you noticed any difficulty swallowing?

b. Have you noticed drooling of saliva?

6. For Retropharyngeal Abscess: (High-grade fever + No stridor)

Have you noticed any drooling of the saliva?

7. For Asthma:

a. Does the baby have any allergies?

b. Have you noticed any relationship to the timings of the day?

PE: HEENT /CVS / Pulmonary

workup

1. CBC with differential, S/E (K+)

2. X-Ray neck

3. CXR

4. Blood Culture

PEDIATRIC PATIENT WITH ENURESIS

Mrs. Smith, bed wetting is extremely common at this age. Studies show that with each
advancing year about 10% of kids with bed wetting will outgrow their symptoms. A
number of behavioral modifications can help decrease bed wetting. These include not
drinking liquids in the last couple hours prior to going to bed, waking the child up in
the middle of the night to urinate, avoiding tea/coffee or caffeine containing soda with
dinner and ensuring that 'Tommy' goes to the bathroom just before going to bed. If
these modifications don't work we may consider bed wetting alarms or even
medications in the future.
GENERAL
(Anxiety)

-Ask if nervous or anxious

1-psychiatry
Panic Disorder:

a. Is there any particular event associated with the racing of heart?

b. Does your breathing rate increase during the episode? Do you feel
dizzy during the episode? racing in your heart?

GAD:Do you feel worried about something in particular or generally about

everything?

Acute stress: (<1 months)

a. Have you experienced nightmares recently?

b. Have you experienced flashbacks?

PTSD: (>1 month)

a. Have you experienced nightmares recently?

b. Have you experienced flashbacks?

2- Caffeine

Do you consume caffeinated beverages? If yes, then ask how much?

3- Substance Abuse

4- Hyperthyroidism

Temp intolerance/Bowel movement/Have you noticed racing of heart/Have you

noticed any skin changes/Have you noticed any tremors of hands?
5-Menopause

PE:

HEENT -CVS -Pulmonary exam

Workup:

1. CBC with differential, S/E

2. TSH, T3 & T4.

3. Urine toxicology screen

4. if +ve palpitation EKG

5. If menopause FSH/LH

____________________________________________________________

(Night sweats)

1-Endocrine:

Hyperthyroidism

Hypoglycemia ( skipped meals/ change of drugs or doses)

2-Cancer: weight/appetite loss

Lymphoma: Belly distention/fullness/swellings

Carcinoid: episodic flushing, racing/ diarrhea/ wheezes

Pheochromocytoma: episodic headache/racing/sweating/tremors

3-Infection:

TB : PPD, travel, living conditions, ill contact

night sweat, cough Bloody sputum, weight loss

HIV: swelling anywhere, IV drug abuser, sore throat, weight loss, Diarrhea

IM: tired more than usual/ belly pain/sore throat/ sexual hx

4- Gyneacology :

Premature Ovarian Failure, Menopause Qs

PE: HEENT /Chest/GI

Workup:

1. Rectal and Pelvic Exam

2. CXR and Sputum analysis

3. Western blot for HIV

4. T3, T4, TSH

5. Blood Sugar Level

6. FSH, LH

Closure
Mr./Ms. XYZ thank you for your patience and cooperation. Depending on the history
and PE, I am considering a number of possibilities of your current complaint that it
might be due to ______________, but I am not sure right now. For this, I will have to
run some tests that will include some blood work up like complete blood count, sputum
examination, and some imaging studies like X-ray and CT scan of your chest. When the
results are available, we will sit together and discuss the further management plan and
you don’t need to worry since you are in safe hands. Meanwhile, I am KUO and
provide adequate hydration and will advise you to always wear a mask, try avoiding
contact with people who have infections and get yourself vaccinated. Exercise
regularly, follow a healthy lifestyle and keep stress at a minimum

______________________________________________________________________
(Fatigue)

1-Endocrine:

-DM

a. Do you feel more thirsty than usual?

b. Do you have to urinate more frequently than usual?

-Hypothyroidism

-Sheehan’s Syndrome

a. any excessive bleeding?

c. Were you able to lose your weight after delivery?

d. Have you been able to breastfeed your child?

2-Infections:

-TB, HIV, IM

3-Malignancy

4-Psychiatry:

-Depression (SIGECAPS)

-Adjustment / PTSD

5-Other:

-Anemia

a. Have you noticed any change of skin color?

b. Have you noticed SOB on exertion?

c. Have you noticed excessive bleeding from any site of the body?

- Apnea

a. Do you snore at night? Or has someone told you?

b. Do you feel restless at night? Or has someone told you?

- Myasthenia

a. How does it progress during the day?

b. Have you noticed weakness of muscles or double vision?

PE:

HEENT / Thyroid Exam

Workup:

1. CBC with differential.

2. TSH, T3, and T4.

3. Monospot

4. ELISA

5. CXR

6. BSL

7. Acetylcholine receptor antibody.

8. CT scan Brain.

9. MRI Brain.
___________________________________________________________
(DELIVERY BAD NEWS)
S-P-I-K-E-S

Setup:

◦ Enter the room, look the patient in the eye and do your standard introduction

◦ “I have scheduled a full 15 minutes and asked my nurse not interrupt us”

Patient perception

◦ “Do you remember why we did this test?”

◦ “what did you think the (symptom) was from?”

Invitation

◦ “I have the results back. Would you like to go over them now?”

◦ “Would you like the basic information or all the details?”

◦ “So if turns out to be something serious you would like to know?”

Knowledge

Mr./Ms.______, I am sorry to have to tell you that the pathology report shows that
what you have is serious and will require treatment.”

◦ The biopsy showed a tumor or The test shows that you have: ______

Emotions:

this is a good time to use the appropriate touch in the shoulder or forearm and offer the
patient a tissue or sip of water, or just sit quietly for a few seconds.

◦ I can see you are upset. I was also upset when I got the results.
◦ I know what you have is serious but we first have to do some additional test to find
out exactly how advance it is. Either way, we do have treatment options and
we are going to be very aggressive. I will help you through this entire process.

◦ have ______ to help you dealing with this? If you would like, at your next visit I can
talk to your family or anyone else who will be helping you.

◦ we also have counselors and support group of other people going through the same
thing

Summarize

◦ Mr./Ms. ________ I know I gave you a lot of information to remember today. I want
to make sure you understand me correctly.”

◦ Do you have any questions

◦ My nurse is going to give you my contact information, please feel free to call me
if you have any questions before your next visit. I will get all the test scheduled
today with my nurse. I would like to see you next week, and we will go over all
of the results. Is that right with you?

______________________________________________________________________

(FOLLOW UP CASES)

Dr : How can I help you today?

Doctor these are my medications please fill them for me!
Dr: Oh, surely I will give you the refills and I know these are very important for
you. But Mr as this is our first encounter and I don't have access to your previous
medical records so let me ask a few questions so that I can have a better idea what
is going on with you. Is that ok? So do you have any active complaint at the
moment?
If the patient says yes, then go to OCD & General Qs .

If the patient says that he has no active complaint, then say: I’m glad to know
that! May I ask for which reason you were using this medication? OR you can say
that my nurse told me that your blood pressure is on the higher side so I am
concerned if your blood pressure/diabetes is controlled with these medications or
not. That’s why I will need to ask a series of questions so that I can get a better
idea of whether to change or add the new medications. Is that alright, Mr. I'll be
very quick
General Qs:

Diagnosis: When were you diagnosed? what symptoms you got at that time?
Medication: What medications do you take? How often do you take it? Side
effects: Do you have any side effect from the drug that you take?

Monitoring: How often do you check your blood pressure/blood sugar? when
was the last time?
Checkup: When was your last checkup with your doctor?
Compliance: How do you take your medication?

Current status: How do you feel now? do you have another concerns for today?
Complications ([Link], [Link]) or other symptoms
Concerns and questions (refills)

A-HTN
B- DM Cases

DIABETIC Qs :

- Diet & decrease glc level (skipped meals & hypoglycemia symptoms)
- infection :Have you had any infection lately? UTI symptoms ?
- A1c hemoglobin
- Blurry vision: Have you noticed any change in your vision lately? When was
your last eye checkup?
- Extremities: Do you have any injury in any of your limbs? When did it
happen? How is now?

- Tingling: Do you feel numbness/weakness/tingling in your legs?

- Impotence: (Have you noticed any change in your sexual Performance )
1 -Psychological causes:

How is the relationship with your spouse?

Do you have morning erections?

(Stress/Sad + SIGECAPS)

2-Vascular causes:

Have you noticed any pain in your legs?

Have you noticed any Weakness of your body?

Have you noticed any Numbness or Tingling of your body?

3-Medications : (are you taking any drugs?

4-Hypogonadism:
Have you noticed any change in your sexual Desire?
Do you have normal pubic and axillary hair?
-CVS : HTN, claudication ,Past Hx of MI, SOB, racing of heart, Chest pain

PE:

HEENT ( Fundoscopy) /CVS Exam

workup:

[Link] with differential.

[Link]

[Link] and HBA1c

[Link] for Microalbuminuria , Urinalysis

————————————————————————————————

(DOMESTIC VIOLENCE)

SAFE GARDS:

Safe: Do you feel safe at home?

Alcohol:Does your husband drink alcohol?
Does your spouse use any recreational drug?How often does he/she use it?
Family/friends: is there anyone in your family or friends know about this
situation?
Emergency: Do you have an emergency plan?

Guns: Is there any gun at home?

Abuse: Are your kids abused too? Have you been abused?
Relationship: “How is your relationship with your husband/wife? Do you feel
threatened by him/her?
Depression: Are you feeling sad/down/low energy? Interest? Have you lost
weight? how is your appetite?
Suicide: have you ever thought about ending your life?Do yo have a plan?Could
you please tell me?

If Assault +ve:
1) Can you describe what happened to you?
2) What did they use to hit you?
3) Where did they hit you?
4) Do you have any pain? Where?

-From what you have told me I understand that at times you feel unsafe at your
own home. That sounds very frustrating. I am glad that you came to seek
attention. If you ever need someone to talk to, do not hesitate to call our office. If
ever you feel unsafe or are hurt you should seek attention from the police or
appropriate authorities. Feel free to contact us at any time, we are here to help
you
-I am really sorry for what happened to you. I want to emphasize that it is not your
fault, and you should not feel guilty about it. I recommend that you report the incident
to the police. In the meantime, I will need to do a pelvic examination to make sure you
have no injuries in the genital area. In addition. 1 will need to take a swabs from your
body and genital area so that they can be used as evidence if you choose to file charges,
and also to look for sexually transmitted infections. we will order a pregnancy test . x-
rays to look for other injuries. We will also give you some antibiotics to protect you
from infections. Finally. I can have our social worker come talk to you and provide you
with resources that will help you process this trauma moving forward. Do you have any
questions for me?

-I am so sorry for what happened to you. It is horrific and must be very difficult to
handle right now. however, its not your fault by any means. right now, I want to
make sure you arc in a safe environment and medically stable. There are a number
of resources available to help you process this event

———————————————————————————————————
(Sleep problems)

a-Do you have any problems falling asleep? any problems staying asleep?What
time do you wake up in the morning? How many hourdo you sleep a day?
b- Bad sleep hygiene:

What do you do before you go to bed?

Do you take naps during the days?

Differential Diagnosis:

Brain: Stress, Circadian Rhythm , psych

Mouth: Drugs, Caffeine

Neck: Hyperthyroidism, OSA

(1)caffeinated : a. Do you consume caffeinated beverages? how much?

b. Do you take tea/Coffee/energy drinks before going to bed?

(2) illicit drugs use ?

(3) Circadian rhythm : Have you traveled for a long distance recently? Have you
changed your work hours (shift) recently?
(4) psych: Depression/GAD/PTSD/stress
(5) OSA:Do you feel sleepy during the day?Do you snore at night? Or has
someone told you?
Do you feel restless at night? Or has someone told you?
(6) thyroid
PE: MMSE & HEENT
Workup:
1. CBC with differential, S/E

2. TSH, T3 & T4

3. Urine Toxicology screen.

4. sleep study

counseling :

*sleep hygiene *alcohol can worse it

I would advise you to avoid caffeinated beverages 3-4 hours before going to bed,
go to your bed only to sleep, make sure your room is dark and curtains are drawn
down, and avoid watching television or reading before going to bed. Eat a healthy
and balanced diet high in fruits and vegetables, low in salt, and caffeinated
beverages. Do regular exercise, follow a healthy lifestyle, and keep stress at a
minimum.

Trauma

any pain anywhere ? what happened ?

Trauma with chest pain:

pneumothorax
hemothorax
fracture rib
muscle sprain
Gynecological Cases
A-Period :
Ok Ms. XYZ now I would like to ask you a few Qs about your gynecological health,
is that ok with you?

1) When did you have your first menstrual period?

2) When was your LMP?

3) Are your periods regular ?

4) How often do you get your menstrual period? 5) How long does it last?

5) How many pads do you use in a usual day?

—————————————————————-

1) Do you have cramps with your periods?

2) Do you have any difficulty with intercourse?
3)Is there any vaginal discharge? What is the color? Does it have any specific odor?
4) any vaginal bleeding?
5) any vaginal itching?
6) Have you been getting regular pap smears? When did you have the last pap
smear? what was the result?

B-Pregnancy:

1) Have you ever been pregnant? How many times?

How many children do you have?

2) Have you ever had a miscarriage or an abortion? How many times? In which
week of your pregnancy?

3) Are you pregnant now? Have you had a pregnancy test recently?

C-Breast:
(1) Do you have any breast/nipple discharge? (2) Do you have any swelling in your breast?

Vaginal bleeding

(1) Is it bright red or there are clots?

(2) Is it heavier that your usual menstruation?
(3) How many pads did you use per day?
(4) Is it related to intercourse?
(5) Have you noticed any vaginal bleeding between your periods?

Vaginal discharge

(1) Since when have you noticed it first

(2) Can you tell me what is the amount?

(3) What is the color?

(4) any blood on it

(5) Has it any bad odor?

Hot flashes

(1) Since when did you start having them?

(2) How often do you have them?
(3) How long do they last?
(4) Is there anything that (increase/decrease) them?
(5) Do you think they are increasing or decreasing in frequency?
(6)Have you noticed sweating/palpitations with flashes?

Menopause

Do you have hot flashes?

(2) Do you have difficulty with intercourse? vaginal itchy? dryness?
(3) Do you have back/bone pain?
(4) Have you noticed any change in your mood?
(5) Do you have any problems controlling your bladder

(1st & 3rd Trimester bleeding)

A: amount (how many pads/day)

B: pain

C: clots? contractions?

D: dizziness

E: evaluation ( when was your last checkup visit? any abnormalities

F: fever ( ectopic, endometritis) / fetal movement changes/ fluid?

RheumatologyCases
A-OCDP LIQRAAA

B-JOINTS

1) Do you have pain in your joint? Other joints?

3) Have you noticed any swelling in your joint?

4) Have you noticed any redness in your joint?

5) Do you feel your joint is warm?

6) any stiffness

C-Overuse & Trauma

any recent heavy lifting /any recent injury

BURN

1-weakness (can you move it or can you walk)/tingling/ numbness

2-incontinence/ erection

3-claudication pain

4-N/V

Rash/Mouth ulcer/Photophobia/ Eye changes/Hair/Skin

********************************************************************

Neck pain meningitis (neck stiffness/ill contact)

shoulder pain angina Qs

Back pain all neuro Qs
Hip pain back Qs
leg & calf pain V.V/DVT as recent immobilization or surgery/cellulitis
knee & heel pain
-SLE qs from R
-Reactive arthritis:
-Lyme dx : tick bite
-with Heel if improve with rest; fracture/strain but if improve with movement;
planter fasciitis
Main D.D of Knee pain :

1-OA 2-RA 3-PFS 4-MENISCAL TEAR

———————————
thank you for your cooperation . now depending on your history and physical
examination, your problem could be related to a variety of condition. it could
be a wear & tear in your knee or a more serious infection in your knees .But
till now I’m not sure what is the cause of what you are dealing with .so I need
to run some tests including some blood work up like a Complete Blood Count
(CBC) and some imaging studies like X-ray and CT scan. once the results are
available, we will meet again to discuss the final dx & the prober management
. Meanwhile,I will keep you under observation and my nurse is going to give
you some pain medications etc.
or meanwhile ( counsel)
Do you have any questions/concerns for me? Yes/ No.
feel free to contact me whenever you have any Qs , it was a pleasure
meeting you, bye( shaking)

shoulder pain
.

you may have a fractured bone, a simple sprain, or a dislocation of the

shoulder joint. We will need to obtain an image of your arm to make a
diagnosis, and MRI may be necessary as well. Your safety is my primary
concern, and I am here to help and support you.

Q:Doctor, do you think I will be able to move my arm again like before ?

Hopefully your range of motion with your arm will go back to normal, but
first we need to out exactly what is causing your problem
calf pain
. My father had a clot in his leg. What do you think I should do to make sure
I don't get one to?

There are several measures you can take that may prevent you from having
a [Link] should avoid immobilization for long periods of time for
example, while sitting at your computer desk or on
plane [Link] to move in place or take a short walk. if you are on oral
contraceptive pills, I strongly recommend that you stop taking them, as
they are known to precipitate clotting.I also suggest that you exercise
regularly and manage your diet."

it is possible. that you had a blood clot. However, we will also look for other possible
causes of your symptoms, such as an infection or a ruptured cyst.
Gastrointestinal Cases
A-General

-Do you have difficulty swallowing?

-Do you feel nauseated?

-Do you vomit (throw up)? How many times? How much was it? Was there
any blood in it? What color was the vomit?

-Do you have heartburn?

-Do you have abdominal pain?

-Do you have diarrhea? constipation?

-Have you noticed any change in the color of your stool?

-Was there any blood or mucus in it?

B-Bowl movements

Is it painful when you have a bowel movement?

Do you feel that despite the urge to defecate you can’t start that? (tenesmus)
Do you feel you’ll not make it on time to the rest room? (urgency)
Do you feel you can’t completely empty your bowel?

C-Contamination
Did you eat any food that may be contaminated?
Do you have any contact with ill persons?
Neurological Cases
A-Head
(1) Do you have headache?

(2) Do you feel dizzy? Tell me exactly what you mean by dizziness? Did you
feel the room spinning around you or did you feel light headed as if you
were going to pass out
(3) Have you ever lost consciousness
(4)Have you had any convulsions
(5)Do you have any difficulty with concentration
(6)Have you been recently forgetting things more than before?

B-Limbs
(1) Do you feel weakness in your limbs? numbness?
(2) Do you have any difficulty while walking?
(3) Do you have tremor?

C-Sense
(1) Do you have difficulty swallowing?Speech difficulty?
(2) Do you have any visual problems?
(3) Do you have any hearing problems? Do you hear any ringing in the ears?

D- Head Trauma
E- Ill contact
F- URTI

MMSE
What’s today? What time is it? Where are we now Who am I?
Now I’ll say 3 words can you please repeat them after me? Hat-Rat-Cat
Now keep them in mind I’ll ask you about them later.
Ok, now one hundred minus seven is? Ninety three minus seven is?
Ok, what where the words that I told you?

Dementia
(1) Do you have any difficulty with concentration?
(2) Have you been recently forgetting things more than before?
(3) Do you have any problems with doing daily life activities like dressing,
bathing, eating? Do you need any help dressing?
(4) Can you do shopping by yourself? Paying bills? Housekeeping?
(5) Is there anything to help you when you need?
(6) Do you have any problems controlling your bladder?

(7) Have you ever lost your way back home?

Parkinson
(1) Do you have hand tremor
(2) Do you have difficulty in starting any movement
(3) Do you have frequent falls
(4) Do you feel your body is stiff?

(Dizziness & LOC)

if Dizziness:

1-what do you mean by dizziness, do you mean you feel the room spinning
around you or do you feel you are going to pass out ?
2-did you passed out?

3- related to position ?

Then:

A-Ear : balance problems ( do you have any problems maintaining your balance)

if +ve :pain/discharge/hearing loss/ringing /URTI

if LOC: for how long?

Did you sense anything unusual before passing out? N/V/sweating

Did anyone notice jerky movements? (Shaking)

Did you bite your Tongue while shaking?

Did you pass urine without your knowledge?

Were you confused after you regained consciousness?

Differential Diagnosis:

CVS: Cardiac arrhythmia, Aortic Stenosis, Orthostatic Hypotension,

vasovagal syncope

CNS:, Mass, Seizure syncope

Other: Panic attack(fear), Hypoglycemia(sugar), Alcohol Withdrawal(drug)

*Hypoglycemia:

Do you have a Hx of High blood sugar level?

Have you skipped meals? Or changed any dose or medications recently?
*Alcoholic withdrawal: (Ask about alcohol use) When was your last
drink?

*Dehydration:

Have you noticed any changes in bowel habits? How many pads do you use
on a heavy day?

*Cardiac Causes:
Have you noticed any chest pain? SOB? Racing of heart? Skipped beats?
Sweating?

*Mass:

Have you noticed any Weakness Numbness Tingling or Headache ?

*Vasovagal Syncope: (Nausea, vomiting)

PE:

MMSE – Orientation Only (AAO) /CVS (auscultation , carotid ,pulse) /CNS Exam

Workup:

1. CBC with differential + S/E.

2. EKG, ECHO, orthostatic vital signs, heart monitor

3. BSL

4. CT scan Brain.

5. MRI Brain.

Closure

Meanwhile, I am KUO and my nurse is going to give you some fluids so that you don’t
feel dizzy anymore. Meanwhile, I would advise you that you should not go out
unaccompanied, keep an I.D. with you always, and don’t drive until labs are available.
(In case of hypoglycemia) Keep a candy or granola bar with you and eat them
whenever you feel dizzy. You should be careful when you stand up or walk. Use hand
railings whenever possible.
_______________________________________________________________________________

Seizures
Same Qs of LOC (before/during/after)

Differential Diagnosis:

1-CNS: Infections (Meningitis, Encephalitis, Abscess), Trauma, Tumer ,Drug

Abuse/Withdrawal(Alcohol, Benzodiazepine),stroke

2- metabolic : hypoglycemia, hyponatremia ( diarrhea, more thirsty)

3-Autoimmune:SLE: Have you noticed any rash or joint pain?

PE: MMSE – Orientation Only (AAO) /CNS Exam

Workup:

1. CBC with differential, S/E (K+)

2. Urine Toxicology screen

3. Blood Culture

4. Lumbar puncture & CSF analysis

Closure

Meanwhile, I am KUO and my nurse is going to give you some fluids so that you
don’t feel dizzy anymore and a new pair of pants as well. Meanwhile, I would
advise you that you should not go out unaccompanied, keep an I.D. with you
always, and don’t drive until labs are available. You should be careful when you
stand up or walk. Use hand railings whenever possible.
URINARY SYSTEM
bladder ca or urolithiasis

I will perform a genital exam as well as a rectal exam to assess your prostate. I will
then order a urine test to look for signs o f infection. Depending on the results we
obtain, I may also order some imaging studies to determine if there is a stone in your
kidneys, an anatomic abnormality

Challenging Questions to Ask

They told me that having blood in my urine is because of my old age. Is that true? No.
Bloody urine is rarely normal. We will need to run a few more testa t o determine
the cause of this finding."

spinal stenosis or metastatic ca

Do you think I can go to work, doctor, Can you write a letter to my boas so that I
can have some time off?

"You're right; heavy construction work can worsen your back pain or cause it t o heal
more slowly. To assess the need

for you to take a time off, I would like ask you some questions and perform a
physical exam

I would like to do a rectal exam and assess your prostate. I will also run some
blood tests and order an x-yay and possibly an MRI of your back so that I can
better determine the cause of your pain, which could be a pinched nerve or
muscle spasm. In the meantime, I will write a note to your employer requesting
that you be given only light duties while you are at work
Cardiovascular and Pulmonary
(1) Have you ever felt dizzy or light headedness?
(2) Do you feel tired?
(3) Do you feel short of breath?
(4) Do you have chest pain?
(5) Do you feel your heart is racing rapidly? Beating fast?
(6) Have you noticed any leg swelling?

________________________________________
(1) Do you have runny nose? sore throat?
(2) Do you feel SOB?
(3) Do you have chest pain?
(4) Have you been wheezing?
(5) Do you have sore throat?
(6) any cough?
(7) Is there any sputum (phlegm) with your cough?
How much is it? Tea spoon? Table spoon? Cupful? What color is it? Is
there any blood in it? Does it have any special smell?

Heart attack

the source of your pain can be a cardiac problem such as a heart attack. or it
may be due to acid reflux, lung problems, or disorders related to the large blood
vessels in your chest it is crucial that we perform some tests to identify the source
of your problem. We will start with an ECG and some blood work.
Is a heart attack? Am I going to die?

"Your chest pain is of significant concern. However, chest pain can be caused by
a large variety of issues. We need to learn more about what's going on to know if
your pain is life threatening."
(Sore Throat)
Differential Diagnosis: PNIG

1. Pharyngitis:

a. Have you noticed any pain or fullness in the ear?

b. Have you noticed any redness or discharge from eyes?

* Gonococcal pharyngitis with sex hx

2. Infection:

[Link]: (IV drug abuse , tattoos , Fatigue, Sexual behavior, swellings,

occupation )

[Link]:

Have you ever been exposed to anybody with similar complaints? Do you
feel more tired than usual? Have you noticed any fullness or pain in the
belly?

3. For GERD:
Have you noticed any burning sensation in your chest? Or change in taste
of your mouth?

5. Post Nasal Drip: Have you noticed recurrent cough?

PE:

1. HEENT

2. inspect, palpate, (Sinus Tenderness)

3. CVS and Pulmonary exam

4. Abdominal Exam (for Splenomegaly)

Workup:
1. CBC with differential, S/E

2. ESR

3. Rapid Strep Test

4. Monospot Test

5. ELISA

6. Western Blot

7. Endoscopy
Table of Contents
Adult Cases.............................................................................................................................................. 1

Upper Abdominal Pain......................................................................................................................... 2

Diarrhea .............................................................................................................................................. 3

Blood in Stools ..................................................................................................................................... 5

Lower Abdominal Pain ......................................................................................................................... 7

Testicular Pain ..................................................................................................................................... 9

Knee Pain .......................................................................................................................................... 10

Arm Pain............................................................................................................................................ 11

Back Pain ........................................................................................................................................... 13

Neck PainText
.......................................................................................................................................... 14

Heel Pain ........................................................................................................................................... 15

Hip Pain ............................................................................................................................................. 16

Calf Pain ............................................................................................................................................ 17

Chest pain ......................................................................................................................................... 18

Palpitations ....................................................................................................................................... 19

Anxiety .............................................................................................................................................. 20

Cough................................................................................................................................................ 21

SOBText
................................................................................................................................................... 23

Text
Sore Throat........................................................................................................................................ 25

Hoarseness ........................................................................................................................................ 26

Jaundice ............................................................................................................................................ 27

Hematuria ......................................................................................................................................... 28
iv
Burning Micturition ........................................................................................................................... 29
Text
Urinary Incontinence ......................................................................................................................... 30

FatigueText
.............................................................................................................................................. 31

DM and HTN follow- up ..................................................................................................................... 33

Pre-Employment Exam ...................................................................................................................... 34

Text
Text
Headache .......................................................................................................................................... 35

Forgetfulness ..................................................................................................................................... 37

Hearing Loss ...................................................................................................................................... 39

Dizziness (Vertigo) ............................................................................................................................. 40

DizzinessText
(LOC) .................................................................................................................................. 41

Menstrual Irregularities ..................................................................................................................... 43

Post-Menopausal Bleeding ................................................................................................................ 45

Vaginal Discharge .............................................................................................................................. 46

Dyspareunia ...................................................................................................................................... 47

Text
Sleep Problems/Insomnia .................................................................................................................. 48

Weight Gain ...................................................................................................................................... 49

Weight Loss ....................................................................................................................................... 50

Tremors............................................................................................................................................. 51

Muscle Weakness .............................................................................................................................. 52

Hallucinations .................................................................................................................................... 54

Seizures ............................................................................................................................................. 56

Pediatric Case........................................................................................................................................ 57

Fever ................................................................................................................................................. 59

v
Seizures ............................................................................................................................................. 61

Diarrhea ............................................................................................................................................ 62

Cough................................................................................................................................................ 63

Picky Eater......................................................................................................................................... 64

Jaw Pain
MTB DANDA
MI
Tooth ace
Fundoscopy Bruxikum: (does your partner notice that you grind
Rectal exam your teeth, any mouth ulcer)
pelvic exam D: Dislocation (popping sound)
A: Arthritis
N: trigeminal neuralgia
D: Dysfunction
A: abuse
SAFEGUARD

ALWAYS OPEN THE BANDAGE

FUNDOSCOPY

FULL SKELETAL SURVEY

TMJ XRAY

Violence doesn’t end on its on, its only increases

in severity. The only way to end violence is to get
away from your partner
necessary supply to a friend and family

vi
Adult Cases
PAM HUG FOSS
PMDC
Flu SHOT

CLosure:
Thanks for your patience. From the information i have gathered so far from quetsions and
examination, i am considering couple of possibilites… But To GET THE BOTTOM OF THIS problem i want to
run some tests “WITH YOUR PERMISSION”
meanwhile i would like to keep you under observation and don’t indulge in activities that will worsen
your condition

1
Upper Abdominal Pain
Mnemonic: TRYS DHIBE

Differential Diagnosis:

Stomach: Gastritis, GERD, Gastric cancer

Pancreas: Pancreatitis, Pancreatic cancer
RUQ: Hepatitis, Cholecystitis
MI

Questions

1. What Type of food aggravates the pain?

2. Is there any Relationship between pain and timing of your food intake?
3. Have you noticed any Yellowness of your eyes or skin?
4. Have you noticed any Distension of your belly? s is shortness of breath
5. Have you noticed any burning sensation in your chest (Heart Burn) or change in taste of your
mouth?
6. Have you ever been exposed to anybody with similar complaints (Infections)?
7. Have you noticed any change in color of your stools or any Blood in the stools?
8. Have you Eaten anything from outside recently?
9. Have you noticed any shortness of breath? Any sweating?

Exam

1. HEENT
2. GIT exam (including Murphy’s sign)
3. CVS

Investigations

1. Rectal & Pelvic Exam

2. EKG
3. Stool for occult blood
4. ALT/AST/Bilirubin/ALP
5. U/S Abdomen
6. Upper GI Endoscopy
7. HIDA scan
8. Noninvasive H. Pylori testing

2
Diarrhea
Differential Diagnosis: Watery, Bloody, Malabsorption

Watery: GC PHAIL. Gastroenteritis/Travelers, Crohn’s Disease, Pseudomembranous Colitis,

Hyperthyroidism, AIDS, IBS, Lactose Intolerance.
Bloody: Ulcerative Colitis, Dysentery, Cancer.
Malabsorption: Pancreatitis, Giardiasis, Celiac Disease.
OFDPAA questions onset,frequency,duration,previous episode,progression,aggravating/relieving factors,associated symptom
What do you mean by diarrhea? (You want to find out ---Do you mean increased frequency or increased
volume?)
What do your stools look like? (You want to find out --- Are they watery or bloody or fatty? Are your
stools abnormally foul smelling?)
For Watery Diarrhea:
1. For Gastroenteritis/Travelers’  Diarrhea:  
a. Have you eaten outside recently?
b. Have you travelled recently?
2. For Crohn’s  Disease:
a. Have you noticed a sense of incomplete evacuation after passing stools?
b. Have you noticed a pain in your belly?
3. For Pseudomembranous Colitis:
a. Have you been taking antibiotics recently?
4. For Hyperthyroidism: (Temp intolerance, Bowel movement)
a. Have you noticed racing of heart?
b. Have you noticed any skin changes?
c. Have you noticed any tremors of hands?
5. For AIDS: (IV drug abuse, low grade fever, lymphadenopathy {lumps or bumps} in the body)
6. For IBS: (>3 months)
a. Have you noticed any relationship of belly pain to bowel movements?
b. Have you noticed any alternating diarrhea and constipation?
7. For Lactose Intolerance:
a. Have you noticed any relationship of diarrhea with any milk products?
For Bloody Diarrhea:
1. For Ulcerative Colitis:
a. Have you noticed a sense of incomplete evacuation after passing stools?
b. Have you noticed a pain in your belly?
c. Do you have to rush to defecate?
d. Have you noticed skin rash or joint pain?
2. For Dysentery: (fever, pain abdomen, nausea, eaten outside)
3. For Cancer: (weight loss, reduced appetite, may have belly pain also )
For Malabsorption:
Are your stools difficult to flush?
3
Have you noticed any change in your weight?

1. For Pancreatitis: (Alcoholic)

a. Do you have a Hx of gallstones?
b. Have you noticed belly pain going to the back?
2. For Giardiasis:
a. Have you been on a hiking trip recently? Or drank from fresh water lake?
3. For Celiac Disease:
a. Have you noticed any relationship to wheat products or any specific food?

Exam

1. HEENT + Thyroid exam

2. GIT exam (including Murphy’s)
3. CVS

Investigations

1. Rectal & Pelvic Exam

2. Stool exam for ova and parasites & fecal leukocytes
3. TSH, T3 & T4
4. ALT/AST/Bilirubin/ALP
5. U/S Abdomen
6. Colonoscopy
7. Serum immunoglobins

4
Blood in Stools
Differential Diagnosis: CHAD UF (Lower GI) LPG (Upper GI).

Colon CA, Hemorrhoids, Angiodysplasia, Diverticulosis, Ulcerative colitis, Anal Fissure, Chronic Liver
Disease, PUD, Gastritis.
Questions
OFDPAA
Have you noticed any change in bowel movements?
Is the blood before, mixed or after passing stools?
What is the color of blood? (What you want to find out --Bright red or dark)
Have you vomited ever since? Does it contain blood? (Go to upper GI questions first)
Have you noticed any pain on passing stools? (Go to lower GI questions first)
1. For Colorectal CA: (weight and appetite changes, family Hx, changes in bowel movement)
a. Have you noticed any change in caliber/thickness of stools?
2. For Hemorrhoids: (Fresh blood)
a. Have you noticed anything coming out of /protruding from the anus?
3. For Angiodysplasia: (Age, Painless heavy bleeding)
4. For Diverticulosis: (Age, Painless heavy bleeding, constipation)
a. What does your primary diet comprise of? (lack of fiber)
5. For Ulcerative colitis: (Abdominal Pain)
a. Have you noticed a sense of incomplete evacuation even after passing stools?
b. Do you have to rush to defecate?
c. Have you noticed joint pain? Or redness of eyes?
6. For Anal Fissure: (Painful bleeding, constipation)
7. For Chronic Liver Disease: (N/V, Alcohol use, skin changes)
a. Have you noticed any distension of your belly?
b. Have you noticed enlargement of breasts?
8. For PUD: (Epigastric pain)
a. Is there any relationship between pain and timing of your food intake?
9. For Gastritis: (GERD, NSAIDs)

Exam

1. HEENT
2. GIT Exam
3. CVS Exam

Investigations

1. Rectal & Pelvic Exam

2. Stool for occult blood
3. ALT/AST/Bilirubin/ALP
4. U/S Abdomen

5
5. Upper GI Endoscopy & Colonoscopy
6. Noninvasive H. Pylori testing

6
Lower Abdominal Pain
Mnemonic: LMP RT CVS PAP & NV BB DIE

Differential Diagnosis: RAPED GANDI

abnormal implanatation Pain + multiple partners
Genitourinary: Ruptured ovarian cyst, Adnexal torsion, PID, Ectopic pregnancy, Endometriosis and
Dysfunctional Uterine Bleeding. infx of ur genital tract

Gastrointestinal: Gastroenteritis, Appendicitis, Nephrolithiasis, Diverticulitis, IBS/IBD.

Questions

Gastrointestinal

1. Do you feel Nauseated?

2. Have you Vomited ever since this illness?
3. Have you noticed any change in Bowel habits?
a. If yes, the EFI
i. Have you Eaten outside?
ii. Do you have Fever?
iii. Have you ever been exposed to anybody with similar complains (Infection)?
4. Have you noticed any Blood in stools?
a. If yes, then ABCO
i. Amount
ii. Color & Clots
iii. Before, After or mixed with stools
iv. Odour
5. What sort of your Diet do you usually eat?
6. What is the relationship of pain with bowel movement? Any pain during the sleep? (IBS)
7. Have you noticed a sense of incomplete Evacuation? Joint pains or oral ulcers?

Genitourinary

Insert transitional statement for Gynae/ Obs questions.

1. When was your LMP?

2. When was your first Menstrual period (Menarche)?
3. Do you feel Pain during intercourse or defecation?
4. Are your cycles Regular?
5. How many Tampons/Pads do you use on a heavy day?
6. Have you noticed Crampy pain during menses?
7. Have you noticed any Vaginal discharge?
8. Have you noticed any Spotting in between periods?
9. Are you Pregnant?

7
10. Have you ever had Abortions?
11. When was your Last Pap smear?

Exam

1. HEENT
2. GIT exam (Rebound Tenderness)
3. CVS

Investigations

1. Rectal & Pelvic Exam

2. β-HCG
3. CBC with Differential, S/E
4. Stool for occult blood
5. ALT/AST/Bilirubin/ALP
6. U/S Abdomen & CT scan Abdomen
7. Upper GI Endoscopy
8. Colonoscopy
9. Laparoscopy

8
atypical: says outside Belly pain

Testicular Pain
Differential Diagnosis: THE OT
Trauma, Hernia, Epididymitis, Orchitis, Torsion.
onset,frequency,duration,progression,PREVIOUS episode,location,intensity on scale of 10,quality,radiation,aggravating/relieving factors,associated symptoms
OFDPLIQRAA Questions.
Have you noticed any warmth, redness or swelling of the testicle?

1. For Trauma:
2. For Hernia:
a. Have you noticed anything coming into your scrotum?
b. Have you noticed any change in bowel habits?
c. Have you noticed any relationship of swelling to position or lying down?
3. For Epididymitis:
a. Have you noticed burning sensation while passing urine?
b. Do you have to urinate more frequently than usual?
c. Do you have to rush to urinate?
4. For Orchitis: (Fever) hx of viral infx
a. Have you noticed swelling elsewhere in the body? (Parotid)
b. Have you noticed any rash on your body?
5. For Torsion: (Nausea)
a. Have you noticed pain in your belly?
b. Have you noticed your testicle in an abnormal position?

Exam

1. HEENT
2. GIT exam
3. CVS

Investigations

1. Rectal & Pelvic Exam

2. CBC with Differential, S/E
3. Urinalysis, Urine culture
4. U/S testes and abdomen.

9
Sports… Septic Arthritis…Pseudogout..petallofemoral syndrome and psoriatic arthritis.. Osteoarthritis.. R:RA..T: Trauma, Tophi S: sle

Knee Pain
Mnemonic: WRSS WNT CHOPPF + CITRUS

Differential Diagnosis: Osteoarthritis, Gout, Pseudo gout, Septic Arthritis (Gonococcal and Non
Gonococcal), SLE, RA.
IVDU… Travel/trauma/tick bite..rash..Ulcer/urinary discharge../ uveitis… STIFFNESS/SORE THROAT
Questions

1. Have you noticed any Warmth of your joint?

2. Have you noticed any Redness of your joint?
citrus: chest
3. Have you noticed any Stiffness of your joint? pain ,cough ,conjuctivitis,insect ,trauma
4. Have you noticed any Swelling of your joint? travel ,rash ,ulcer in the mouth ,urinary
5. Have you noticed any Weakness of your joint? discoloration ,stiffness
6. Have you noticed any Numbness or Tingling of your joint?
7. Have you noticed any disColoration of your fingers in cold?
8. Have you noticed any Hair loss recently?
9. Do you have pain in any Other joint?
10. Have you noticed any discomfort on Exposure to sunlight?(Photosensitivity)
11. Have you noticed any Popping sound from knee?
12. Do you feel more tired than usual (Fatigue)?

Exam

1. HEENT
2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses, Gait- Compare to the other side.
3. CVS MRSPG

I will LIKE TO DO SPECIAL MANUVEURS.

Investigations
Mcmurey… Drawer test
1. CBC with differential, S/E
2. ESR
3. Arthrocentesis and analysis
4. X-ray Knee AP & Lat. view
5. CT scan Knee
6. MRI Knee
7. DEXA scan
8. Ca++ & Vitamin-D levels

10
Arm Pain
Mnemonic: WRSS WNT + CITRUS

Differential Diagnosis: MAR FEST

Muscle strain, Angina/MI, Rotator cuff tear, Fracture, Elder Abuse, Shoulder Dislocation, Tendinitis.

Questions

1. Have you noticed any Warmth of your joint?

2. Have you noticed any Redness of your joint?
3. Have you noticed any Stiffness of your joint?
4. Have you noticed any Swelling of your joint?
5. Have you noticed any Weakness of your joint?
6. Have you noticed any Numbness or Tingling of your joint?
7. Rule out MI by asking following [Link]
a. Have you noticed any chest pain? If yes, does this pain go to any other part of body?
b. Have you noticed any shortness of pain?
c. Have you noticed any sweating?
d. Have you noticed racing of heart?
8. If patient seems quite, afraid and injury seems not consistent with Hx, ask SAFE GARD question.
a. Do you feel Safe at home?
b. Are you AFraid of _________? F:do ur Family know abt it?
c. Do you have any Emergency (Exit) plan?
d. Do you have a Gun at home?
e. Is your __________ Alcoholic?
f. How is the Relationship of your ___________ with others?
g. Do you feel Depressed (Suicidal ideation)?

Exam

1. HEENT
2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses - Compare to the other side.
3. CVS

Investigations

1. CBC with differential, S/E

2. ESR
3. X-ray Shoulder/Arm AP & Lat view ARM SLING, rest, pain medication
4. CT scan Arm
5. MRI Shoulder

11
6. Arthrocentesis and analysis
7. DEXA scan
8. Ca++ & Vitamin-D levels

12
Back Pain
Mnemonic: WRSS WNT GLIP + CITRUS
LIM COTS… / MOTIVE
Differential Diagnosis: Lumber spinal stenosis: improves on bending worse on standing
MM: bone pain; multiple bone pains… Fatigue/ chest pain/ anemia
FODS
With WNT: Osteoarthritis, Disc Herniation, Fracture, Spondylosis.

Without WNT: Muscle Strain, Metastatic Cancer, Multiple Myeloma, Meningitis, SLE, RA.

Questions

1. Have you noticed any Warmth of your joint? BACK PAin with pyelonephritis & hx of stone. Fever
2. Have you noticed any Redness of your joint?
3. Have you noticed any Stiffness of your joint?
4. Have you noticed any Swelling of your joint?
5. Have you noticed any Weakness of your joint?
6. Have you noticed any Numbness or Tingling of your joint?
7. Have you noticed any changes in your Gait?
8. Have you been Lifting any heavy weight recently?
9. Have you ever passes Urine/Stools without your knowledge/intention? (Incompetence)
10. Have you noticed any effect of Position on pain?
11 ask abt impotence
Exam SLRRRRRRRRRRR
SLRRRRRRRRRRR !!!!!!
Text
1. HEENT
2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses, Gait

Investigations

1. Rectal and Pelvic exam

2. CBC with differential, S/E
3. ESR
4. X-ray spine AP & Lat view
5. CT scan
6. MRI
7. DEXA scan
8. Ca++ & Vitamin-D levels
9. RA factor, ANA

13
Neck Pain
MOTIVE
Mnemonic: WRSS WNT GLIPBP + CITRUS MM, Muscle strain, meningitis, mets
osteoprosis & osteoarthritis
Trauma, TB
Differential Diagnosis: IV: IVDisk herniation
FODS
With WNT: Osteoarthritis, Disc Herniation,
Text Fracture, Cervical Spondylosis.

Without WNT: Muscle Strain, Metastatic Cancer, Multiple Myeloma, Meningitis, RA.

Questions

1. Have you noticed any Warmth of your joint?

2. Have you noticed any Redness of your joint?
3. Have you noticed any Stiffness of your joint?
4. Have you noticed any Swelling of your joint?
5. Have you noticed any Weakness of your joint?
6. Have you noticed any Numbness or Tingling of your joint?
7. Have you noticed any changes in your Gait?
8. Have you been Lifting any heavy weight recently?
9. Have you ever passed Urine/Stools without your knowledge/intention? (Incompetence)
10. Have you noticed any effect of Position on pain?
11. Have you noticed any trouble Breathing?
12. Have you noticed any trouble in bright light? (Photosensitivity)

Exam

1. HEENT
2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses, Gait

Investigations

1. CBC with differential, S/E

2. ESR
rest & NECK BRACE
3. LP and CSF analysis Pain medication
4. BUN:Cr
5. SPEC
6. X-ray Neck AP & Lat view
7. CT scan
8. MRI
9. DEXA scan
10. Ca++ & Vitamin-D levels
11. RA factor, ANA

14
ALWAYS TAKE OFF BANDAGE

Heel Pain
Mnemonic: WRSS WNT TWO FFP + CITRUS

Differential Diagnosis: PAC R FAT

Plantar fasciitis, Ankylosing spondylitis, Calcaneal stress fracture, Retrocalcaneal bursitis, Foreign body,
Ankle sprain, Tarsal tunnel syndrome.
plantar fascitis: increased in sports ,jumping, and morning
Questions
tarsal tunnel syndrome : evening and aggravates on walking
1. Have you noticed any Warmth of your joint? cellulitis :fever
2. Have you noticed any Redness of your joint?
3. Have you noticed any Stiffness of your joint?
4. Have you noticed any Swelling of your joint?
5. Have you noticed any Weakness of your joint?
6. Have you noticed any Numbness or Tingling of your joint?
7. What Time does it hurt the most? (morning or evening)
8. Have you noticed any difficulty Walking?
9. What precipitates your pain? Walking or Jumping? (Overuse)
10. Have you ever had any Fracture?
11. Have you stepped on any pointed object? (Foreign Body)
12. Have you noticed any Popping sound?

Exam
Can you push the gas pedal
1. HEENT
2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses, Gait

Investigations

1. CBC with differential, S/E

2. ESR
3. Arthrocentesis and analysis
4. X-ray Heel AP & Lat view
5. CT scan
6. MRI
7. DEXA scan
8. Ca++ & Vitamin-D levels

15
Hip Pain
Mnemonic: WRSS WNT + CITRUS

Differential Diagnosis: BRASSS OF.

Bursitis, Referred Pain, Arterial Insufficiency, Steroid Abuse, Muscle Strain, Septic Arthritis,
Osteoarthritis/Osteoporosis, Fractures.

1. For Bursitis:
a. Have you noticed pain when you lie on that side?
2. For Referred Pain:
a. Have you noticed pain elsewhere in the body?
3. For Arterial Insufficiency:
a. Have you noticed any problem maintaining an erection?
b. Do you feel any improvement in pain if you rest after walking some distance?
4. For Sprain:
a. Have you lifted any heavy weights recently?
5. For Steroid/Drugs:
6. For Osteoarthritis:
a. Have you noticed any stiffness of joints?
b. Have you noticed any scratching sensations in your joint?
7. For Osteoporosis: (Menstrual Hx, Age, No HRT)
8. For Fractures:
a. Have you noticed nay trauma recently?
b. Have you been following a vigorous exercise plan recently?

Exam

1. HEENT EXPOSE THE HIP… always check for tenderness

2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses, Gait

Investigations

1. CBC with differential, S/E

2. ESR
3. Arthrocentesis and analysis
4. X-ray Hip AP & Lat view
5. CT scan
6. MRI
7. DEXA scan
8. Ca++ & Vitamin-D levels

16
Calf Pain
Mnemonic: WRSS VOIS
Differential Diagnosis: Decrease β-HCG Slowly
DVT, Baker’s  Cyst,  Hematoma, Cellulitis/Myositis, Gastrocnemius tendon rupture, Muscle Strain
Questions
1. Have you noticed any Warmth of your joint?
2. Have you noticed any Redness of your joint?
3. Have you noticed any Stiffness of your joint?
4. Have you noticed any Swelling of your joint?
5. Have you noticed any Visible veins/pulsations?
6. Have you been Immobilized recently?
7. Are you using Oral Contraceptive Pills recently?
8. Have you noticed any Shortness of breath? Any Chest pain?
Exam
1. HEENT
2. Inspect, Palpate, ROM (at both knee and ankle), Homan’s  sign, Pulses,
3. Motor, Reflexes, Sensations of Ankle and Knee Joint
4. CVS and Pulmonary exam
Investigations
1. CBC with differential, S/E
2. ESR
3. D-dimer and FDPs
4. Doppler U/S
5. Arteriography and Venography
17
Case of pleuritis and pericarditis.

Case of costocondritis
Chest pain
Differential Diagnosis: MP4 GC DC

MI, Pneumonia, Pericarditis, Pulmonary embolism, Pleuritis, GERD, Chostochondritis, Aortic Dissection,
Cocaine Abuse

Questions

Any relationship of pain to breathing or position?

1. For MI:
a. Have you noticed any Shortness of breath?
b. Is the pain associated with sweating? Racing of heart?
c. Has the pain improved after resting?
2. For Pericarditis: (pain related to position)
a. Have you recently suffered from flu (runny nose, watery eyes, sore throat, fever,
fatigue)?
3. For Pneumonia:
a. Have you ever been exposed to anybody with similar complaints?
b. Have you suffered from cough recently?
4. For PE:
a. Have you noticed calf pain or swelling?
b. Have you been immobilized recently? DO you have pain when you walk
c. Are you using Oral Contraceptive Pills recently?
Any problem breathing?
5. For Pleuritis: (pain related to breathing) Are you anxious about anything
6. For GERD:
a. Have you noticed any burning sensation in your chest or change in taste of your mouth?
7. For Chostochondritis: (pain related to touching or pressing)
8. For Aortic Dissection: (HTN)
9. For Cocaine Abuse:

Exam

1. HEENT
2. Inspect, Palpate, ROM, Homan’s  sign, Pulses,
3. CVS and Pulmonary exam

Investigations

1. CBC with differential, S/E

2. EKG, Cardiac Enzymes
3. CXR
4. D-dimer and FDPs, Doppler U/S
5. Arteriography and Venography

18
Palpitations
Differential Diagnosis: CC FAGAT or 2C A FAT PG.

Cardiac Arrhythmia, Caffeine, Fever, Anxiety/Panic Disorder, HypoGlycemia, Anemia, HyperThyroidism.

OFDPAA Questions.

1. For Cardiac Arrhythmia:

a. Have you noticed any chest pain? SOB? Racing of heart? Skipped beats? Sweating?
2. For Caffeine:
a. Do you consume caffeinated beverages? If yes, then ask how much?
3. For Fever:
4. For Anxiety/Panic Disorder:
a. Is there any event associated with the racing of heart?
b. Does your breathing rate increase or feel shortness of breath during the episode?
c. Do you feel dizzy during the episode?
5. For HypoGlycemia:
a. Do you have a Hx of High blood sugar level?
b. Have you skipped meals? Or changed any dose or medications recently?
6. For Anemia: Have you noticed any change in your stool color…. 2. what is your diet consist of 3. craving for ice
a. Have you noticed any change of skin color?
b. Have you noticed SOB on exertion?
c. Have you noticed bleeding (excessive-for menses) from any site of the body?
7. For HyperThyroidism: (Temp intolerance, Bowel movement)
a. Have you noticed racing of heart?
b. Have you noticed any skin changes?
c. Have you noticed any tremors of hands?

Exam

1. HEENT
2. Inspect, Palpate, ROM, Homan’s  sign, Pulses,
3. CVS and Pulmonary exam

Investigations

1. CBC with differential, S/E

2. EKG, Cardiac Enzymes
3. Holter Monitoring
4. BSL
5. TSH, T3 & T4 .

19
Anxiety
Differential Diagnosis: PAPA HCG ST.

Panic Disorder, Acute stress & PTSD, Adjustment, Hypochondriasis, Caffeine, GAD, Substance Abuse,
HyperThyroidism. cardiac arythmia

OFDPAA Questions.

1. For Panic Disorder:

a. Is there any particular event associated with the racing of heart?
b. Does your breathing rate increase during the episode?
c. Do you feel dizzy during the episode?
2. For Acute stress: (<1 months)
a. Have you experienced any tragic event/accident in the past? When?
b. Have you experienced nightmares recently?
c. Have you experienced flashbacks?
3. For PTSD: (>1 month) any recent trauma
a. Have you experienced nightmares recently?
b. Have you experienced flashbacks?
4. For Adjustment: (Stress, Time more than 1 month)
5. For Hypochondriasis: (excessive preoccupation with disease)
6. For Caffeine:
a. Do you consume caffeinated beverages? If yes, then ask how much?
7. For GAD:
a. Do you feel worried about something in particular or generally about everything?
8. For Substance Abuse:
9. For HyperThyroidism: (Temp intolerance, Bowel movement)
a. Have you noticed racing of heart?
b. Have you noticed any skin changes?
c. Have you noticed any tremors of hands?

Exam

1. HEENT
2. CVS and Pulmonary exam

Investigations
EKG, Holter monitoring
1. CBC with differential, S/E
2. TSH, T3 & T4.
3. Urine toxicology screen.

20
in ALL CHRONIC COUGH ask about TB and HIV
Cough
Differential Diagnosis: ABAy FMG, C2A P, T.B, CA, Bronchiectasis

Non-Productive: Atypical Pneumonia, Acute Bronchitis, Asthma Fibrosis, Medications, GERD.

Productive without Blood: COPD, CCF, Aspiration, Pneumonia (typical).
Productive with Blood: T.B (PENT Qs), CA Lung, Bronchiectasis.
* Since Asthma and Bronchitis can present in any for so it is prudent to ask their related questions in all
types of cough.

Questions

Is the cough associated with Phlegm production? If yes, then ABCO

Do you bring anything up with your cough
Any dripping sensation in your throat
Amount runny nose
Blood present or Not facial pain
Color of Phlegm
Odor
1) Non-Productive Cough:
a) For Atypical Pneumonia: (Fever +) Also ask about grade, continuous/intermittent, chills etc.
b) For Acute Bronchitis: (Fever -)
i) Have you recently suffered from flu (runny nose, watery eyes, sore throat, fever, fatigue)?
c) For Asthma: (Night time awakening for asthma is at Dawn)
i) Is there any relationship with exercise or weather? Seasonal, weather, cold , exercise
ii) Do you have any pets at home?
iii) Do you have to wake up at night to catch breath? (If yes, timing at night)
d) For Fibrosis:
i) What do you do for living? (Occupation)
ii) Have you ever been exposed to radiation or cancer drugs?
e) For Medications: (ACEi/ARBs)
f) For GERD:
i) Have you noticed any burning sensation in your chest (Heart Burn) or change in taste of your
mouth?
2) Productive, Non Bloody Cough:
a) For COPD:
i) Have you noticed any Shortness of breath?
ii) Have you noticed any abnormal sound while breathing?
b) For CCF: (Night time awakening for asthma is after few hours of Sleep)
i) Do you have to use more pillows than usual?
ii) Do you have to wake up at night to catch breath? (If yes, timing at night)
iii) Have you noticed any swelling of your feet?
c) For Aspiration: (Alcoholic person is a risk factor)
i) Have you experienced any loss of consciousness recently?
ii) Have you noticed any difficulty swallowing (Stroke)?
21
d) For Pneumonia: (Fever)
i) Have you ever been exposed to anybody with similar complaints?
ii) If sputum +, then ABCO.
3) For Productive, Bloody Cough:
a) For T.B: (PENT Questions)
i) When was your last PPD/Monteux? If yes, then result.
ii) Have you ever been Exposed to anybody with similar complaints?
iii) Have you experienced Night sweats?
iv) Have you Travelled recently (to endemic areas)?
b) For CA Lung: (Smoking, Weight loss, Appetite)
c) For Bronchiectasis:
i) DO you have to assume a specific position to produce phlegm?

Exam

1. HEENT
2. CVS and Pulmonary Exam

Investigations

1. Sputum stain, and culture.

2. CBC with Differential, S/E.
3. Blood Culture
4. CXR
5. CT scan Chest.
6. BAL.

Use tissue when you cough

22
SOB
Differential Diagnosis: (CAP)2 FAT.
COPD, CCF, Aspiration, Asthma, Pneumonia, Pulmonary Embolism, Fibrosis, Anemia, TB
OFDPAA questions
1. For COPD:
a. Have you noticed any Shortness of breath?
b. Have you noticed any abnormal sound while breathing?
2. For CCF: (Night time awakening for asthma is after few hours of Sleep)
a. Do you have to use more pillows than usual?
b. Do you have to wake up at night to catch breath? (If yes, timing at night)
Text
c. Have you noticed any swelling of your feet?
3. For Aspiration: (Alcoholic person is a risk factor)
a. Have you experienced any loss of consciousness recently?
b. Have you noticed any difficulty swallowing (Stroke)?
4. For Asthma: (Night time awakening for asthma is at Dawn)
a. Is there any relationship with exercise or weather?
b. Do you have any pets at home?
c. Do you have to wake up at night to catch breath? (If yes, timing at night)
5. For Pneumonia: (Fever+) Also ask about grade, continuous/intermittent, chills etc.
a. Have you ever been exposed to anybody with similar complaints?
b. If sputum +, then ABCO.
6. For Pulmonary Embolism:
a. Have you noticed calf pain or swelling?
b. Have you been immobilized recently?
c. Are you using Oral Contraceptive Pills recently?
7. For Fibrosis:
d. What do you do for living? (Occupation)
e. Have you ever been exposed to radiation or chemotherapeutic drugs?
8. For Anemia:
a. Have you noticed any change of skin color?
b. Have you noticed SOB on exertion?
c. Have you noticed excessive bleeding from any site of the body?
9. For T.B:
a. When was your last PPD/Monteux? If yes, then result.
b. Have you ever been Exposed to anybody with similar complaints?
c. Have you experienced Night sweats?
d. Have you Travelled recently (to endemic areas)?

Exam

1. HEENT
2. CVS and Pulmonary Exam

23
Investigations

1. Sputum stain, and culture.

2. CBC with Differential, S/E.
3. PEFR.
4. Sputum stain and culture.
5. Blood Culture
6. CXR
7. Spiral CT scan Chest.

24
Throat discomfort—> what you mean if Voice change : Hoarsness.. Otherwise Soar Throat

Sore Throat
Differential Diagnosis: PHIGNS

Pharyngitis, HIV, Infectious Mononucleosis, GERD, Post Nasal Discharge, Scarlet Fever.

Questions

Have you noticed any pain on swallowing?

Have you noticed any swellings in neck?
Do you have to clear your throat frequently?

1. For Pharyngitis: Facial pain. swelling in neck, dysphagia,

a. Have you noticed any pain or fullness in ear? rheumatic: change in urine color, joint pain and rash
b. Have you noticed any redness or discharge from eyes?
2. For HIV: (IV drug abuse, Fatigue, Sexual behavior)
3. For IM:
a. Have you ever been exposed to anybody with similar complaints?
b. Do you feel more tired than usual?
c. Have you noticed any fullness or pain in belly?
4. For GERD:
a. Have you noticed any burning sensation in your chest? Or change in taste of your mouth?
5. For Post Nasal Drip:
a. Have you noticed nasal stiffness?
b. Have you noticed recurrent cough?
6. For Scarlet Fever:
a. Have you noticed any rash on the body?

Exam

1. HEENT
2. Inspect, Palpate, (Sinus Tenderness)
3. CVS and Pulmonary exam
4. Abdominal Exam (for Splenomegaly)

Investigations

1. CBC with differential, S/Efor mononucleosis: peripheral smear

2. ESR
3. Rapid Strep Test SEXUAL HISTORY IS VERY IMP.
4. Monospot Test
5. ELISA Closure: always advise safe sex & avoid contact sport
6. Western Blot
7. Endoscopy

25
growth on your voice box or over use of it.

Ask: hospitalization: any procedure undergoing involving yur food pipe or wind pipe
Hoarseness
Differential Diagnosis: PM leaves CAP in LGH.

Pharyngitis, Mitral Stenosis, Cancer, Abuse/over use, Polyp, Laryngitis, GERD, Hypothyroidism.

Have you noticed pain while speaking?

1. For Pharyngitis: (Painful)

a. Have you noticed any pain or fullness in ear?
b. Have you noticed any redness or discharge from eyes?
2. For Mitral Stenosis: (Painless)
a. Have you noticed any Shortness of Breath?
b. Have you noticed any difficulty in swallowing?
c. Do you have a Hx of rheumatic fever?
3. For Laryngeal CA: (Painful)-Smoking and Alcohol use.
4. For Abuse/overuse: (Painful)-Profession
5. For Polyp: (Painless)
6. For Laryngitis: (Painful)
a. Have you recently suffered from flu (runny nose, watery eyes, sore throat)?
7. For GERD: (Painful):
a. Have you noticed any burning sensation in your chest (Heart Burn) or change in taste of
your mouth?
8. For Hypothyroidism (Painless): (Cold Intolerance)
a. Have you noticed any changes in skin?
b. Have you noticed any changes in bowel movement?

Exam

1. HEENT + Thyroid
2. CVS Exam

Investigations

1. CBC with differential, S/E.

2. TSH, T3 & T4.
3. ECHO, EKG.
4. Throat swab.
5. CT scan chest.

26
Jaundice
Differential Diagnosis: O CAVA
Obstructive Jaundice, Cholangitis, Alcohol, Viral Hepatitis, Autoimmune. Qs are JETR.

Questions

1. What is the Colour of your stools?(Dark or Light)

2. What is the Colour of your urine?(Dark or Light)
3. Have you noticed any Itching of the body?
4. Have you noticed any Pain/distension of your belly?
5. Have you noticed any pain in Joints?
6. Have you Eaten out recently?
7. Have you noticed any Traveled recently?
8. Have you noticed any Relationship of pain to meals?

Exam

1. HEENT
2. GIT  exam  (Murphy’s)
3. CVS

Investigations

1. Rectal & Pelvic Exam

2. Stool for occult blood
3. ALT/AST/Bilirubin/ALP
4. U/S Abdomen
5. Anti HAV, HBsAg, Anti-HCV.
6. ERCP
7. HIDA scan

27
Hematuria
F BUN SHIP
Differential Diagnosis: HITTERS.
Hematologic causes, Infections, Trauma, Tumor (including BPH), Exercise, Renal, Stone.

Questions

Is the blood before, mixed or after urination?

Have you experienced any sore throat recently?
Have you started any medications recently? (Cyclophosphamide etc)
1. For Hematologic Causes:
a. Have you noticed bleeding from any other site of the body?
b. Do you have any history of easy bruising?
2. For Infection/UTI:
a. Do you have to pass urine more frequently than usual?
b. Have you noticed any trouble holding urine or do you have to rush to urinate?
c. Have you noticed any burning sensation while urinating?
d. Have you noticed any pain in your belly? If yes, then ask OFDPLIQRAA.
3. For Tumor (including BPH): (Smoking)
a. Do you have to strain during micturition?
b. Have you noticed any change in urinary stream?
c. Do you have to wake up at night to urinate?
d. Do you feel a sense of bladder fullness even after passing urine?
4. For Trauma:
5. For Exercise: (What aggravates?)
6. For Renal (Glomerulonephritis):
a. Have you noticed any swelling on your body?
b. Have you noticed any Joint pain or rash on your body?
7. For Renal Stones:
a. Do you have any History of kidney stones?

Exam

1. HEENT
2. GIT exam + Renal Punch for CVA tenderness
3. CVS BACK FOR RENAL PUNCH

Investigations

1. Rectal Exam
2. Urinalysis, Urine stain and Culture
3. U/S and CT Abdomen
4. BUN: Cr
5. CBC with Differential, PT and APTT
6. Cystoscopy
28
Burning Micturition
Differential Diagnosis: PAPU on CTV. CUPID:
F2 PUB.??
Pyelonephritis, Allergic/Irritational, Prostatitis, Urethritis, Cystitis, Trauma, Vulvovaginitis.

OFDP questions,
Do you have to urinate more frequently than usual?
Do you have to rush to urinate?
1. For Pyelonephritis: (Fever with chills, Nausea)
a. Have you noticed any pain in your flanks/belly? If + OFDPLIQRAA
2. For Allergic/Irritational:
a. Have you recently changed your contraceptive method?
3. For Prostatitis:
a. Do you have a Hx of recurrent urinary symptoms?
b. Have you noticed pain around your genital region?
4. For Urethritis:
a. Have you noticed any discharge in urine, If yes ABCO.
5. For Cystitis:
a. Have you noticed pain in your (lower) belly?
6. For Trauma:
7. For Vulvovaginitis:
a. Have you noticed any discharge from vagina?
b. Have you noticed any pain during intercourse?

Exam

1. HEENT
2. GIT exam + Renal Punch for CVA tenderness
3. CVS

Investigations

1. Rectal Exam
2. Urinalysis, Urine stain and Culture
3. CT Abdomen
4. U/S Abdomen
5. BUN: Cr
6. CBC with Differential.
7. Cystoscopy

if latex allergy—> use latex free condom

29
SOUND
S: stress
O: over flow Urinary Incontinence
U: urge
N: NPHDiagnosis: Motor Incontinence, Overflow incontinence, Stress incontinence, Urge
Differential
D: DM
Incontinence.
OFDPAA questions
Do you consume excessive fluids?
Has it impaired performance of your daily activities?
Are you consuming more fluids than usual?
1. For Motor Incontinence:
a. Do you have to urinate more frequently than usual?
b. Do you have to rush to urinate?
2. For Overflow incontinence: (DM)
a. Have you ever suffered a trauma to your back?
b. Have you noticed any Weakness of your body?
c. Have you noticed any Numbness or Tingling of your body?
3. For Stress incontinence: (Hx of multiple SVDs, or Hx of pelvic surgeries)
a. Have you noticed problem holding urine while laughing, coughing, and sneezing?
4. For Urge Incontinence:
a. Have you noticed leakage of urine, which follows a sudden strong urge?

Exam

1. HEENT
2. GIT exam
3. CVS

Investigations

1. Rectal Exam
2. Urinalysis, Urine stain and Culture
3. Q-Tip
4. Urodynamic Studies
5. Cystoscopy

30
CAse of OSA with statin.
Fatigue
in OPDaa An M3 Pg Delivered A Speech on Fatigue by Hypothyroidism
Differential Diagnosis: I3M2P A3DHD & Sheehan’s  Syndrome.

Infections (T.B, HIV, IM), Malignancy, Myasthenia Gravis, Adjustment Disorder, Anemia, Apnea, DM,
Hypothyroidism, Depression.

Questions

OFDP Questions
Have you noticed any problem performing your daily activities e.g. bathing, dressing, cooking etc.?
Any event that is associated to the problem?

1. For Infections:
a. T.B: (PENT Questions)
Mononucleosis
b. I.M: (Ill contact, Pain Abdomen)
c. HIV: (Ill contact, IV drug abuse, Irresponsible sexual behavior)
2. For Myasthenia Gravis:
a. How does it progress during the day?
b. Have you noticed weakness of muscles or double vision?
3. For (occult) Malignancy: (Weigh loss)
a. Have you noticed any pain in your belly?
4. For PTSD: (Sleep changes, Stress/ Trauma)
a. Have you experienced nightmares recently?
5. For Apnea:
a. Do you snore at night? Or has someone told you? feel sleepy during the day
b. Do you feel restless at night? Or has someone told you?
6. For Anemia:
a. Have you noticed any change of skin color?
b. Have you noticed SOB on exertion?
c. Have you noticed excessive bleeding from any site of the body?
7. For Adjustment: (Stress, Time more than 1 month)
8. For Depression: (Mood + SIGECAPS)
9. For Hypothyroidism: (Temp Intolerance, Skin Changes, Bowel changes)
10. For Diabetes Mellitus:
a. Do you feel more thirsty than usual?
b. Do you have to urinate more frequently than usual?
11. For Sheehan’s  Syndrome:
a. Was the delivery normal? Or there was any excessive bleeding?
b. Have you been able to breastfeed your child? (inability to breast feed)

Text Exam

1. HEENT + Thyroid Exam 1st Pelvis and breast exam

2. Orientation
Prolactin, FSH:LH…. MRI Brain…
31
Counselling:
MEANWHILE I WILL KEEP U UNDER
OBSERVATION
Investigations

1. CBC with differential.

2. TSH, T3 and T4.
3. Monospot
4. ELISA
5. CXR
6. BSL
7. Acetylcholine receptor antibody.
8. CT scan Brain.
9. MRI Brain.

32
DM and HTN follow- up
Ask about symptoms in following systems. Eye, Heart, Stomach, Kidney, Perineum, Legs, Foot; Neuro, If
Erectile Dysfunction, then ask: Psychological causes, Vascular, Depression, Drugs.

For how long? Taking Meds? Compliant? Side effects? Check BSL regularly? Under control? Last
reading? Last visit to doctor? What was your last HBA1c ?

1. For Eyes:
a. Have you noticed any changes in your vision?
b. When was you last eye checkup?
2. For Heart: (Past Hx of MI, SOB, Pacing of heart, Chest pain, Sweating)
3. For Pulmonary: (SOB)
4. For GIT: (Bowel habits, Polyphagia, Abnormal Discomfort-GERD)
5. For Genitourinary: (Polyuria, Polydipsia) IMP
6. For Neuro: (Past Hx of Stroke or TIA, WNT, Speech or swallowing difficulty) ALSO DEPRESSION
7. For Sexual:
a. Have you noticed any change in your sexual Desire?
b. Have you noticed any change in your sexual Performance? If yes, then ask;
c. Psychological causes
i. When did it start?
ii. How is the relationship with your spouse?
iii. Do you have morning erections?
iv. On a scale of 1 to 10, where 1 being flaccid & 6 being adequate for penetration,
How do you grade your erection?
v. Are you under any sort of excessive stress these days?
d. Vascular causes:
i. Have you noticed any pain in your legs?
ii. Have you noticed any Weakness of your body?
iii. Have you noticed any Numbness or Tingling of your body?
e. Depression (Mood + SIGECAPS)
f. Medications (are you taking any drugs?)
g. Hypogonadism: (desire issue)
i. Do you have normal pubic and axillary hair?

Exam
Carotid bruit
1. HEENT + Fundoscopy fundoscopy
2. CVS Exam
Cranial nerve

Investigations
Walk on even ground, keep foot
1. CBC with differential.
also Cardiac..: EKG & Enzyme clean
2. CXR Dynamic cavernography regular checkup
3. BSL and HBA1c regular labs
4. Urine for Micro albumin, Urinalysis.
33
THEN FRCS

Pre-Employment Exam
Ask about symptoms in following systems: Head, Eye, Ear, Nose, Mouth, Neck, Heart, Stomach, Kidney,
Perineum, Extremities, Foot, Psychiatric, Skin.

For how long? Taking Meds? Compliant? Side effects? Check BSL regularly? Under control? Last
reading? Last visit to doctor? What was your last HBA1c ?

1. For Head:
a. Do you have a Hx of head trauma?
b. Do you have a Hx of Dizziness, LOC/ fainting spells?
c. Do you have a Hx of Stroke or TIA?
d. Do you have a Hx of seizures?
2. For Eyes:
a. Have you noticed any changes in your vision?
3. For Ear:
a. Have you noticed any changes in your hearing?
b. Have you noticed any problem with your balance or gait?
4. For Sinus:
a. Have you noticed chronic facial pain or nasal stuffiness?
5. For Neck:
a. Have you noticed any pain or swellings in your neck?
6. For Heart: (Past Hx of MI, SOB, Pacing of heart, Chest pain, Sweating)
7. For Pulmonary: (SOB, Cough)
8. For GIT: (Pain, distension, Bowel habits, Polyphagia, Abnormal Discomfort-GERD)
9. For Genitourinary: (Polyuria, Polydipsia)
10. For Obs/Gnae: (LMP RT CVS PAP)
11. For Psychiatric:
a. Do you have a Hx of psychiatric illness or admission?
12. For Skin:
a. Have you noticed rash or any other skin problems?

Exam

1. HEENT
2. CVS Exam

Investigations

1. CBC with differential + S/E.

2. CXR
3. Urinalysis.

34
Headache
Differential Diagnosis: M2CB R S2T4D GC. (MCB owner had Resistant STDs in GC)

Migraine, Meningitis, Cluster Headache, Benign Intracranial HTN, Refractive errors, SAH, Sinusitis,
Trauma, TIA, Tumor, Tension Headache, Depression.

Questions

1. For Migraine: (ANP)

a. Have you noticed any unusual symptoms before the onset of headache (Aura)?
b. Do you feel Nauseated or like vomiting?
c. Are you abnormally sensitive to light/sound?
d. Any relationship of headache to menses?
Text
2. For Meningitis/Encephalitis:
a. Have you noticed any pain or stiffness in neck?
b. Have you noticed any rash on your body?
3. For Cluster Headache:
a. Do you have a runny nose?
b. Have you noticed any redness or discharge from eyes? Or pain in the back of eyes?
4. For Benign Intracranial HTN: Pseudotumor cereberi
a. Have you noticed any changes in your vision?
b. Are you using Oral Contraceptive Pills recently?
5. For Refractive Errors: (Vision Changes)
a. Have you noticed any pain with reading or concentrating?
6. For Sinusitis: (Runny nose, Sore throat)
a. Have you noticed any in face?
b. Have you noticed any relationship of timing to the pain? (Morning or Evening)
7. For Subarachnoid Hemorrhage: (Neck Stiffness, Vision Changes, Nausea/ Vomiting)
8. For Temporal Arteritis: (Vision Changes, Fatigue)
a. Have you noticed any pain while chewing or combing hair?
b. Have you noticed any muscle stiffness?
9. For TIA: (WNT, Gait, Vision)
a. Have you noticed any problem swallowing?
b. Have you ever lost consciousness?
10. For Trauma/Subdural Hematoma:
11. For Tumor: (Weight loss, Appetite, Family Hx, Night headache)
12. For Tension Headache: (Excessive Stress, Vase like tightening)
13. For Glaucoma: (Vision Changes, Pain in eye, predisposing factor)
14. For Cocaine Abuse:

Exam

35
1. HEENT
2. Inspect, Palpate, (Sinus Tenderness)
3. CNS with cranial Nerves
4. Fundoscopy

Investigations

1. CBC with differential, S/E

2. ESR
3. CT Scan
4. LP and Analysis
5. Visual Acuity

First let me learn as much as i can about your pain and then i will prescribe you the best medication i
can for the pain

36
Forgetfulness
Differential Diagnosis: AN SVD in H2BL.
Neurosp
Alzheimer’s,  Normal Pressure Hydrocephalus, Subdural hematoma, Vascular, Depression,
Hypothyroidism, Huntington’s  chorea,  Vitamin  B12 Deficiency, Lewy Body Dementia.
ABCD + Hair and Voice change
Questions

OFDP, in case of Delirium, ask A,A, if Dementia, then ask;

Have you noticed any problem performing your daily activities e.g. bathing, dressing, cooking etc.?

1. For Alzheimer’s  Dementia: (Age, Family Hx)

2. For Normal Pressure Hydrocephalus:
a. Have you noticed any changes in your gait?
b. Have you ever passed urine unintentionally?
3. For Subdural Hematoma:
a. Do you have any recent Hx of fall or trauma to head?
4. For Vascular Dementia:
a. Have you noticed any Weakness of your body?
b. Have you noticed any Numbness or Tingling of your body?
c. Have you noticed any difficulty with speech?
5. For Depression: (Mood + SIGECAPS)
a. How is your mood these days?
b. Have you noticed any changes in your Sleep? If yes, ask about early morning awakening?
Trouble falling sleep? Staying Sleep?
c. Do you enjoy the activities that you used to enjoy previously? (Interest)
d. Do you feel Guilty about anything?
e. Do you feel as Energetic as before?
f. Concentration Qs? Serial 7s or spell backwards.
g. Have you noticed any change in your Appetite?
h. Psychomotor retardation?
i. Have you ever thought about Suicide? Have you ever planned or attempted suicide?
6. For Hypothyroidism? (Cold Intolerance)
a. Have you noticed any changes in skin?
b. Have you noticed any changes in bowel movement?
7. For  Huntington’s  Chorea:  (Family  Hx)
a. Have you noticed any involuntary jerking or writhing movements (chorea)?
b. Have you noticed any impaired gait, posture and balance?
c. Have you noticed any problems or difficulty with speech?
8. For Vitamin B12 Deficiency:
a. What does your primary diet comprises of?
b. Have you noticed any abnormal sensation in your hands or feet?
9. For Lewy Body Dementia: stiffness
a. Have you noticed any tremors in your hands?
37
b. Have you noticed any stiffness of your body?
c. Have you noticed any slowing of your body movements?
10. For Delirium: Ask Dehydration Qs (Heat stroke or Diarrhea)

Exam
CAROTID BRUIT AND fundo
1. HEENT + Fundoscopy
2. CVS exam + Orthostatic signs + Auscultation
3. CNS exam (Motor, Reflexes, Sensory, Gait, MMSE)
4. In MMSE:
a. General Questions (AAO x 3)
i. What is your full name?
ii. What is the date today?
iii. Where are you right now?
b. Immediate Memory:
i. Now I will name 3 objects e.g. Bat, Mat, and Hat.
ii. Can you please repeat that?
iii. Please remember and I will ask you later on.
c. Short Term Memory:
i. What did you have in your last meal
d. Long Term Memory:
i. When did you graduate/ married?
e. Recall:
i. Can you please recall those 3 objects for me?
f. Concentration:
i. Can  you  please  spell  “CAR”  backwards?
g. Judgment:
i. If there is a fire in that corner, what will you do?

Investigations

1. CBC with differential.

2. TSH, T3 and T4.
3. CT scan Brain.
VDRL/ RPR
4. MRI Brain.
5. Vitamin B12 level.

Don’t go unaccompained, Want to meet ypur family member and talk to socail worker to assist at home safety measures

38
Hearing Loss
Differential Diagnosis: PD of IPL in COMA. POOD PALM

With Balance Problems; Perilymphatic Fistula, Acoustic Neuroma, Labyrinthitis, Meniere’s  disease.

Without Balance Problems; Presbycusis, Drugs, Infections, Cochlear Nerve Damage, Otosclerosis.

OFDPLAA questions
Do you have any problems maintaining balance?
1. For Perilymphatic Fistula: (Trauma + Balance)
2. For Acoustic Neuroma:
a. Have you noticed any problem in localizing sounds?
b. Have you noticed any lesions on your skins?
c. Have you noticed any problem with your gait or balance?
3. For Labyrinthitis: (URI + Hearing loss + Balance)
4. For Meniere’s  disease:
a. Have you noticed any pain or fullness in ear?
b. Have you noticed any ringing sounds in your ears?
c. Have you noticed any problem with you balance?
5. For Presbycusis: (Age)
a. Is the hearing lost for all sounds or for any specific sounds? Or hearing with background
noise?
b. Have you noticed any problem understanding speech?
c. Do the word sound jumbled or distorted?
6. For Drugs:
7. For Infections:
a. Have you noticed any ear pain or discharge?
8. For Cochlear Nerve Damage:
a. Are you exposed to loud sounds at home or work?
9. For Otosclerosis: (Age, starts from one ear and progresses to other)
a. Have you noticed any problem hearing a whisper?

Exam

1. HEENT + Whisper, Weber  &  Rhine’s  test  +  Otoscopy

2. CNS Exam (Cerebellar exam MRSPG)

Investigations

1. CBC with differential + S/E.

2. Audiometry & Tympanometry.
3. CT scan Brain.
4. MRI Brain.
5. Brainstem Auditory evoked potential
39
6. VDRL.

Dizziness (Vertigo)
BV PALM
Differential Diagnosis: BV on My LAP

Without Hearing Loss: Benign Positional Vertigo, Vestibular Neuronitis

With Hearing Loss: Meniere’s  disease, Labyrinthitis, Acoustic Neuroma, Perilymphatic Fistula

Questions

What do you mean by dizziness? Have you noticed any problem in hearing?

Have you ever lost consciousness? If yes, then go to LOC case on next page.

1. For Benign Positions Vertigo:

a. Have you noticed any relationship to position?
2. For Vestibular Neuronitis: (Nausea + Vomiting)
a. Have you recently suffered from flu (runny nose, watery eyes, sore throat, fever,
fatigue)?
3. For Meniere’s  Disease:
a. Have you noticed any ringing sounds in your ears?
b. Have you noticed fullness of your ears?
4. For Labyrinthitis: (Vestibular Neuronitis + Hearing loss)
5. For Acoustic Neuroma: (Family Hx + hearing loss + weight loss/appetite)
a. Have you noticed any problem with your gait?
b. Have you noticed any lesions on your skins?
6. For Perilymphatic Fistula:
a. Have you noticed or have any head trauma?

Exam

1. HEENT  +  Weber  &  Rhine’s  test

2. CNS Exam (Cerebellar exam)

Investigations

1. CBC with differential + S/E.

2. Audiometry.
3. CT scan Brain. don’t drive
4. MRI Brain. unaccompained
fix for hearing aid

40
Dizziness (LOC)
Differential Diagnosis: HAD CAMPUS.

Hypoglycemia, Alcoholic Withdrawal, Dehydration/Orthostatic Hypotension, Cardiac Arrhythmias, Aortic

Stenosis, Mass e.g., abscess, tumor, Panic attack, Unexplained e.g. Vasovagal, Seizures.

Questions

What do you mean by dizziness or LOC? any waning sign

did you smell anything unusual

Have you ever lost consciousness? If yes, then please tell me more about that. Who was with you? What
were you doing when it happened? How long did it take to regain consciousness?

1. For Hypoglycemia: (sweating, Nausea, racing of heart)

a. Do you have a Hx of High blood sugar level?
b. Have you skipped meals? Or changed any dose or medications recently?
2. For Alcoholic withdrawal: (Ask about alcohol use)
a. When was you last drink?
3. For Dehydration: (DMG)
a. Have you noticed any changes in bowel habits?
b. Have you noticed any meds or dosages?
c. How many pads do you use on a heavy day?
4. For Cardiac Arrhythmia:
a. Have you noticed any chest pain? SOB? Racing of heart? Skipped beats? Sweating?
5. For Aortic Stenosis: (SOB, Chest pain)
6. For Mass (Malignancy, Abscess, Lymphoma):
a. Have you noticed any Weakness of your body?
b. Have you noticed any Numbness or Tingling of your body?
c. Have you noticed any headache? If yes, what time of day?
7. For Panic Attack: (chest pain, SOB, racing of heart, Nausea, Vomiting)
a. How did this happen, please tell me more about it?
8. For Unexplained (Vasovagal Syncope): (Nausea, vomiting)
a. How did this happen, please tell me more about it?
9. For Seizures (AuSTIC):
a. Did you notice any warning signs or any unusual sensations before passing out? (Aura)
b. Did anyone notice jerky movements? (Shaking)
c. Did you bite your Tongue while shaking?
d. Did you pass urine without your knowledge?
e. Were you confused after you regained consciousness?
10. For Convulsive Syncope;
11. For Metabolic derangement (Electrolyte imbalance etc.):

Exam

1. HEENT
41
2. CVS Exam
3. CNS Exam (MMSE)

Investigations

1. CBC with differential + S/E.

2. EKG, ECHO
3. BSL
4. CT scan Brain.
5. MRI Brain.

Closure: don’t drive, carry your id card with you, don’t go

out unaccompanied and void strenuous activities

42
Menstrual Irregularities
Differential Diagnosis: PHATA PEEPA.
Pregnancy, Hyperprolactinemia, Anorexia, Thyroid, Anxiety, Premature ovarian failure, Endometriosis,
Exercise, Asherman Syndrome, PCOS.
ODP, LMP RT CVS PAP.
1. For Pregnancy:
a. Have you noticed any fullness or tenderness of breast?
2. For Hyperprolactinemia:
a. Have you noticed any discharge from the nipples?
b. Have you noticed any change in your vision recently?
c. Have you noticed any headache recently?
d. Have you started any new medications recently?
3. For Anorexia: (weight/appetite changes)
a. How do you feel about this problem?
b. How do you feel about your physical appearance?
4. For Thyroid
a. Have you noticed any changes in your skin texture?
5. For Anxiety:
a. Are you under any sort of excessive stress these days?
6. For Premature ovarian failure:
a. Have you noticed sudden episodes of increased warmth or sweating of the body?
b. Have you noticed any itching/dryness of your genital region?
7. For Endometriosis:
a. Have you noticed any pain during menstruation?
b. Have you noticed any pain during intercourse?
c. Have you noticed any abnormal bleeding or bleeding in between periods?
8. For Exercise:
a. Are you following a vigorous exercise plan recently?
9. For Asherman Syndrome:
a. Have you ever had a gynecological procedure recently?
b. Have you ever had problems conceiving?
10. For PCOS:
a. Have you noticed any excessive hair growth recently?
b. Have you noticed any abnormal pigmentation of the body?

Exam

1. HEENT
2. Abdominal Exam

Investigations

1. Rectal & Pelvic Exam

43
2. β-HCG
Transvaginal u/s.. for fibroid and
3. CBC with differential, S/E adenomysosis
4. FSH:LH
5. U/S Abdomen
6. CT & MRI Brain. Heavy menorrhagia—> Fibroids

44
Post-Menopausal Bleeding
Differential Diagnosis: ICE PACT.

Infections, CA Cervix, Endometrial Hyperplasia, Polyp, Atrophic Vaginitis, CA Endometrium, Trauma.

OFDPAA, when was your LMP?

1. For Infections: (fever + pain)

a. Have you noticed any discharge from vagina? If yes, then ABCO
2. For CA Cervix: (weight loss)
a. Have you noticed any bleeding after intercourse?
3. For Endometrial Hyperplasia:
a. Are you taking HRT?
4. For Polyp:
a. Have you noticed anything coming out of vagina?
5. For Atrophic Vaginitis:
a. Have you noticed any burning sensation?
b. Have you noticed any itching/dryness of your genital region?
6. For CA Endometrium:
a. Have you noticed any pain in your belly?
b. Are you taking any medication for menopause?
7. For Trauma:

Exam

1. HEENT
2. Abdominal Exam

Investigations

1. Rectal & Pelvic Exam

2. β-HCG
3. CBC with differential, S/E
4. Blood Culture
5. FSH:LH
6. U/S Abdomen
7. Pap smear
8. Endometrial Biopsy

45
Vaginal Discharge
Differential Diagnosis: PVCAT or ATV on PC. LMP RT CVS PAL.. + antibiotic/ sterioid+ Hx of DM.

Atrophic Vaginitis, Trichomonas, Bacterial Vaginosis, PID, Candidial infection.

Have you noticed any redness or itching of your genital region?
Ask following details about discharge:
Amount
Blood present or Not clot too!
Color of discharge
Odour
1. For Atrophic Vaginitis:
a. Have you noticed sudden episodes of increased warmth or sweating of the body?
b. Have you noticed any itching/dryness of your genital region?
2. For Trichomonas: (Multiple sexual partners, Greenish discharge, Treat male partner)
3. For Bacterial Vaginosis: (Grayish discharge)
a. Have you been taking antibiotics recently?
4. For PID: (Fever)
a. Have you noticed any pain in your belly?
5. For Candidial infection: (curd like discharge)
a. Do you have a Hx of DM?
b. Have you been using steroids recently?

Exam

1. HEENT
2. Abdominal Exam

Investigations

1. Rectal & Pelvic Exam

2. Discharge exam and Culture
3. CBC with differential, S/E
4. Blood Culture
5. U/S Abdomen
6. Pap smear

46
Dyspareunia
Mnemonic: LMP RT CVS PAP & DAC-Desire, Abuse, Conflict (if + SAFE GARD).

Differential Diagnosis: PV3 A2CE.

Pelvic tumor, Vaginismus, Vulvodynia, Vulvovaginitis, Atrophic Vaginitis, Abuse, Cervicitis,
Endometriosis.

Questions

Insert transitional statement for Gynae/ Obs questions.

1. When was your LMP?

2. When was your first Menstrual period (Menarche)?
3. Do you feel Pain during intercourse or defecation?
4. Are your cycles Regular?
5. How many Tampons/Pads do you use on a heavy day?
6. Have you noticed Crampy pain during menses?
7. Have you noticed any Vaginal discharge? If yes ABCO
8. Have you noticed any Spotting in between periods?
9. Are you Pregnant?
10. Have you ever had Abortions?
11. When was your Last Pap smear?
12. Have you noticed any change in your sexual Desire?
13. Have you ever been Abused?
14. Do you have any Conflict with your partner/husband? If yes, then SAFE GARD
a. Do you feel Safe at home?
b. Are you AFraid of _________?
c. Do you have any Emergency (Exit) plan?
d. Do you have a Gun at home?
e. Is your __________ Alcoholic?
f. How is the Relationship of your ___________ with others?
g. Do you feel Depressed (Suicidal ideation)?

Exam
1. HEENT
2. GIT and CVS Exam

Investigations

1. Rectal & Pelvic Exam.

2. CBC with Differential, S/E.
3. Stain and Culture of Discharge.
4. U/S Abdomen & CT scan Abdomen.
5. Laparoscopy.
47
Sleep Problems/Insomnia
Differential Diagnosis: SADICCH. SAD INSOMNICs

Stress/Adjustment, OSA, Drugs, Illicit Drug use, Caffeine, Circadian Rhythm, Hyperthyroidism.

What do you do before you go to sleep?

What time do you usually go to bed?
Have you noticed any trouble falling sleep?
Do you wake up at night during sleep? if yes than WHY
What time you wake up in the morning? and do you feel awake
Do you feel sleepy or take naps during the days?
1. For Stress/Adjustment:
2. For OSA:
a. Do you snore at night? Or has someone told you?
b. Do you feel restless at night? Or has someone told you?
3. For Illicit Drugs:
4. For Caffeine:
a. Do you consume caffeinated beverages? If yes, then ask how much?
b. Do you take tea/Coffee/energy drinks before going to bed?
5. For Circadian Rhythm problems: If sleep duration is adequate then
a. Advanced Sleep Syndrome; sleeps at 2:00am
b. Delayed Sleep Syndrome; sleeps at 6:00pm
c. Jet Lag; History of recent Travel.
6. For Hyperthyroidism: (Temp intolerance, Bowel movement)
a. Have you noticed racing of heart?
b. Have you noticed any skin changes?
c. Have you noticed any tremors of hands?

Exam

1. HEENT
2. CVS Exam

Investigations
1st POLYSOMNOGRAOPHY.

1. CBC with differential, S/E

2. TSH, T3 & T4
3. Urine Toxicology screen.
4. Cortisol levels.

48
Weight Gain
Differential Diagnosis: DPT Qs in FCPS.

Depression, Pregnancy, HypoThyroidism, Familial tendency, Cushing’s,  PCOS, Smoking Cessation.

ODP questions,
How much weight have you gained? Over how much time? Intentional or unintentional?
1. For Depression: (Mood + SIGECAPS)
2. For Pregnancy: (LMP + Morning sickness)
3. For HypoThyroidism :(Temp intolerance, skin changes, bowel habits)
4. For Familial tendency:
a. Any family Hx of obesity?
5. For Cushing’s:
a. Have you noticed any stria on your body?
6. For PCOS:
a. Have you noticed any excessive hair growth recently?
b. Have you noticed any abnormal pigmentation of the body?
7. For Smoking Cessation: (Normal weight gain is 2kg)

Exam

1. HEENT + Thyroid Exam

2. GIT Exam

Investigations

1. CBC with differential, S/E

2. TSH, T3 & T4
3. Glucose, Cholesterol, Triglyceride levels.
4. Cortisol levels.
5. Urine  β-HCG.

49
Weight Loss
Differential Diagnosis: Dear HAMID MD.

Diabetes Mellitus, Hyperthyroidism, Anorexia Nervosa, Malignancy, Infections e.g., TB, HIV, Depression,
Drugs, Malabsorption.

ODP questions,
How much weight have you lost? Over how much time? Intentional or unintentional?
1. For Diabetes Mellitus: (Excessive thirst, urinary frequency)
2. For Hyperthyroidism: (Temp intolerance, tremors, Palpitations, Bowel habits)
3. For Anorexia Nervosa: (weight/appetite changes)
a. How do you feel about this problem?
b. How do you feel about your physical appearance?
4. For Malignancy: (Fatigue, smoking, Alcoholic)
5. For Infections:
a. T.B: PENT Questions
b. HIV: Ill contact, low grade fever, IV drug abuse.
6. For Depression (Mood + SIGECAPS)
7. For Drugs: (Laxatives, Thyroxine)
8. For Malabsorption:
a. Are your stools difficult to flush?
b. Are your stools foul smelling?
c. Have you noticed a sense of incomplete evacuation after passing stools?

Exam

1. HEENT + Thyroid Exam

2. GIT Exam

Investigations

1. CBC with differential, S/E

2. TSH, T3 & T4
3. PCR or ELISA for HIV
4. Sputum for AFB
5. Urinalysis
6. CXR

50
Tremors
Differential Diagnosis: In PC we learnt that PE has high LDH.
Physiological, Cerebellar, Parkinsonism, Essential Tremors, Liver Disease, Drugs, Hyperthyroidism.
OFDPLAA questions
DoC WILSON Please HELP my
Are the tremors at rest? tremors.

1. For Physiological:
a. Is the tremor associated with any event?
2. For Cerebellar Disease:
a. Have you noticed any abnormal eye movements?
b. Have you noticed any problems with movements/complex movements?
3. For Parkinsonism:
a. Have you noticed any slowing of your movement?
b. Have you noticed any stiffness of body?
c. Have you noticed any changes in your writing?
4. For Essential Tremors: (Family Hx, Relived by Alcohol or Propranolol)
5. For Liver Disease:
a. Have you noticed any distension of your belly?
b. Have you noticed enlargement of breasts?
c. Have you noticed any change in your skin?
6. For Drugs:  (caffeine,  nicotine,  β-agonists, TCA, Lithium, Valproate etc.)
7. For Hyperthyroidism: (Temp intolerance, Bowel movement)
a. Have you noticed racing of heart?
b. Have you noticed any skin changes?
c. Have you noticed any tremors of hands?

Exam

1. HEENT + Thyroid Exam

Cerebellar
2. CNS  Exam,  Romberg’s
3. GIT exam for liver disease

Investigations

1. CBC with differential, S/E

2. TSH, T3 & T4
3. ALT/AST/ALP/Bilirubin

51
Muscle Weakness
Differential Diagnosis:

With Stiffness; Funny PM has PTSD. Muscle. Fibromyalgia, PMR, Muscle Strain, Myotonic Dystrophy.
Neuro. TIA/Stroke, Parkinsonism, Multiple Sclerosis. Drugs. Anti-Dopamine & Anti-Psychotics.

Without Stiffness; Muscle. Polymyositis, Dermatomyositis. Neuro. GBS, Myasthenia Gravis. Drugs.
Steroids, Statins. Electrolytes; Hypokalemia. HyperThyroidism.

With stiffness:

1. For Fibromyalgia: (Sleep problems or Depressions)

a. Have you noticed tender points in the body?
2. For PMR:
a. Have you noticed any difficulty on standing from sitting position?
b. Have you noticed any changes in vision or headaches?
c. Have you noticed any problems while chewing?
3. For Muscle Strain (Trauma):
a. Have you lifted a heavy weight recently?
4. For Myotonic Dystrophy: (Family Hx)
a. Have you noticed any hair loss from head?
b. Have you noticed any difficulty releasing hand grip?
5. For TIA/Stroke: (WNT, Gait, Vision)
a. Have you noticed any problem swallowing?
6. For Parkinsonism:
a. Have you noticed any slowing of your movement? Changes in gait?
b. Have you noticed any stiffness of body? tremors
c. Have you noticed any changes in your writing?
7. For Multiple Sclerosis: (Female, Age)
a. Have you noticed any change in your vision?
8. For Drugs: (Anti-Dopamine & Anti-Psychotics).

Without Stiffness:

1. For Polymyositis:
a. Have you noticed any difficulty combing head or standing from sitting position
2. For Dermatomyositis:
a. Have you noticed any rash on your body?
3. For GBS:
a. Do you have any Hx of Diarrhea or sore throat?
b. How did the weakness progress?
4. For Myasthenia Gravis:
a. Have you noticed any problem swallowing?
b. Have you noticed any problem in vision or double vision?
5. For Drugs( Steroids, Statins.)
52
6. For Electrolytes; (Hypokalemia)
a. Do you have a recent Hx of Diarrhea?
8. For HyperThyroidism (Temp intolerance, Bowel movement)
a. Have you noticed racing of heart?
b. Have you noticed any skin changes?
c. Have you noticed any tremors of hands?

Exam

1. HEENT + Thyroid Exam

2. CNS Exam
3. Extremities exam

Investigations

1. CBC with differential, S/E (K+)

2. TSH, T3 & T4
3. Nerve Conduction study
4. MRI Brain
5. ANA, Anti-Ro, Anti-LA

53
Hallucinations
Differential Diagnosis:

Auditory Hallucination; Brief Psychotic disorder, Schizophreniform, Schizophrenia.

Visual Hallucinations; Tumor, Substance Abuse, Seizures, Delirium and Dementia.

Tactile & Gustatory Hallucinations; Cocaine, Alcohol withdrawal.

Secondary to Medical disorder; Parathyroidism, Narcolepsy, Postpartum Psychosis.

OFDPAA questions.
Can you please tell me more about that?
Do you see, hear or feel things?
Do they control you?
Do they tell you to harm yourself or others?
Does anyone else experiences that or are you the only one?
Has it affected your daily life performance?

For Auditory Hallucination:

1. For Brief Psychotic disorder: (stress, sleep, decreased functioning)

2. For Schizophreniform & Schizophrenia: (ideas of reference, classify according to time)
For Visual Hallucinations:

1. For Bain Tumor: (weight loss, headache)

a. Have you noticed any changes in your vision?
2. For Substance Abuse:
3. For Seizures:
4. For Delirium and Dementia: (reversible Vs. Irreversible)
For Tactile & Gustatory Hallucinations:

1. For Cocaine withdrawal:

2. For Alcohol withdrawal:
For Secondary to Medical disorder:

1. For Parathyroidism:
a. Have you noticed any change in your bowel habits?
b. Have you noticed any pain in belly?
c. Do you have a Hx of kidney stones?
2. For Narcolepsy:
a. Have you noticed any problems with sleep?
3. For Postpartum Psychosis:
a. When was your LMP?
54
Exam

1. HEENT
2. CNS Exam & MMSE.

Investigations

1. CBC with differential, S/E (K+)

2. Urine Toxicology screen.

55
Seizures
Differential Diagnosis: VITAMINS D.

Vascular, Infections (Meningitis, Encephalitis, Abscess), Trauma, Autoimmune (SLE), Metabolic

(hypoglycemia, hyponatremia), Idiopathic, Neoplasms, pSychiatric, Drug Abuse/Withdrawal.

ODPAA questions.
What were you doing before that happened?
Did you lose consciousness? Did anyone witnessed that?
Did you bite your tongue, passed urine or stools without your knowledge?
What happened after the episode?

1. For Vascular problem: (DM, HTN)

a. Have you noticed a weakness, numbness of tingling of your body?
2. For Infections: (Fever)
a. Meningitis: Neck stiffness
b. Encephalitis: Confusion, LOC
c. Abscess: WNT
3. For Trauma:
4. For Autoimmune:
a. SLE: Have you noticed any rash or joint pain?
5. For Metabolic derangement:
a. Hypoglycemia: (DM, changes in medication or dosages)
b. Hyponatremia:
i. Have you had diarrhea recently?
ii. Are you feeling more thirsty than usual?
6. For Idiopathic:
7. For Neoplasms: (weight loss)
a. Have you noticed any headache or changes in vision?
8. For pSychiatric (conversion disorder etc): (No Postictal confusion)
a. Are you under excessive stress these days?
9. For Drug Abuse/Withdrawal: (Alcohol, Benzodiazepine)

Exam

1. HEENT
2. CNS Exam & MMSE.

Investigations

1. CBC with differential, S/E (K+)

2. Urine Toxicology screen
3. Blood Culture
4. Lumbar puncture & CSF analysis

56
Pediatric
Case

57
Prerequisites for Pediatric cases:

Can you please tell the name and age of the child?
Are you legal guardian of the child?
Do you need any help with your son/daughter/grandson/granddaughter etc?
Instead of PAM HUG FOSS for adults, replace PAM F BIND.
Birth Hx:
o Did you take iron/multivitamins during pregnancy?
o Did you smoke or drink alcohol during pregnancy?
o Was the baby delivered at term?
o Was the delivery normal? What was the mode of delivery?
o Any complications during or after pregnancy?
o Did your child had any problem after delivery?
o When did your child passed first stool?
Immunization:
o What is the immunization status of the baby? Can you please show me?
o If on the phone, please bring you immunization card to the hospital?
Nutrition:
o How do you feed your child? (breast/formula)
o When was solid food added to the diet?
o What is the diet now?
Development Hx:
o When did he/she started smiling?
o When did he/she started to sit?
o When did he/she started to walk?
o When did he speak his first word?
o How many words does he speak now?

58
Fever
MULU GOV
Differential Diagnosis: VO MUL GU

Viral illness, Otitis Media, Meningitis, URI, LRI, Gastroenteritis, UTI.

What do  you  mean  by  “burning  up”?

For how long? Continuous or intermittent? High grade or low grade? What is the reading? Oral or
rectal?
How is the child’s look? (Lethargic, irritated or playful)
Has the child come in contact with anybody with similar complaints?
1. For Viral illness:
a. Have you noticed any rash on the body?
b. Have you noticed any swelling of the body?
2. For Otitis Media:
a. Does he/she pulls the ear?
b. Have you noticed runny nose or redness of eyes?
c. Have you noticed any discharge from ear? If yes, then ABCO
3. For Meningitis/Encephalitis:
a. Have you noticed any stiffness in neck?
b. Did he/she lose consciousness?
c. Have you noticed any shaky movements?
d. Have you noticed bulging of fontanels or soft spots on head?
4. For URI: (day care)
a. Croup: Text
i. Have you noticed any cough?
ii. Have you noticed any sound accompanying? (stridor)
b. Epiglottitis:
i. Have you noticed any difficulty swallowing?
ii. Have you noticed drooling of saliva?
5. For LRI: (Bronchiolitis)
a. Have you noticed any difficulty breathing?
b. Have you noticed fast breathing or abnormal sounds with breathing?
6. For Gastroenteritis:
a. Have you noticed any change in bowel habits?
b. Have you noticed nausea or vomiting?
c. Have you noticed any distension of the belly?
d. Do you have to use more diapers than usual?
7. For UTI:
a. Have you noticed any change in urinary habits?
b. Does the baby cry while urinating?

Exam

1. HEENT
2. CVS Exam.
59
Investigations

1. CBC with differential, S/E (K+)

2. CXR
3. Blood Culture
4. Lumbar puncture & CSF analysis
5. Urinalysis

60
Seizures
Differential Diagnosis: FM TH FMHH

Febrile, Meningitis, Trauma/hemorrhage, Hypo/Hypernatremia.

Please tell me more about that? Describe the event in detail?

What was the child doing before the fit?
Have you noticed any LOC? Tongue biting or frothing? Passed urine or stools without knowledge?
What happened after the episode?
1. For Febrile seizure: (Fever, Family Hx)
a. Do you have a Hx of recent illness?
2. For Meningitis:
a. Have you noticed any stiffness in neck?
b. Did he/she lose consciousness?
c. Have you noticed any shaky movements?
d. Have you noticed bulging of fontanels?
3. For Trauma/hemorrhage:
a. Are there any bleeding tendencies in the family?
4. For Hypo/Hypernatremia:
a. Have you noticed any change in bowel habits?
b. Have you noticed nausea or vomiting?
c. Have you diluted the formula feed?

Exam

1. HEENT
2. CVS Exam.

Investigations

1. CBC with differential, S/E (K+)

2. CXR
3. Lumbar puncture & CSF analysis
4. CT scan brain
5. Urinalysis

61
Diarrhea
Differential Diagnosis: Infection, Malabsorption, Intussception, Overfeeding

1. For Infection:
a. Do you have to use more diapers than usual?
b. Have you noticed any dryness of mouth or tongue?
c. Have you noticed any dryness of skin?
d. Have you noticed sunken eyes?
2. For Malabsorption:
a. Have you noticed any abnormal smell from stools?
3. For Intussception:
a. Have you noticed crying spells or episodes relived by bending?
4. For Overfeeding:
a. How much and how frequently do you feed the child?

Exam

1. HEENT
2. GIT Exam.

Investigations

1. CBC with differential, S/E (K+)

2. Stool examination

62
Cough
Differential Diagnosis: LPC FERA Bai.

Laryngitis, Pertussis, Croup, Foreign Body, Epiglottitis, Retropharyngeal Abscess, Asthma, Bronchiolitis.

Can you please tell me more about it? How will you describe the cough?
1. For Laryngitis:
Text
a. Have you noticed any change in the voice?
2. For Pertussis:
a. Have you noticed runny nose or watering from eyes before the cough appeared?
b. Have you noticed any additional sound along with cough?
c. Did the baby throw up?
3. For Croup:
a. Have you noticed any cough?
b. Have you noticed any sound accompanying? (stridor)
4. For Foreign Body:
a. What was he doing when cough started?
5. For Epiglottitis:
a. Have you noticed any difficulty swallowing?
b. Have you noticed drooling of saliva?
6. For Retropharyngeal Abscess: (High grade fever + No stridor)
a. Have you noticed any drooling of the saliva?
b. Have you noticed any problem moving the neck?
7. For Asthma:
a. Does the baby have any allergies?
b. Have you noticed any relationship to the timings of the day?
8. For Bronchiolitis:
a. Have you noticed any difficulty breathing?
b. Have you noticed fast breathing or abnormal sounds with breathing?

Exam

1. HEENT
2. CVS and Pulmonary Exam.

Investigations

1. CBC with differential, S/E (K+)

2. X-Ray neck
3. CXR
4. Blood Culture

63
Picky Eater
Differential Diagnosis: OHIO ATA.

Organic disorder, Habitual Eating Disorder, Iron Deficiency, Oppositional Defiant disorder, Autism,
HypoThyroidism, Adjustment disorder.

OFD Questions
How is the child growing? Weight gained? Milestones achieved?
1. For Organic disorder:
a. Have you noticed any change in bowel habits?
b. Have you noticed any blood in stools?
c. Have you noticed crying discomfort on passing stools?
2. For Habitual Eating Disorder:
a. Do you follow a set schedule of meals?
b. Does he drink a lot of high calorie drinks?
3. For Iron Deficiency:
a. Have you noticed a change in skin colour?
b. Have you noticed a bleeding from any site?
4. For Oppositional Defiant disorder:
a. How is his behavior towards others?
5. For Autism:
a. Does the child have problems playing with others?
6. For HypoThyroidism: (temp intolerance)
a. Have you noticed a change in bowel habits?
7. For Adjustment disorder:
a. Have you recently moved?
b. Has the child suffered any trauma recently?

Exam

1. HEENT
2. GIT Exam.

Investigations

1. CBC with differential, S/E (K+)

64
Introduction:

Enter SMILING and shoulders up (relaxed)

Good Morning/Afternoon/Evening Mr./Ms./Mizz xxxx (SMILE)!

I’m Dr. XXXX. I’m the physician on duty here today.
Nice to meet you!
Is everything fine in this room? (Yes)
Look into their eyes!

Please be seated. (If patient is standing)

Let me make you slightly more comfortable. (Pull drape, place drape)

May I sit down?

(Do not move chair closer or away from the patient = 1 meter = This is the comfort zone)
(Sit down if it is a general/office patient)
(Stay standing: If it is an emergency case)

Attentive position: Leaning forward 10% with straight head and shoulders up.

Maintain eye contact throughout the encounter. Looking into eyes may disturb you, so look at forehead
(midline just above the nose: patient will think that you are looking into their eyes.)

Facilitate and encourage with sounds (Ah….ha…..yes…..go-on…..I see…ok……excellent…......... oh my

goodness…………..really……….please continue…......... )

Minimize distractions: including writing down notes

Give proper time to SP to explain everything. Do not interrupt.

Tell me, how can I help you?

Oh! I’m really sorry to know about your problem. (Empathy!)

I shall try my level best to help you in this regard.

Other ways to show empathy:

 I can see you have been under a lot of stress.
 How you are feeling about that?
 How has it affected you?
 Oh my goodness!
 This must be putting you under considerable strain

Are there any other concerns that you have?............... anything else?

(If multiple problems, then ask:) As you have a number of concerns, what seems more important to you?

Would you please tell me more about it from the beginning?

What made you decide to get it checked now?

I hope you won’t mind if I write down a few notes while we talk?

History taking:
O P D S F C A A A (All cases)
O P D S F C L I Q R A A A (pain)
O P D S F C A B C O (vomiting, diarrhea, constipation, cough, vaginal discharge)

Onset:
When did it start/when did you first notice?
Was the onset sudden or gradual?

Progression:
How did it progress? Did it get better or did it become worse?

Duration:
How long have you been having this problem?
Setting:
What were you doing when it started?

Frequency:
How frequent/often does it occur?
How many episodes of xxx do you have per day?

Constant v/s intermittent:

Was it consistently there or did it come and go?

Location:
Would you please locate the exact site with your finger?

Intensity:
How would you grade your pain on a scale of 1-10, where 10 represents the most severe pain?

Quality:
How would you describe the pain? Piercing, burning, throbbing, dull or sharp?

Radiation:
Does the pain move/travel 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…..?
Nausea, fever, headache, neck stiffness, limb weakness, numbness or tingling, etc.

Do you remember any factor or event which could be responsible for it?

Amount:
What was the volume or quantity of blood/cough etc? A cupful, a teaspoon, or a tablespoon?

Blood:
Have you noticed any blood in it?

Color:
What color was the vomit/discharge/stool?

Consistency:
How did it appear? Was it watery, fatty or bloody?

Content:
What did it contain?

Odor:
How did it smell – any specific odor?

PAMHUGSFOSSWA

Have you had any similar episodes in the past?

What other medical problems do you have?

Blood pressure, diabetes, stroke, heart attack, etc.

Are you allergic to anything? Any foods, pet, fumes or smoke?

Are you taking any medicine or have you taken any?

Have you ever been hospitalized?

Do you have any urinary problem?

Do you have any problem with bowel movement?

How is your sleep?

The way medicine works; there could be some additional clues in your personal information, which I’d like
to ask. Is this okay with you? (Yes) Thanks!

Does anybody in your family have a similar medical problem?

Are your parents alive?
How did they pass away?
Is there any history of blood pressure, diabetes or cancer in your family?

When did you have your first menstrual period?

Were your menses normal/regular?
When did you have your last menstrual period?
Are you married?
How many kids do you have?
Were they delivered normally?

Now, I’d like to ask something about your lifestyle. Is this okay with you? (Yes) Thanks.
SODA

Do you smoke?
How long have you been smoking?
How many packs per day?

Do you drink alcohol?

What type of alcohol do you drink?
On an average, how many pegs/beer do you drink per day?
How many days per week?
Have you ever thought to cut down on your drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever had a drink first thing in the morning?
Have you ever had guilty feeling about drinking?

Do you take illegal drugs?

How do you take it?
How frequently do you take it?

Avoid leading questions: For example, “…….and you don’t have any fever?” – you need a negative answer
from SP!

What do you do?

Now I’m going to ask a something very personal, please do not feel embarrassed. All the information will
be kept confidential.

Are you sexually active?

How many partners?
What is your sexual preference? Are you active heterosexually or homosexually or both?
Do you use any contraceptives?
Have you ever been diagnosed with a sexually transmitted disease?
Do you know your HIV status?

Have you noticed any change in your weight?

How is your appetite?

Summarize:
To summarize your history, “.............. ”

Is there anything you’d like to tell me or add before I start your physical?
Okay, now I’d like to perform a quick physical examination, is this okay with you? (Yes) Thanks.

Wash hands:
Excuse me for a moment, let me wash my hands.
Always engage the SP in a conversation while washing your hands. Don’t let him/her feel unattended.

PE:

Let me perform a physical examination. May I?

Let me have a quick look at your eyes? (Examine eyes)

P I C K L E: Pallor, icterus, cyanosis, koilonychia, lymphadenopathy and edema

Patient in sitting position over couch:

Examine eyes, oral cavity, neck (thyroid and glands).
Examine thyroid from back also.

Now I need to examine your chest and heart. May I untie your gown?
Simultaneously examine posterior chest. Perform auscultation in all routine cases
“I want to listen to your chest.” Keep diaphragm for about 5 seconds at every area. You may utilize this
time to plan for your next strategy.
Also examine tenderness over CVA region or spine.
Now you may bring the gown down to expose front of chest.
“Now I want to listen to your heart and chest.”
(Auscultate chest as earlier. Auscultate heart with “quick & dirty examination technique” by placing
diaphragm in Lt parasternal location for 10 sec. (Examine heart in 4 locations with Lt decubitus position if
it is relevant to case)
Let me tie your gown.

Patient is still sitting. Now tell him that you are now observing legs for edema, fingers for any signs of
underlying disease and perform the examination simultaneously.

Now let the patient lie down. Help during the process and pull the foot support out.
Now examine neck for JVP, carotid bruit and tell him that you are watching the blood channels in the neck.
Now perform abdominal examination if required in the case.

If abdominal examination is not required move for the other parts of the examination in a sitting position
e.g. neurological examination.
Never forget to offer basic help and courtesy during the examination. For example, help the patient move
in or out of the bed.

Conclude:

“Thanks for your co-operation.” (Now be seated on stool and start counseling.)

On the basis of information I gathered from your history and physical examination, it appears that you are
probably having xxxx. However, there are some other possibilities such as xxxxx. To rule out these
possibilities we need to run a few investigations. This will include some routine blood/urine tests, x-rays,
etc.

Once these results are available, please come back to my office and we will discuss the management.

Counsel:

Being a concerned physician I must advise you to limit the quantity of alcohol you drink and try to quit
tobacco. Do you have any plan to quit?
(Yes) Excellent!
(No) I understand it is very difficult to quit suddenly.
We have a very well developed support program. Please feel free to contact me anytime for specific steps
we can take, I would be very happy to help you in this regard.

I hope you have understood what we have discussed today?

Do you have any other questions or concerns?

I hope I have answered your questions?

Please feel free to contact me any time, if you require any clarification or help.

It was a pleasure meeting with you.

(Shake hands) Have a good day.

Reference:
1. Ferrell, B.G., "Clinical performance assessment using standardized patients: A primer," Fam.
Med., 27, 14-19(1995).

Neurological Examination:

Mental state
CN
Motor system
Sensory system
Reflexes
Coordination and gait
Special tests

Q’s to ask:

Move from head to toe:

Head: HeadacheBlurring of vision Ear: Dizziness, Lightheadedness, Ear discharge, Hearing problem,
Fullness in ear  Mouth:Speech Trauma,Fall

Chest: Chest pain,cough and palpitation

Abdomen: Urination,bowel

Limbs: Gait,Weakness/numbness/tingling

Body: Shaking of body

Mood: How is your mood? How you feel about your life?

Mental state:

Where are you Mr. XXX

What date is today?
Who is president of US?

MMSE:

What’s your name, Where are you, who is president of US, what day is today?

Can you spell word WORLD backwards for me?

Now I’ll pronounce three words, you have to repeat them immediately and later when I ask you to repeat-
Is it okay?

Now I’ll write a command –you have to follow it and perform whatever it says.

What will you do, if you see fire coming out of this dustbin?

MMSE-When running out of time (Five minutes remaining and examination yet not started): Ask the
patient what’s your name, Where are you, who is president of US, what day is today?
Describing various tests:

 MRI is imaging of body parts by a computerized machine using a large magnet.

 CT is imaging of body parts by a computerized machine using X-Rays.

 Ultrasound imaging of body parts by a computerized machine using sound waves which we can
not hear

 Carotid Doppler: Imaging of large blood vessel conveying blood from heart to brain by a
computerized machine using sound waves which we can not hear

 ECG: graphical recording of heart

 EKG Graphical recording of rain function

How to evaluate case of fatigue:

Step-1: Follow the principle of “OPD FC AAA”

Onset Progression  D and F not applicable  Consistent/Any specific time or situation  any factor or
event responsible?  Associated problems? (Nausea, vomiting/Fever, chills & night sweat)  Aggravating
 Alleviating

Step-2: Follow Head to toe history like Neuro case in a modified manner

Headache/Lightheadedness  Loss of consciousness Neck (or other parts) glands  Chest pain or
cough  Pain any where in tummy  Problem with urination

Step-3: Ask hypothyroid history

ABCD HV
Appetite  Bowel  Cold intolerance  Depression (how is your mood)  Hair fall  Voice

Step-4: Ask about depression questions FACE SLIPS

Do you feel any guilt?

How is your memory and concentration?
How is your energy level?
Do you find any difficulty falling/staying asleep or waking up?
How is your libido?
How is your life? How do you performing in your job?
Do you have any thought to hurting yourself or ending your life? Any plan?

Do you snore?
Do you hear or see anything which others can’t?
Do you hold any idea that others want to control you or harm you?

Step-5: Ask about probable CA’s/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?
(Chest symptoms already asked)
Have you ever noticed yellowness of skin, dark urine or clay colored stools?

Step-6: PAMHUGSFOSS W A-already done with hypothyroid

Evaluation of OA:

Follow OPDFC  Then DPS W: Deformity, Pain (LIQRAAA, bilateral? worse on which side, during
night/resting state), S = Stiffness (When mostly felt?) and sound (any cracking sound? During
movement), weakness of muscles around knee

 How long have you been having the osteoarthritis?

 How is it progressing?
 Do you consistently feel pain?
 Is there anything which makes the pain better or worse?
 Is it on both sides? Which side is worse?
 Do you know any specific situation where you feel more pain?
 Do you feel pain during sleep or resting state?(S/o advanced stage)
 Have you noticed any stiffness? When it is seen most of the time?
 Have you noticed any cracking sound during movement?
 Have you noticed any muscular weakness around knee?
 What treatment are you taking for it?
 Did you have any injury of knees anytime?
 Describe your usual activities and exercise routine?
 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, as well as keep joints moving. Other positive effects include
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
Chest pain with Sickle cell anemia:

In addition of routine Q’s about chest pain add:

1. Factors that precipitate sickle cell crisis like dehyadration,diarrhea,fever etc
2. H/o hematuria
3. H/o blood transfusion
4. H/o Blood clot formation (Personal and family)
5. Examination: do not put stethoscope over area of tenderness, examine fingers and calf
6. Counseling:
 Avoid hypoxemia,dehyadration
 Drinking at least 8 glasses of water every day, especially in warm weather
 Exercising regularly, but not to the point that you become very tired
 Limiting the amount of alcohol you drink.
 Quitting smoking.
 Contact your doctor if you have any signs of an infection, such as a fever or trouble
breathing.
 Flu shot every year.

Musculoskeletal Case: Knee pain/Acute arthritis

CITRUS HPT

Chest problem/Cough/Pain
Insect/Tick Bite
Travel/Trauma
Rash
Ulcers in mouth
Stiffness

Hair loss
Photosensitivity
Temperature: Cold reaction? Abnormal reaction /fingers?

Fever:

In any case of fever always ask about coexisting night sweats and chills, recent ill-contacts and
exposure to anybody with TB?

In a pediatric –phone case of fever we may use “CITRUS” in modified way:

Chest problem/Cough/Pain
Insect/Tick Bite/Exposure to Infection
Travel
Rash
Ulcers in mouth
Stiffness in any limb? (Septic arthritis?)
Challenging questions & situations:

 Will I pass it to my students? (A teacher with diarrhea)

Some of the diarrheas may be transmitted to the other people through contamination of water
and food. We are not aware of the type of diarrhea you are having and in order to know about it,
I need to run a few investigations. Though being a teacher you might not be handling food and
water but to minimize the risk I'll suggest you to maintain toilet hygiene and frequently wash
your hands.

 Crying! (Keep silence for a moment and offer him a tissue. Show empathy on your face. Gently
touch his shoulder.)”I understand you feel sad. Would you please tell me more about it.”

Pediatric Patient: General Questions to ask:

Begin with birth history:

Alcohol,Smoking or drugs during preg  Complication during pregnancyRoutine checkupsUSG during

preg

Complication during delivery Term? CS or normal?

Complication after delivery  Any infection after birth First bowel

Milestones:
First smile, first sit-up, talking, walking, dressing up, tying shoe, short sentences, followed two step
commands

Breast fed /Diet? Describe typical diet?(What are his eating habits? Can you describe his typical diet?)Solid
food,fortified with iron,Multivitamin Immunization,Appetite

Followed by:

 Does he have any symptom like fever, cough, or diarrhea? (Then ask more about symptom)
 ON CALL IDIOT : (More appropriate for diarrhea/vomiting)
Onset,Number,Cry,Consistency of stool/Cough, Associated
symptoms,Listlessness,Liquids(Urine),Immunization, Diet/Dehydration/Day care, Infection in
family,ORS,Travel

 Does he have appetite for non-nutritive substances (e.g., coal, soil, feces, chalk, paper etc?

 When did he visit physician last time?

 How was the child’s weight gain and growth?

 How is toilet training going?

 Is he a physically active child?

 Is the child safe at home?

 Do you use child proof equipment?
 Do you use child seat in the car when you travel with the child?

DDX Temper Tantrum v/s ADHD:

 Is the child distractible?
 Does he have difficulty with concentration and focus?
 How is his memory?
 Does he have any problems organizing ideas and belongings?
 Does he show any impulsivity?
 Does he have weak planning and execution?

DDX Child not eating well? R/o infective process,lead poisoning,iron def anemia
Picky Eater

Picky eater telephone case (with constipation)

History taking:

Good Morning, Mrs. Smith. I’m Dr. Xxx; I am an attending physician here at the medical center. How can I
help you today? (My son is a picky eater; I am wonder if you could give me some advice on what I should
do about it?).

Ok, Mrs. Smith, I’d like to ask a few questions about your son.
How old is your son? (He is 4 years old)

Why do you think that he is a “picky eater” - does he have any specific preferences for the food?(OK, for
example, he only eats some potato chips, candies and drinks fruit He doesn’t like to eat regular meal.)

Does he constantly behave like that?

How long has he been having this problem?

How is it progressing -getting worse or getter better?

Have you ever punished, bribed or rewarded your son to alter his eating behavior?

Does he often drink high calorie drinks like juice, soda or milk?

Do you follow a set schedule of meals?

Do you often offer desserts along with routine meals?

Does he watch TV before mealtime? (Yes, he watches TV sometimes)

Does he have any pain in his belly? (No, he didn’t mention it)

Does he have any problems with his bowel movement? (He has constipation)

How many times a week does he have bowel movements? (2-3 times a week) Constipation =
<3 stools per week(problem > 2months =Chronic)

How are the stools? (Are stools hard, dry and unusually large?)

What is the caliber of stool?

Are stools difficult to pass or painful to pass?

What color of the stool is?

Have you noticed any blood in the stools? Was it fresh blood or blood admixed with stools?

Have you ever noticed bright red blood on the toilet tissue after your child has a bowel
movement?

When did your child sit on the toilet?

How long does your child sit on the toilet?

Does he avoid the toilet because of his activities or play?

Does he resist toilet training?

Does he have any Stomach pain and bloating?

(Now ask about associated symptom)

Does he have any headaches? a fever? Cough? Short of breath? Diarrhea? (No)
(Now ask about PAM HUGS FOSS question)

Did he ever have similar episodes in the past? (No)

Has he ever been diagnosed with any medical illness before? (No)

Does he have any allergies? (No)

Is he taking any medications? (No)

Has he ever been hospitalized? (No)

Does he have any problems with his urination? (No)

Does he have any problem with sleeping?

How many children do you have? (He is the only one)

How much time do parents spend time with him? (A few hours a day, because both of us work)

Who takes care of your child when you are working? (He goes to day care center)

What kind of house do you live? (Very old one)

Then ask Milestones questions (I use IDIOT mnemonic)

Are his immunizations up to date? (Yes)

When was his last well-child check-up? (Six months ago, everything is fine at that time?)

Did he have any infections before? (No)

Did you have any problems with your delivery? (No, everything was fine)

Has your family moved recently? (Yes, we just moved here six months ago)

Sample Closure:

“Mrs. Smith, according to the information you provided me, I feel that your son is probably going through
a normal phase of growth. It is a common isolated problem in this age group. Fortunately it responds well
to a few behavioral changes. First of all, I’d suggest you to strictly follow a set schedule and offer him a
variety of foods at the meal time. Discourage high calorie drinks in between the meals. The children are
often moody and they need to offer the same food multiple times before they accept it. The next
important thing is the environment at mealtime. It should be conducive and pleasant enough without any
distractions. Any argument or watching television should be avoided at the same time. Regarding the
constipation, I’d suggest you to provide him high fiber diet like cereals, vegetables etc. You may
encourage your child to follow a planned time to sit on toilet by rewarding him. But do not to use food as a
reward. However, I’d also require examining him personally and ordering some tests on him to rule out
some other possible causes of constipation and behavioral disorders, before I make any definitive
diagnosis or give final advices. Does this sound good to you? 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.”

Differential Diagnosis
1. Low fiber diet
2. Lead poisoning
3. Hypothyroidism
4. Oppositional Defiant Disorder
5. Attention deficit Hyperactivity Disorder

Diagnostic Workup
1. CBC
2. TSH,T3,T4
3. Serum lead level
4. Stool ova and parasitology
5. Serum calcium
Stridor:

When did it start?

What was he doing when it started? (Eating peanuts or playing with toys?)

Was it sudden in onset or presented in a gradual manner?

(Acute: Foreign body aspiration, infections such as croup and epiglottitis/Chronic: Laryngomalacia)

How is it progressing now-Getting worse or constant?

Is the sound consistently there or does it come and go?

Do you know anything which may have caused it?

Do you know any thing which makes it worse or better?

Like feeding, crying, supine position, sleep?

When it is best heard-While inhaling air or while exhaling?

How you will grade its severity?

Is he able to breath, cough and talk? (Choking?)

Did you intervene in any manner or tried any treatment?

Does he have any associated problems? Like cough or fever?

Tell me more about cough-Is it barking in nature? Is it productive? Have you seen any blood in cough?

Is he crying? How is he crying? Muffled or weak?

Have you noticed any drooling?

Have you noticed any blueness of skin?

Does he have any difficulty in swallowing food?

Did he have similar episode in the past?

Have you noticed any hoarseness of voice?

Does he snore at night? (Chronic case)

Is there any history of intubation into airway or any other complication at the time or after the delivery?

Is there any history of allergies in the family (Atopy-angioedema?)

Has he suffered any psychological or social stress in the recent past?

How is his growth & development on the whole?

Does he have any pain in his belly? (No, he didn’t mention it)

Does he have any problems with his bowel movement? (He has constipation)

Did he ever have similar episodes in the past? (No)

Has he ever been diagnosed with any medical illness before? (No)

Does he have any allergies? (No)

Is he taking any medications? (No)

Has he ever been hospitalized? (No)

Does he have any problems with his urination? (No)

Does he have any problem with sleeping?

Then ask Milestones questions (I use IDIOT mnemonic)

Are his immunizations up to date? (Yes)

When was his last well-child check-up? (Six months ago, everything is fine at that time?)

Did he have any infections before? (No)

Sample Closure

Mrs. Wheaton, according the information I gathered from you, I’m considering a possibility of foreign body
aspiration in this case. However, possibility of some infection causing the same problem might not be
ruled out. I feel that she needs an emergency medical attention. As you told me that you are not having
any transportation, I’d suggest you to immediately Call 911 and bring him to the medical center.
Meanwhile I’ll suggest you that please do not put finger in his mouth or perform any blind finger sweep
because the foreign body may become more deeply lodged, if it is actually present. In case, if you observe
a significant respiratory compromise or choking please perform a Heimlich maneuver by thrusting tummy
with sudden pressure. 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.”

Differential Diagnosis
1. Foreign body aspiration
2. Croup
3. Epiglottitis
4. Laryngitis
5. Retropharyngeal abscess
6. Angioedema

Diagnostic Workup
1. Arterial Blood Gases
2. CBC
3. X-ray Neck AP and lateral
4. CxR PA in expiration
Newly diagnosed case of Diabetes in a child:

When did it diagnose?

How was it diagnosed?

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)

Is he compliant with the Insulin or taking it regularly?

Is there any side effect of Insulin?

When did you measure his blood glucose last time? What was the level?

Are you measuring blood glucose regularly at your home?

How it has affected the family and child?

Does he have any abnormal thirst or extreme hunger?

Does he feel any weakness or fatigue? Or Depressed?

Is he irritable?

Does he have any problem with vision like blurring of vision?

Has he lost some weight in recent past?

Does he have any tingling or numbness in limbs?

Does he have frequent infections of skin or gums? Or itchy skin?

Have you noticed any skin lesion?

What is his weight and height?

Is he following any specific diet? Would you pls tell me more about his diet schedule?

Does he play? How many hours? At what time? What does he play?

PAMHUGSF

How is his growth & development on the whole?

Does he have any pain in his belly? (No, he didn’t mention it)

Does he have any problems with his bowel movement? (He has constipation)

Has he ever been diagnosed with any medical illness before? (No)

Does he have any allergies? (No)

Is he taking any medications? (No)

Has he ever been hospitalized? (No)

Does he have any problems with his urination? (No)

Does he have any problem with sleeping?

Then ask Milestones questions (I use IDIOT mnemonic)

Are his immunizations up to date? (Yes)

When did he visit his physician last time?

Did he have any infections before? (No)

Did you have any problems with your delivery? (No, everything was fine)

Does anybody in family have similar problem?

Sample Closure:

“Mrs. Davidson, I can understand the way you are feeling after your daughter diagnosis of diabetes .
Diabetes may alter the dynamics of the entire family and affects everyone. Your life is going to be a little
different now but believe me we can mange this disease very well through combination of insulin
,balanced diet and regular exercise First of all, you should understand the disease and know how to
manage it? You will need to attend diabetes classes with your daughter.. Secondly; everyone including the
patient herself should be able to recognize signs of low glucose levels like confusion, disorientation or
fainting and should be in position to provide appropriate help. She should always carry glucose tables or
juices as an “emergency kit” . Her teachers and friends should also be aware of her disease. Hope you
understood whatever we discussed today? Do you have any concern or question?”

Differential Diagnosis
1. Type-1 Diabetes Mellitus
2. Type-2 Diabetes Mellitus
3. Secondary Diabetes
4 Dysmetabolic Syndrome-X
5. Maturity-onset diabetes of youth
6. Prader-Willi syndrome

Diagnostic Workup
1. Fasting glucose
2. Serum electrolytes
3. UA for glucose, ketones, and protein
4. Hb A1c
5. Insulin and C-Peptide levels
6. Islet cell antibodies
Child with Jaundice:
When did you first notice?
(Jaundice within 24 hrs or Color geting deeper after 7 days old or Jaundice is not gone after 14 days of
age or Jaundice began or reappeared after 7 days of age require attention)

Are the skin as well as white of eyes both yellow?

Does the Skin appear deep yellow or orange?

Severity according to body part involved?

Vomiting?
Distension abdomen?

How old is your child? (First 24 hrs after birth: Pathological? ABO/Rh)

How is it progressing now-Getting worse?

What’s your blood group?

Do you know the blood groups of your husband?

Have you been pregnant before or aborted earlier?

When did you start breast feeding the child? Is he bottle fed?

Are you adequately breast-feeding him?

Is he sucking well?

Did he pass any stool? What color was stool?

Is he passing urine regularly? How many diapers per day? (< 6/day needs evaluation)

Has he passed urine in last 8 hours (Not =Dehydrated)

What color is urine?

Is your child awake and responsive?

Is he playful, crying and moving well? Or he is lethargic and listless?

Is there any sign of dehydration like very dry mouth, sunken soft spot?

Does he have any fever or low temperature? Did you measure it?

Fever? Cough, pulling ear, runny nose, distended abd, cry when urine is passed?

PAMHUGSF

How is his growth & development on the whole?

Does he have any pain in his belly? (No, he didn’t mention it)

Does he have any problems with his bowel movement? (He has constipation)

Has he ever been diagnosed with any medical illness before? (No)

Does he have any allergies? (No)

Is he taking any medications? (No)

Has he ever been hospitalized? (No)

Does he have any problems with his urination? (No)

Does he have any problem with sleeping?

Then ask Milestones questions (I use IDIOT mnemonic)

Are his immunizations up to date? (Yes)

When did he visit his physician last time?

Did he have any infections before? (No)

Did you have any problems with your delivery? (No, everything was fine)

Does anybody in family have similar problem?

Sample Closure

“Mrs. Whitestone, as per the information provided by you, I’m considering a possibility of physiological or
natural jaundice. It usually peaks on day 4 or 5 and then gradually disappears over 1-2 weeks. However,
there are certain other possibilities like jaundice because of breast feeding or some other pathological
conditions or birth defects. I’d suggest you to bring the child to the medical center for further evaluation.
Meanwhile I’ll suggest you to feed your baby every 1- 2 hours during the day and don’t let him sleep more
than 4 hours at night without a feeding. As your child is having less than 3 stools/day, you need to
facilitate passage of stools simply by carefully inserting tip of a lubricated thermometer into his anus and
slowly moving it from side to side. Improved stool frequency may also lower the pigment levels in the
body by excreting it into the [Link] you understood whatever we discussed today. Do you have any
concern or question?”

Differential Diagnosis
1. Physiological Jaundice
2. ABO or Rh incompatibility
3. Neonatal Sepsis
4. Cephalohematoma
5. Breast feeding jaundice
6. Polycythemia

Diagnostic Workup
1. Total and indirect bilirubin
2. Blood Typing
3. Direct Coomb’s Test
4. C reactive protein
5. CBC
6. Titers for CMV, toxoplasmosis and rubella (If required)
HALLUCINATIONS

Would you please tell me more about it? What exactly happened?

Was it sudden in onset? (acute:Delirium)

How long have you been having this problem?

Other false perceptions like smell, taste, voices, visual, tactile (Bugs crawling on body).Did you hear a
voice? or see something? Or sensation of feeling something or being touched?

When did hallucinations first appear?

How frequent does it occur?

How long did you experience the same?

What were you doing when it was experienced?

Was this first episode? Or did you have similar episode in the past?

Do you know what could be responsible for it?

Was there a known precipitating factor to the symptoms?

At what time of the day are the symptoms worse?

Do you have any fever? Any vomiting?

Is it interfering in daily activities and job?

How is your sleep? Do you find any difficulty falling asleep or staying asleep?

Is your sleep and wake pattern normal?

Is there any relation with sleep like experiencing while falling asleep or waking up?

How is your memory and concentration?

Do you feel depressed?

Do you feel restless and agitated?

Do you have any idea of hurting yourself or others?

Is there any elated feeling of well being?

Are you taking any illegal drugs or have you ever taken the same?

If yes: How long have you been taking this? How frequent? Have you ever taken IV drugs also? Do you
know your HIV status?

Do you have any palpitations?

Do you have risk factor for developing stroke like high blood pressure, high cholesterol, diabetes,
smoking, family history.

Do you hold any idea that other people want to control you or want to harm you?

Are you suffering from any stress in your personal or professional life?

Is there any traumatic event in the past?

Do you have any problem with law? Have you ever been convicted due to any reason?

How is your relationship with your family members?

Do you have any disability like problem in hearing or vision?

Do you have any headache or history of migraine?

Do you have any problem with speech?

Have you ever been diagnosed with mental illnesses?

Do you have any severe medical illness? like including liver failure, kidney failure etc

History of fall/trauma or LOC chest problem pain in belly  Urinary problem Weakness in limbs
H/o any shaking of body

PAMHUGSFOSS

PE:
1. MMSE
2. Hearing and vision examination
3. Quick neurological examination
4. Neck stiffness
5. CV+ Chest auscultation
Counseling:
 Need to interview close friends and relatives
W/U:
1. CBC
2. BMP
3. Urine toxicology and serum alcohol levels
4. TSH
5. CT/MRI
6. EEG
Stress Incontinence:

When did you first notice?

How is it progressing?

How frequent does it occur in a day?

Is it consistently present or is it transient and intermittent?

When do you feel this incontinence? Is there any specific time or situation?

Is there any thing which makes it worse or better?

What are the factors which precipitate the event? Like coughing, sneezing or heavy lifting, laugh, or
exercise.

Do you leak every time you cough, sneeze, laugh or exercise?

Do you wear absorbent pads?

Does it occur during sexual activity?

How it has affected your activities of daily living and general well being?

How it has affected your interpersonal relationship?

How much liquid or water do you drink every day?

How many times do you urinate every day? (Bothersome urination eight or more times a day or two or
more times at night = overactive bladder)

Did you ever notice a sudden and strong need to urinate immediately?

Have you noticed leakage or gushing of urine that follows a sudden, strong urge?

Did you notice it during the sleep? (Urge incontinence?)

Do you have frequent urinary tract infections? Did you notice increased frequency, burning sensation in
urine or painful urination?

Do you smoke? Do you have any breathing problem or chronic cough?

Do you have diabetes?

Do you consume excessive caffeine or alcohol?

Do you play any sports like running or tennis?

Did you have any surgeries like prostatic surgery? Or do you have kids? How many? Were they delivered
normally? Was it a forceps delivery?

What’s your height and weight? (BMI = Obesity?)

PAMHUGSFOSS

PE:

Abdomen and genitals

A neurological exam to identify sensory problems
Auscultate chest and heart
PICKLE
Sample Closure:

“Mrs. Andrews, according the information I gathered from you, I’m considering a possibility of stress
incontinence. In this condition the valve mechanism controlling the outlet of your urinary bag becomes
weak and an increase of pressure on the bladder may lead to leaking. It is basically a problem with
muscles and nerves that help to hold or release urine. However, there are certain other causes like
infection in urinary bag or neurologic illnesses which may also lead to similar problem. In order to know
more about the problem I need to run a few investigations like routine urine examination and assessment
of the quantity of urine retained after voiding. Once the results of these investigations are available we will
go over the things in detail and I will tell you more about management and treatment options in detail.
Meanwhile I will suggest you to follow a few measures to relieve your symptoms or lessen the frequency
of episodes. Please restrict the amount of fluid and strictly avoid caffeinated and alcoholic beverages.
Frequently pass urine and wear absorbent pads to avoid embarrassing incidents.

Differential Diagnosis
1. Stress incontinence
2. Urge incontinence
3. Functional incontinence
4. Overflow incontinence
5. Mixed incontinence
Diagnostic Workup
1. UA
2. US abdomen with Post Void residue
3. Urodynamic Study
4. Cystoscopy
Some common trade names of medications used by SP’s:

Advil: Ibuprofen

Allegra: Fexofenadine

Augmentin: Amoxicillin + Clavulanic acid

Lopressor : Metaprolol

Mylanta: Antacid

Maalox: Antacid

Nexium: Esmoprazole

Peptobismol:Antidiarrheal

Prilosec : Omeprazole

Synthroid: Levothyroxine

Tylenol: Acetominophen

Zyban: Bupripion

Commonly asked and very important cases:

All given in first aid-so don’t waste your time in asking cases at xxxx center at various forums.