CS Clinical Encounter.

(Typical Sheet)
History Taking.
Greeting:
( Knock the door 3 times, then partially open the door )--- you knock on the door
before entering to let the patient know you are entering - and not to ask for
permission
1. HELLO, Mr /Ms Last name? Did I say your name right?(If its a complicated name)
2. My name is Dr.. ,I am the Physician in the office today, (While Shaking Hands If
Appropriate) Its NICE TO MEET YOU.(If the pt. is angry ,in discomfort, distress or
severe pain-Dont do Hand shaking
3. Im here to do a physical exam and ask you some questions, is it ok?
First, let me cover you to make you more comfortable(Better) OR

Are you comfortable in this room ?May I put this drape on your lap-Thank You
(Drape the patient: must be before the examination but do it now better)

4. Do you mind if I( sit down and) write some notes while we talk? Thank you.(Optional
as in real life you are taking notes without permission)) (NOT SAID IN EMERGENCY
ENCOUNTERS)
5. , "So Mr. Last Name, How can I help you today?" OR
What medical problem that brought you here?
6. Show Sympathy After The Chief Complaint {Oh, I am very sorry to hear (that/about
your situation/about what you are experiencing),
OR

I assure you that I will do my best to help you (today/In this Regard) , Okay?
Im gonna do everything I can to {help you feel better today/ resolve this issue}
7. Could you please tell me more about your PROBLEM?(1st open ended Q)
Dont cross your arms in front of your chest when talking to the patient, especially with the clipboard in your hands. Its best to sit down on the stool, relax,
and keep the clipboard on your lap. If you decide to stand, maintain a
distance of approximately two feet between yourself and the patient.

To justify your silence say: Im just taking some notes to keep tracking of what we are
talking about so we can help resolving this problem

For All Cases : OCCCPDF + AAA

For Pain/Headache: LIQR+ OCCCPDF + AAA
For (Any Fluid Coming From The Body:e.g Vomiting-Diarrhea-Cough(with Phlegm)-Vaginal
discharge-Blood)+Constipations , (OCCCPDF+ABCO)
ABCO stands For (Amount-Blood-Color-Consistency Odour )
Amount:
How much is the phlegm/blood/vomit? Was it
A teaspoon=5cc? A tablespoon=15cc? A cupful=240cc?
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?
Odour:
How did it smell? Any Specific Odour?
(Any PAIN)
Location: Can you show me exactly where it hurts? /Can you point to the pain?
Intensity: On a scale from one to ten being ten is the worst, how do you rate your pain?
Oh that sounds very painful I am sorry for that, I will do my best to make you feel better.
Quality: How would you describe your pain? How does it feel like?-(If pt doesnt answer)
clarify more by these: Is it burning, throbbing, stabbing, stitching, cramping, dull aching?)
*Onset:

When did it start? Or For how long you have had this?

*Context=Description: What were you doing when it started? Or anything in particular

happened before this started?
*Course: Was it sudden or happened over time?
*Progression: Is it getting better or getting worse?
Constant Or Intermittent: Does it come and go or it is constant?...If said intermittent,ask
*Duration: When you have the pain, how long does it last?
*Frequency: How often do you have the pain? Or How frequent does this occur?
Radiation: Does the pain Move/ Do you feel it (pain or any symptom) anywhere else?
Aggravating Factors: What makes your pain worse? Or What brings the pain on?
Alleviating Factors: Anything in particular makes it better?
Common factors {specific position-rest or exertion-time of the day-medication-meals-period}
Impact on the patientImp to ask
Does this (Pain-Fatigue-etc) interfere with your sleep?
How does this (pain) affect your daily activities or your job?
Associated Symptoms Divided Into two parts:
1- System Related Qs.(e.g. Joint Pain Ask About musculoskeletal system history )
2- DD Based Qs(Fever-Chills-Night sweats/Headache/Throwing Up/Tingling ,etc)
e.g. *Associated symptoms for cough (General + URTI+ LRTI symptoms )

For Any Pain (Always ask about the sympathetic response: Sweating-Nausea-Vomiting)
Review Of Systems(ROS): (Main + General + DD) not more than this in any history
1. General(Constitutional)
Have you had any recent infection? Any fever? Any night sweat?
Do you feel tired?
Endocrinal Questions:
*Do you (feel uncomfortable)(have any discomfort) in hot temperature/in cold temperature?
*Have you noticed any changes with your skin? With your hair? With your voice?
Sleep: How is your sleep? Then How many hours? Do you have any trouble (Falling/Staying)
asleep? /Do you wake up(throughout the night/Early in the morning) Do you(snore/take naps)
2. HEENT {URI (runny nose, sore throat, cough)}
Head:
Have you had any headaches? Have you had any sinus infection? any light-headedness? Have you
had any trauma to your head?
Eyes: Have you noticed any changes in your vision? If yes, do you see flashes of light?
Nose: Do you ever have any nosebleeds? Do you have runny nose?
Ears: How is your hearing? Do you feel that the room is spinning around you? Do you hear any
ringing in your ears? Do you feel any (pressure /pain) in your ears? Do you have discharge from
them? Did you put anything in them? Have you been exposed to loud voices?
Throat: Have you had any sore throat? Have you experienced any difficulty swallowing?
3. Neck
Have you ever noticed any (lumps/swellings) in your neck? Any neck stiffness?
4. Cardiovascular
Do you feel your heart is beating fast? Was your heart racing?
Do you have any chest pain? If so, analyze + do you have it at rest or with activity? Do you
have it when you are breathing in?
Do you have difficulty walking up the stairs?
5. Respiratory(Do you have any difficulty breathing?)
Are you ever short of breath (SOB)? If so, when, by day or by night?
Do you have noisy breathing=wheezes?
Do you have a cough? If so, is it dry or anything comes out? Have you coughed blood before?
6. Gastrointestinal(Have you had any changes with your bowel movements lately?)
Do you have diarrhea? And Are you constipated? and for how long? (If No-Ask the rest)
Do you feel nauseated? Did you throw up?
Do you feel any pain in your belly? /Have you had any (blood, mucous) in your stool?
Do you have pain with defecation? Do you have the urge to pass stool and you dont do it?
Appetite: How is your appetite?
Diet
: Are you (following/on) a special diet?
Weight: Have you had any recent weight loss or weight gain? How many pounds?
Over (what period of time?/How long of period) Was it Intentional?
8. Urinary(Have you noticed any changes with your urination?) If No---No more Qs
(Irritative symptoms: Dysuria, frequency, nocturia, urgency)
Do you have any burning sensation with urination? Have you noticed any blood in your urine?
Did you notice any increased frequency of urination? How many times do you get up by night

Do you ever feel that you must pass urine immediately & rush to the bathroom?
(Obstructive symptoms: Poor stream-terminal dribbling- Hesitancy -stranguary)
Have you noticed any reduced force of your urinary stream? Any dribbling of urine? (Male Q)
Do you ever have any difficulty in starting urination (hesitancy)?
Do you need to strain/push during urination?(Stranguary)
Have you ever lost control of your bladder? (Incontinence/Both Males& females)
9. Musculoskeletal (Do you have any other painful joints or bony pains or aches?)
Does your (Knee-wrist-fingers) feel stiff in the morning/in the evening?
Is there any redness on your Joint? Is it swollen?
Is it warm to the touch?
Do you hear any crackling sounds when you move it?
Have you been hiking recently?
10. Hematologic
Have you had a rash recently? If yes, can you describe it to me?
Do you bruise easily?
Have you ever had a blood transfusion for any reason?
11. NeuorologicalWeakness-Walking/Seizures-Speech
Are you having any difficulty (walking=with your balance)? Any difficulty with your speech?
Do you feel weakness anywhere? Any numbness?
Do you have difficult time getting up from the chair? (Proximal weakness)
Did you have any shaking movements? If Yes --Did you bite your tongue?
Do you ever feel dizzy? Do you fall easily? If yes, did you injure your head? Any LOC
12. Psychiatry:
How about your mood? Do you know why do you feel this way?
Followed by Depression Questions +/- Psychosis Questions.(mainly hallucination/suicide)
======================================================
Past History: (PAM HS FOSS):Transition statement *Okay Mr. / Ms. Last name, now I
would like to ask you few questions regarding your health in general, is that okay with you?
1- Previous episodes or Past Medical diseases:
1-Have you ever had this before? Followed By
2-Do you have any other medical diseases/problems? (pause as its open ended Qs) then
say Like High Blood pressure, blood sugar, cholesterol?
2- Allergy: Are you allergic to any medications? To any food, to anything else?
3- Medications: Are you currently taking any prescribed medication? How about over the
counter medications? How often do you take them? /Do you take birth control pills?
4- Hospitalization: Have you ever been hospitalized? What for?
5- Surgery: Have you done any surgeries before?
6- Family History: (Transition) Okay Mr. /Ms Last name, now I would like to ask about
your family health, is that okay with you?
1- Are your parents alive and well?
*NO--Sorry for (that/your loss),
*If diseased: hope s/he gets well soon.
Do you know the cause of his/her/their death? OR It must be very struggling for her/you.

2-Does anyone in your family have similar symptoms?

3-Do you have a Family history of cancer, mental illness or any medical disease? (Optional= if
relevant)
OB/GYN History:Okay Ms Last name, now I would like to ask you few questions regarding
women health, Is that okay?
(Non Ob/Gyn Case)
(Ob/Gyn Case)
Female in Child bearing
Period: Menarche/ LMP/ Length/Description/ Clots(=heavy) /
period
No. of Pads/Pain during menses/Cramps
*When was your LMP?
Cycle: Regularity/Break through bleeding/
*Are your Cycles Regular?
Bleeding: Context/ Duration / Amount =No. of pads/ Clots
Discharge: Analyze it(ABCO) / Itching
*Have you had PAP Smear
before? when was last one? Intercourse Do you have any pain during it? Any bleeding
during or after it? , How soon did you bleed?
was it normal?
Urinary System: Do you have any problems with urination ?
Female in menopause:
*Any vaginal bleeding
Obstetric History
*Any discharge/Itching
*Have you ever been pregnant? How many times?
* Have you ever had any
*Have you ever had any miscarriages? How many times? Do you
abnormal PaP smear?
remember in What trimester?
* Any hot flashes.
*How many children do you have?
* Any mood swings.
*Have you ever had any complications with your pregnancy?
Sexual History: (Transition):Note That Not All Questions Will Be Asked.
Okay Mr/Ms Last name, now I would like to ask you few questions regarding your Personal
Life, be sure that whatever you tell me will be kept confidential, Is that okay with you?
1- Are you sexually active? If Yes With whom?(If said with my wifeno more Qs)
If anything else ask for how long you have been with her/him?
If said for less than one year Then Ask
2- Do you use any kind of protection? Do you use it regularly?
3- Have you had any other sexual partners during the last year? men or women
4- Have you ever had any sexually transmitted disease? (A must)
Have you ever been tested for HIV?(For Multiple sexual partners/symptom
related disease)
Social History : {TIA WT ELSS}
1-Tobacco: Have you ever used any tobacco products? (As s/he may quit yesterday)
How many packs a day? For how long have you been smoking?
Have you tried to quit?
2- Illicit drugs: Have you ever tried any recreational drugs? What is the drug?
How do you take it? And when was the last dose?
3-Alcohol: Do you drink any alcoholic beverages? What type?
How much do you drink ?(Ask it even if s/he said occasionally)
(If a man consumes > 2 drinks/day or a woman > 1 drink/day ) ask then
(Alcohol related case)
Have you ever tried to Cut down on drinking?
Do you feel Annoyed by other people comments about your drinking behavior?
Do you ever feel Guilt about drinking?
Have you ever had to drink alcohol in the Early morning?(1st Q to be asked

if +ve: Dont ask all the Questions / If ve :Ask the rest of the Questions.
If s/he said no to all so, s/he is NOT alcoholic, SO maybe drink occasionally
4-Work: what do you do for living?
5-Travel: Have you traveled outside the Country recently? When and Where?
Have you gone camping lately? Do you know if you got bitten by an insect?
5-Exercise : Do you exercise regularly? (In general checkup-DM-HTN-In F/U6-Living: Whom do you live with?-Are you safe at home?
Can you tell me about your living conditions?(esp in abuse or elderly)
6-Stress : Are you under any kind of stress ?
7- Support System: Do you have any support system around you when you are upset?
======================================================

HITSORY PEARLS
1 - Ask about thyroid symptoms in:, depression, amenorrhea, weight changes
2 - Abdominal pain: Ask about black or tarry stools / Ask about relation of the pain with food intake.
3 - Abuse: Ask about emergency plan, if family and/or friends know about what's going on /support
system
4 - Bruise, depression: Ask about abuse
5 - Chronic cough: Ask about HIV, TB, ACE inhibitors use
6- Any Cough: Must ask about Travel/TB/Pets
7 - CNS case: Ask about previous stroke, migraine, seizures, syphilis
8 - Dizziness: Ask about tendency to fall towards left or right /ear symptoms/neuro& cardiac
symptoms
9 - Depression: Ask about guns and pills at home, auditory hallucinations
10 - Forgetfulness: Ask about ADLs, IADLs, social support, head trauma, depression, syphilis
11 - Jaundice: Ask about urine and stools color- weight changes
12 - Hearing loss: Ask about exposure to loud noises
13 - If you have to say "I don't know", say "I don't know yet!" / DO NOT SAY trauma...say
accident
14 - Insomnia: Ask if the problem is falling asleep, staying asleep or waking from sleep; frequent
movements of legs, hot flashes; order sleep diary for 2 weeks
15 - Menopause: Ask about mood swings, Fx of breast and uterine cancer; counsel about weight
bearing exercises.
16 - Palpitations, insomnia: Ask about caffeine intake
18 - Rash: Ask about sun exposure, ticks, mosquitoes bites ,allergic reactions, joint pain, recent travel
or camping
19 - Pain in hand: Ask about repetitive movements, job, such as operating a keyboard
20 - Obesity: Ask about joint pain, hypercholesterolemia, BP
21 - SOB: Ask about wheezing, on lying flat, how many pillows, PND
22 - Swelling: Ask about diurnal variation
23 - Psychiatric cases: Always check social support, offer social worker help
24 - Thyroid problem: Ask about change in voice, hair, period, bowel, temp tolerance
25 - Trauma in elderly: Ask about abuse
26 - Vomiting: Ask about fever, headache, if it is projectile; if yes for any, do a fundoscopy (Suspect
brain tumor)
27-PREGNANCY : Regardless of the menstrual Hx , suspect it in a woman of childbearing age who
has unexplained weight gain.
28- In a back pain or musculoskeletal pain We should start the HPI with the age & the occupation
of the pt.
29-Remember Passing out = spell = blackout = LOC = syncope
31-Remember in any epigastric pain ask about: jaundice, black stools, blood on the stools,
postpandrial fullness( bloating of the belly), or early satiety.

32-In any case of Dark Urine , remember to ask: Have you eaten any food that could cause this
change in color, such as berries, colored candy, or beets?/ Chest symptoms (For pulmonary renal
syndrome)
33-Remember to ask in any case of dark stool: Have you taken any iron supplements, beets, or
peptobismol (Antidiarrheal)?
35-In any fever: Ask about night sweats & chills / recent ill contacts / exposure to anyone with TB
36-In any accidents: Ask about Head trauma& LOC.
37-In any respiratory infection : Ask about chest Qs + HEENT Qs(for URI)
38-In any trauma case(MVA/Sexual assault/Fight/Falling from above):Same history-Scan from
above downwards focusing on head trauma pain anywhere (ask always about PMI)-

N.B:
Two important features of CIS are " Paraphrasing " and "Summarizing" and also showing
sympathy when appropriate.
*) Paraphrasing : After asking the patient about the Chief complaint in detail repeat what he
told to him; this shows that you are listening to the SP. Do this thing at least 2 times in your
history. Paraphrasing concentrates on only a particular symptom unlike Summarizing which
gives overview of the whole case.
*) Summarize after the history in brief . Do the counseling bit here if you had not done that
before. Now proceed to the physical
* At least 3 PARAPHRASES in history / Use the patients NAME at least 3 times.
* You should also use OPEN-ENDED QUESTIONS at least 3 times.
* If the final bell rings & you havent finished the encounter, immediately excuse yourself
telling the patient Sorry Mrs. XYZ, I have to go now and come back to you as soon as
possible. Its totally acceptable & will save you from a very awkward end to the encounter .
Empathy and reassurance:
*I (Understand-realize-can see-can imagine) that it must be so difficult for you
*That (seems-looks) like very uncomfortable for you
*Imp Words: Painful/Hard/Difficult/Annoying/Uncomfortable/Distressful=distressing
/ upsetting /hurtful /bothering
Challenging Questions:
*I understand your concern (I can understand what you are going through now),but its early
for me to make a diagnosis (right now / at this point).
There are many causes of your symptom..and(Pts suspicion) could be a possibility.(optional)
*I need to run some blood tests and take some pictures of your , once I get the results, we
will meet again to discuss your diagnosis &the management plans. OR
I understand your concern Mr., but Im in the middle of my assessment. I need to ask you
some more questions and do a physical exam then we will order some tests. After that, I will
be able to tell you exactly what you have. Does this address your concern?
*If he asked after the closure, tell him (Lets wait for the lab results, once I get them..etc).
As far as (The pain medication/note to your letter/etc) , Id like to give it to you ,
However I do need to ask you some questions & do a physical exam so we can understand
whats going on before I give you this .. is that okay? OR
In order to treat you appropriately, Ive to ask you some questions& do a PE, is that okay?

Money issues: Let our social workers help you with the cost issues.If necessary, I can write
a note to your insurance company indicating the importance of these tests.
Child alone: I understand your concern about your child, but right now staying in the
hospital is in your best interest. One of our social workers will arrange for your child care.
STDs: The important step is to have you both evaluated & treated
Impotence+Aging: We have medications that may improve your sexual function.
Herbal ttt: their safety and efficacy may not always be clear-cut. Let me know the name of
the herbal medicine and I will check its treatment effect for this disease.
Tumour(Benign/malignant): We really dont know until we take a biopsy and get a
pathology report on it.
Surgey or Not: I will try to manage your problem medically, but if that doesnt work, you
may need surgery. Well see how things go and then try to make that decision together in the
future.
Getting better: This depends on the underlying problem& its prognosis, but we have a lot to
offer in terms of controlling the symptoms and improving your quality of life.
We will do our best and hope for the best.
A patient with COPD asks, Will I get better if I stop smoking?
Most patients will experience a gradual improvement in their symptoms. But It may take a while
before you notice the benefits of quitting smoking. In the long term, it will significantly
decrease your risk of lung cancer in the future.
Angry Pt.: I am sorry that you had to wait so long. The clinic was so busy today. But Im
here now, for you and your concerns, I apologize again, How can I help you today?
-If patient start crying sit down for a while, wait for 3-4 seconds hold his / her shoulder
by your hand for a second express empathy by saying {This must be a very difficult time
for you. MsWould you like to share with me what happened ?}
*And also offer tissue paper (never lose a sight of the human connection)
-If patient starts talking irrelevantly Excuse me for interrupting you, MrI know these
concerns have really been bothering you. However, right now I wanna focus completely on
you.
Do you think they are going to give me the job?
Employers routinely request medical examinations to ensure that the employees are t for
the job, & dont have any medical conditions that are hazardous to others in the work
environment.
I will ask you few questions and perform a physical examination, and on the basis of what I
nd, I may or may not order further tests. Hopefully everything will be ne.
Will I ever be able to sleep well again, doctor?
I think so, but rst we need to run some tests to rule out any underlying medical problems. In the

meantime, I would recommend you to change your lifestyle:

*If you drink lots of caffeine: Try to cut down on drinking coffee
*You should get used to go to bed early and at a fixed time
*You might try listening to soft music before you go to sleep.
Doctor, do you think I will be able to move my arm again like before?
I hope so, but rst we need to nd out exactly what is causing your problem.
We had not planned to have a baby so soon after marriage.What should I do, doc?
I understand your anxiety about this unplanned pregnancy. I suggest that our social worker
can help you& your husband dealing with this issue.
I wanna assure you that I am here to support whatever the decision you take.
Do you think I am going to die?
I understand your concern but I need to know more about your condition by asking some more
questions and do a physical exam to know if your pain is life threatening.
I wanna assure you that we will be monitoring you very closely from now on, and you have
made the right call by coming here today and Im here to assist you. You are in safe hands.
If the pt got bothered from your questions:
I know these questions may not seem relevant to what you are experiencing but sometimes
they are related in a different way. So, please bear with me for a few minutes. Im here to
help you.
A diabetic pt asking : Will I lose my feet, doctor?
If we keep your blood sugar and cholesterol levels well controlled plus caring measures of
your feet, we can keep it healthy and you will not lose your feet.
Questions about medical Facts:
My mother/brother had breast/colon cancer. What is the possibility that I will
have breast/colon cancer, too?
You maybe at risk, but it doesnt mean that you will get it. There are other risk factors that
need to be considered, and regular screening tests will be very important. OR
I need to get more information about your personal and family history to determine your
level of risk.(Optional)
A 55-year-old man says, I had a colonoscopy six years ago, and they removed a
polyp. Do you think that I have to repeat the colonoscopy?
Yes, it should be repeated. We need to screen for more polyps, and in this way we hope to
prevent the development of colon cancer.
An educated 58-year-old woman asks, I read in a scientific journal that hormonal
replacement therapy causes breast cancer. What do you think of that, doctor?
It appears to be true. Studies show a slight increase in the risk of developing breast cancer
after four years of HRT. The current recommendations are to use hormonal replacement
therapy only for the relief of hot flashes, and only for a limited period of time.
Can I get pregnant even though my tubes are tied?

There is no single contraceptive method that is 100% effective. Your chance of getting
pregnant is <1%, but it is a real risk.
A woman who is in her 1st trimester of pregnancy with vaginal bleeding asks, Do
you think I am losing my pregnancy?
Its a probability but I wanna assure you that most women who have bleeding carry the
pregnancy to term without problems. Also we will do some imaging studies to be sure that
everything is okay
Obesity runs in my family. Do you think that this is why I am overweight?
Genes play an important role in obesity, but lifestyle, diet, and daily habits are also major factors
influencing weight. We can use these factors to help you lose weight.
I am drinking a lot of water, doctor. What do you think the reason is?
This may simply be due to dehydration, or it may be a sign of a disease such as diabetes.
We need to do some tests to determine the cause.
HIV pt: What is CD count? ,how often will i be tested? How long before i get sick?
who am I obligated to tell?
*Cd4 cells are the infection fighting cells of our body.
*You should ideally have the test every 3-6 months.
*Mr., its hard to predict exactly when you will be sick. But I want to reassure you that there
are medications to fight HIV and you are not alone, so you can call our office anytime if you
have any questions.
*Also I suggest you discuss your diagnosis with you sexual partners and convince them to
seek medical advice.
Pt needs a refill:
Based on the information youve given me and the PE, I do believe that you need a refill on
your medication and Ill write you a prescription today. If you have any other symptoms or your
symptoms are not resolved, plz feel free to call our office.
My father had a clot in his leg. What do you think I should do to make sure I dont
get one too?
There are several measures you can do:
1-Avoid immobilization for long periods of timefor example, while sitting at your computer
desk or on long-distance trips. Try to move in place and perhaps take a short walk.
2-If you are on OCP, I would strongly recommend that you stop taking them, as they are
known to precipitate clotting
3-Exercise regularly and manage your diet.
I want to go back to smoking because I believe that I have started gaining weight
since I quit.
*I understand your concern, but its clear that the health consequences of smoking far outweigh
those associated with weight gain.
*We also need to exclude other causes of your weight gain by running some blood tests.
*We have an expert dietician here that can help you & give you the proper advice
=============================================================
==========================================

Specific Situations:
Smoking :
*Ms. Ray, as a concerned physician, I strongly recommend you to quit smoking as its a
major cause of cancer plus heart & lung problems. Are you interested in quitting/Do you have
any plans to quit?
*We have many tools & resources here in our institution to help you do that, my nurse will
bring you a pamphlet.
*(Optional) Also You can use Nicotine patches or Gum to help reduce those withdrawal
symptoms. I will give you their phone numbers. "
*If said no:
I understand that you arent ready to quit smoking yet, but I want to assure you that
whenever you are ready, I will be more than happy to assist you
Alcoholism / Alcoholic Patients If yes for eye opener or any other 2 questions:
*Mr..,I am concerned about your drinking habits, Excess alcohol causes Liver& pancreatic
disease and is known also to raise your risk of high blood pressure, strokes.
(In females only) It can cause birth defects if consumed during pregnancy
Are you interested in cutting down or quitting?
*If you decide to cut down or quit alcohol, we have a professional team that can help you
deal with it better. Feel free to contact them anytime.
*For Cutting down:
- Limit intake to one drink per day ( for women) or two per day (for men).
- Eating food while drinking will slow alcohol absorption.
- Avoid drinking before or when driving, or whenever it puts you or others at risk.
*If said no:
In the event that you decide to cut down or stop drinking , you can call our office anytime ,
we have a lot of wonderful programs that can assist you with this , Okay?
Recreational drugs:
Mr.., As far as Cocaine , marijuana , Both of them are extremely dangerous for your health,
, and they are not good for your nervous system as well. Are you interested in stopping these
stuff. We have wonderful etc
N.B: If the pt answers yes to all of the three questions To save time, tell him/her:
As far as the cigarettes, alcohol and marijuana, All of these three things are very bad for you
health,& open the gates for many diseases . So are you interested in changing these habits.
we have a program for each that can assist you so much..would be interested in a pamphlet?
Diet(Obesity/HTN/DM)

*Mr., we have a lot of evidences that weight reduction alone, could reduce your symptoms by
50% or even more".
*We have an expert dietician here in our clinic, who can give you information about the healthy
diet and how to develop healthy-eating habits
*So if you are interested, I can refer you to him/her, and I believe s/he will help us a lot to treat
your condition
* You can Walk 20 minutes , 3 times/week to start
Diabetes:
Mr. XYZ - First of all, you should understand the disease and know how to manage it to keep yourself
healthy and reduce complications. These are some essential rules to know:
1. Follow regular exercise and diet instructions that will be provided to you (low salt , high fiber ,
low calories)
2- Learn how to recognize the symptoms of low sugar levels, such as confusion, disorientation, or
fainting. You should always carry glucose tablets or juices as an emergency kit.
3. Diabetic patients are vulnerable to injury-induced ulcers on the foot, so make a habit of using soft
footwear whenever you walk - indoors or outdoors. Keep your feet dry & clean
4. Be regular in blood-sugar monitoring 2X/DAY so that dose adjustments can be done on time. As
Persistently high blood sugar can cause damage to your eyes, kidneys, and nerves.
5.Fortunately, we have a diabetes counselor who may be able to help you. Are you interested in
meeting hi m?
Hypertension Counseling:
*Mr., High BP could cause stroke, affect the functioning of the heart, and even the kidneys.
*There are some simple rules : regular exercise, reduction of weight (if the patient appears
overweight), and limiting salt in your food could help in keeping your hypertension in check.
*I strongly advise you to do regular check-ups to help control your blood pressure.
*However, there may be some patients with treatable causes - we need to order a few tests to
see if we can detect those in you."
HIV Counseling:
*The biggest danger in HIV may not be the HIV itself but the diseases that can occur more
easily due to reduced body resistance.
*Thus, periodic examinations and follow-ups are important. We have a professional support
group here which can help you with that
Safe-Sex Counseling points:
1. Ms., I understand that you may not like to use condoms, but Im concerned as you are
putting yourself at risk for STDs like HIV, gonorrohea, hepatitis and increase the risk of
Cervical Cancer, unwanted pregnancies.
2. I would strongly recommend you to use condoms regularly. (If patient or partner is on OCPs you
can add)Also, I would like to tell you that Oral Contraceptive pills dont protect against
sexually transmitted disease.
3. Watch for symptoms of STDs, such as unusual discharge, sores, redness, or growths in your
and your partner's genital area, or pain while urinating.
4.After your consent, we can do a blood test for HIV
5. Add counseling about PAP smear depending on the Patients age !
Lab-Result (Trichomonas):
1. Ms., You and your partner need treatment.
2. While you are on Metronidazole therapy - alcohol is to be avoided, As it will cause unpleasing

effects like nausea and vomitting (Disulfiram like reaction)

3. Abstinence from sexual intercourse until therapy is complete
Counseling for Heel Pain:
1. Mr., Use soft-heeled or soft-padded footwear.
2. Refrain from long standing positions or long walking activities
3. If the prescribed pain medications do not work, plz give me a call
Counseling a Non-Compliant Seizure Patient who wants to drive:
1. Mr., Driving is dangerous not only to you but also to others on the road if you have any
fits
2-Also swimming should be supervised because of the riks of accidents,
Counseling a reluctant patient (Not speaking)
*You look quiet and sad to me. I know it could be a very tough time for you, However in
order to help you , I need you to tell me more about your problem. if you do so, I will be able
to determine what is wrong with you and help you feel better.
Counseling domestic violence:
* Ms Smith , From what you said I understand that sometimes, You feel unsafe at your own
home. It sounds very frustrating. I am glad that you came here to seek help.
*And if you ever feel unsafe or hurt, you should seek attention from the appropriate
authorities. I will get you the telephone numbers and their contact information
*Remember, its not your fault, you did nothing wrong and you dont deserve to be abused.
*And if you ever need someone to talk with, please dont hesitate to call our office.
*(Optional according if there are children or not ) Although everything we discuss is
condential, I must involve the child service if I believe that your children are at risk.
Counseling depressed pts:
*Mr Smith , I know that dealing with depression can be very difficult and can cause physical
and emotional stress.
* We have here wonderful groups and professional counselors who can help you through this
difficult time. I just want you to know that you are not alone. Would you like to talk to
counselor? Or join a support group?
*Also, I want you to promise me that if you feel like hurting yourself, you will call someone who
can help you or go immediately to an emergency department.
MEMORY LOSS
*Ms. XYZ, I wanna ask your permission to speak with one of your family members about
your social support and safety at home. Is it ok?.
*We have an excellent social worker that can help you in managing your daily activities and
future living plans in case you need it.
*(If Abused),Im really concerned about your safety, we have here nice shelters for the senior
citizens that can help you a lot
Loss of consciousness=passing out
*Ms xyz, At this time I strongly recommend you not to drive again until we find out what caused
your LOC I understand that this might be inconvenient to you but its mainly for your safety.
*I assure you that I will do everything I can to get to the bottom of your problem, so that
you can resume your regular daily activities
Asthma

*Mr. Smith, asthma is a chronic disease that needs long term therapy. Most common cause of
recurrence of asthma symptoms is interruption of controller medications.
*The inhaled medication (name it if the patient told you the name) is a steroid that
suppresses swelling of your airways and prevents symptoms.
*You should take it every day without missing a single dose.
*I am glad to see that you are regular with your checkups and I want to see you again in
about 3 months for another checkup
Osteoporosis:
*Ms,As you know, its a problem of aging and related to wear& tear of the joints. The pillars
of management are regular exercise, weight reduction& regular pain killer to relieve pain.
*We may also try heat & cold therapies or local massage with oils and anti-inflammatory
ointments.
* surgery or joint replacement only in advanced cases
-----------------------------------------------------------------------------------------------Enuresis (Bed wetting) Counseling :
*Ms. Cole, kids with bedwetting usually undergo natural healing with age, but this problem needs
tenderness. Punishing your child could worsen it You should rather praise and reward him if he
stays dry while sleeping.
*I would advise you to monitor your child's drinking habits before going to bed and encourage
the child to go to bathroom before going to bed.
*We also need to do some tests to figure out any underlying causes.
Constipation in Children:
Ms .., There are many things you can do to help your child:
1- Start by increasing the fluids, fruits and vegetables and decrease the amount of candy or
sugar in his /her diet
2- Do make him sit on the toilet at least 10 minutes at the same time each day, especially after meal.
3- Begin rewarding your child for just sitting on the toilet by stars on chart, trip to movie
theatre or to the park. Dont use food as a reward.
Emergency in Children(Noisy breathing)
1- MsI strongly suggest that you call 911 immediately and bring her/him to the medical
center as your children condition could be serious.
2- If you observe signicant respiratory compromise or choking, please perform the Heimlich
maneuver by thrusting your childs tummy with sudden pressure.
3- I hope you understood what we have discussed today.(essential)
Picky Eater:
1-Ms Smith, I think its an isolated problem in this age group, children are moody in this age
2-First of all, Id suggest you to strictly follow a set schedule and offer him/her a variety of food at the meal
time. Discourage high caloric food in between the meals
3-The next important thing is the environment at mealtime. It should be pleasant. Avoid any arguments or
watching TV
Jaundiced Child:

* Ms. Xxxx, I would recommend you to Keep him/her well hydrated. Nurse your baby every 1 to 2
hours during the day.
*Don't let your baby sleep more than 4 hours at night without feeding.
*If your baby is 5 days or older AND has less than 3 stools/day, carefully insert the tip of lubricated
thermometer into his/her anus and gently move it from side to side a few times to stimulate
a stool which will carry bilirubin out of the body. Do this once or twice per day until jaundice

improves or stool frequency becomes normal.

ORS Counseling in dehydration: Enquire if the woman knows about Oral Rehydration

Solution and whether she has Pedialyte at home - if Yes, she can start having her baby sip on
it. If she does not, you can suggest a quick home-made solution like this, till bring him in
A. Water - 4 Cups

B. Salt - 1 Teaspoon

C. Sugar - 8 Teaspoons

*Hope you understood whatever we discussed today? (In All Cases)

Psychiatric History
Depression:
Onset: For how long have you been feeling (This way) unhappy/sad/anxious/confused?
Course: Do you have any idea why do you feel this way? (Mostly not answering)
I know it could be hard for you but Would you like to share with me what made you feel this
way? Im here to help you
FACE SLIPS Mnemonics:
F: Feelings of guilt, anger. {Do you feel guilty about anything?}
A: Abuse --- {Have you ever been abused?}
Appetite (diet, weight) ---- {How is your appetite? Then has your weight changed recently?}
C: Concentration levels. {Do you have difficult time concentrating?}
E: Energy levels in daily activities. {Can you still perform your daily activities?}
S: Sleep disturbances {Do you have any changes in your sleeping habits?}
L: Life stress-{Have you had any recent stressful events?}/How is your libido?
Hallucinations: {Do you hear or see things that others dont?}
I: Interest? Hobies? {Have you lost your interest in your social activities and relationships?}
P: Psychomotor symptoms---- {Do you feel restless?}
S: Suicidal thoughts, any plans? {Have you ever thought about hurting yourself or ending
your life?-Do you have any plans? Do you have guns at home?}
Then Past Medical History. (PAM HS FOSS)
=========================================================
Psychosis:
Onset: Age of first symptom: when did you first notice something is happening to you?
Did they begin suddenly or gradually? Were you upset about that?
Negative symptoms
Blunted affect: observe nonverbal signs of emotion-body movements,
Decreased speech: Do you have difficulty with your speech?
Social withdrawal, decreased motivation: How is your energy level lately? How is your relation with
your family/friends?
Cognitive symptom: Do you have racing thoughts?
Positive symptoms:
Delusions: Do you hold beliefs about yourself or the world that other people nd it odd?
Hallucinations: Have you ever seen or heard things that others cant see or hear? what are
these? What are they telling you?
Disorganized thoughts, disorganized or catatonic behavior)
Do you ever feel that people want to harm or control you?
Do you ever feel that TV is talking to you or about your thoughts?
Do you feel restless and agitated?

Organic causes of psychosis(DD)

Do you have any hearing/vision problems?
Brain tumor Infection Encephalitis - drugs
Insight: Would you like to join a support group or talk to a counselor?(A must)
Then Past Medical History.(PAM HS FOSS)-mainly Fx of mental illness/(Social History)
Living conditions/Stress/Support system
In Any Psychiatric case : Always ask about Abuse & Thyroid disease
Dmentia (Memory problems)
Do you have any difficulty with your daily activities like (bathing-feeding yourselfgetting dressed-using the restroom)
Do you need any help {taking your medications/using the telephone/doing the
shopping/preparing food/doing housekeeping /doing bills = accounting?}
How about transportation, are you able to drive?
Have you ever lost control of your urine or bowel?
Domestic Abuse (Women Elderly)
1-Can you tell me about your living conditions?
2- Are you safe at home?
3- Does anyone in your personal life treat you badly?
4- Do you know why s/he is doing that?
5- Has it ever happened before? If yes - How many times?
6- Do you have a plan of what to do if you feel threatened?
7- Do you have guns at home?
8- So, How is your mood? (Depression Qs is mandatory)
I notice you have a number of bruises. Can you tell me more about them?
It does not look like being caused from a fall. Did someone do this to you?" If said no and
anxious ---tell her,
"I understand that you may be uncomfortable to discuss about this but as your concerned
physician, your safety and your health are my first priority. Would you like to share it with
me?
*Children--" How many children do u have? How old are they?
How is their relationship with your husband? Has he ever hit or threatened them?

Paediatric History(HPI+PMH+CLOSURE+COUNSELLING)
Hello Ms., Hi, My name is Dr Im the physician in the office today. Its nice to speak with
youOkay MsHow Can I help you today? -----Chief Complaint
Ask about Name / Age ? Then sympathy(Im really sorry to hear about your situation, I
will do everything I can to help you today.
Full analysis of CC: Can you plz (explain to me what happened /tell me more about that)?
ROS: now Im gonna ask you some questions about his/her general health, is it okay?
General: (Fever-Seizure-Rash)
Has s/he had any recent infection (mainly respiratory in children)?
Was s/he feverish? Have you taken his/her Temp.?How high was it? Did you take it
orally or rectally? Is s/he shaking at all?
Does s/he have any rash anywhere? If yes, when did it start? Can you describe it?
How does s/he look? - Is s/he tired or playful? Then is s/he crying a lot? v.v.v Imp Q
How is his/her sleeping? If Not good, does s/he snore at night (esp. in Bed wetting)
Impact on the patient& Family (Mostly in older cases > 6yrs),How does this affect you?
Head: Have you noticed any stiffness when s/he moves his/her head?
Neck: Any swelling in his neck?
Eye: Have you noticed any redness or teary eyes?
Ear: Do you know if s/he is pulling at his ear? How often? Any discharge?
Nose: Does s/he have a runny nose?
Throat: Does s/he have difficult time swallowing?
Chest:
Does s/he have any difficulty breathing -Is s/he breathing fast? If yes, Is s/he turned blue?
Is s/he coughing? If Yes, Anything comes out from his mouth? then analyze it
GIT:
Is s/he eating well? Did s/he throw up?
Any changes with bowel motion (Stool caliber- frequency- color-blood & consistency)
Have you noticed any weight changes with him/her? Then Is he following any Particular diet?
Does s/he scream or cry during bowel movements?-or Any belly pain was noticed?
Urinary:
Has s/he ever had any changes with his/her urination? (Urine frequency-color-blood)
Does s/he cry when s/he urinates?
How many diapers are you changing per day?
Musculoskeletal: Do you know if s/he has any weakness of his limbs?
Neurological: Has s/he ever had any type of shaking movements?

======================================================
Past History {PAM HS FS}
P: 1-Has s/he ever had similar episodes in the past? Followed By
2-Has s/he ever been sick before?
A: Does your child have any allergies?(medication-food-Pets)
M: Is your child taking any prescribed medications? Or any over the counter medications
H: Has your child ever been hospitalized?
S: Has your child done any surgeries before?
F: Does anyone in your family have similar symptoms or problems with(e.g, Kidney disease)?
S: Have you noticed any ticks or insect bites on his body?
Id like to ask you some questions about the pregnancy & his/her birth is it okay?
Prenatal History:
Did you have any prenatal care? Did you take multivitamins?
Did you have any complications during your pregnancy?
Did you smoke, drink, or use recreational drugs during your pregnancy?(3 separate
Qs)
Natal

(Birth) History:
How was the labor? Was it normal vaginal delivery?
Was s/he full term?
How much did s/he weigh?

Neonatal History:
When did your child have his rst bowel movement?(Very important)
When s/he was born,
-Did s/he have any discoloration of his/her skin cyanosis-jaundice?
-Did s/he take any medications?
How long did you stay in the hospital after delivery?
Feeding History:
After birth, did you breast-feed your child? And for how long? Or bottle fed
Can you describe to me his/her typical diet?
Is s/he taking any vitamins? What kind?
When did your child start eating solid food?
How many diapers are you changing per day ?(<6 needs evaluation)
Development:
How about his/her development? Or is s/he growing well?
When did your child start smiling-2m/sit up by himself-6m/walking-1yr?(Optional)
Routine care:
Are your childs immunizations up to date?
Does s/he do checkups? When was the last one? Was it normal? With whom does s/he
follow up?
S: School/Preschool Daycare is after 6 wks.
Does your child go to a daycare or preschool?
Has he been around anyone who is sick either at home or the daycare?
How about his/her academic progress at school?

S: Social History:
Who does s/he live with? What kind of house do you live in?
Has your family moved recently?
Are there any stressful events or family problems that s/he is passing through?
Does s/he have any siblings? If yes, is s/he getting along with his siblings and friends?
How much time do you spend with him/her?
( Any pets / Any family member smokes )at home?-Mainly in chest cases

Closure
Well, thank you Ms. Smith, for answering my questions.
Okay, let me summarize what you have just told me. You said .Is that right/correct?
Would u like to add anything else?
*Based on the information youve given me, I think your child might have .. , however, we
also need to exclude some other possibilities , such as..
*For that reason, I would like to examine him/her and order some tests before I make my
final diagnosis.
*Is it possible to bring him in today? Yes. That would be great.
Do you have any problems with transportation? If No, thats it.
If Yes,OK, Ms. Smith, in that case, we have social worker here who can help you with your
transportation. After we are done on the phone, I will transfer your call to him; he will help
you with this issue. Does this sound good to you? (Absolutely)
*Do you have any other questions or concerns for me? If yes, answer it
If NO, Please, do not hesitate to call our office if you have any questions.
Im looking forward to meeting you again and Have a good day.bye bye
======================================================

Challenging questions & Counseling situations:

Can you explain to me exactly what is going on with my child and what can be
done for it? or Can you give me something for her?
*I understand your concern Ms, but
It is hard for me to give you an accurate answer (right now/over the phone). OR
Right now, its too early for me to know whats is going on with your child so,
*I would like you to bring your baby here so, I can examine him/her and perhaps run some
tests. After that, I will be able to give you a more accurate assessment of his/her condition.
Determine if its an emergency:
like baby not waking up, no urine passed since a long time, incessant diarrhea etc. Tell her,
{Its urgent to get the baby to the hospital immediately as it could be an emergency}
If the mom has no time / no car / no one else to get the kid - ask her to call 911!!

N.B: If s/he goes to daycare:

I think s/he shouldnt go to the daycare until his symptoms are resolved .Because s/he may
have an infection that could be transmitted to other children or he may have got that
infection from another child.

Before the Physical Exam Show Sympathy then Summarize the history
Mr./Ms..,Im very sorry to hear about what you are{ experiencing going through }
Lets summarize up, You said, you have and , also, you , Is that right/correct?
(Physical Examination)=3-4 systems are so enough
1- Based on these information, I need to do a physical exam on you, is that okay?
If Said NO: To understand your problem correctly, I need to do a PE, Ill be as quick as
possible. Im here to help you.
2- Can you plz excuse me while I wash my hands.
3- While you are washing your hands,ask the SP about (Keep Him Engaged)
So Mr/Ms last name, What do you do for living?
So Mr/Ms last name , Is there anything else you would like to bring up? (Promote
challenging questions)
Answer: Whatever it turns out to be, I wanna assure you that I will do everything possible
to make you feel better.
Patient In the setting position:
A. Examine Head(eyes, oral cavity) & Neck(thyroid & glands)lymph nodes palpation
B. Then Examine Thyroid From The Back.
C. Now I need To Examine Your Chest & Heart. May I Untie your gown. Finish off and tell
him , Let me tie back your gown. Thank You.
D. Examine The legs for swellings and fingers for any signs of any underlying disease.
E. If required, Do The Neurological examination
Patient Is Lying down/back(Help during the process& pull the leg support out)
When you make the patient lie down ask him: Are you comfortable?
A. Examine neck for JVP& carotid bruit.
B. If Required, Do the abdominal examination (Dont make the pt. lies twice).
When To Do HEENT & Neck exam (Headache-Head trauma)/(Ocular problems visual
disturbance eye pain)/(Ear problems Tinnitus-vertigo-hearing loss)/ (Nasal problems
rhinorrhes-epistaxis-sinus pain)/(Pharyngitis-voice changes-jaw pain)- Fatigue
*Only perform the relevant components of the HEENT and Neck/Thyroid exams depending on your DD
1. HEENT exam:
Head:
1. Inspect the head for signs of trauma and scars.(Now Im looking at your head for any
skin changes , swelling, or scars
2. Palpate
A-the head :for tenderness or abnormalities.( Im gonna feel around your head. Please let me
know if you have any discomfort)- Thank you

B-The sinuses:{Frontal-Maxillary One side at a time- with your thumbs}Now Im gonna press
on your forehead and sinuses ,plz let me know if it hurts)do it in any chest case
Neck:
Lymph nodes: Now Im checking your neck for any lumps. Followed By:
Thyroid: * Im checking your thyroid gland which sets in the front of your neck , I need you to
swallow for me ,Plz? Do you need some water? Okay let me get it for you? Thank you
*Im gonna press lightly on your thyroid gland to check for any enlargement or
abnormalities , Can you swallow again for me plz , Thank you

Eyes: .( I need to examine your eyes now.)

1. Inspect the sclerae and conjunctivae for
color and irritation.
2. Check the extraocular movements of the
eyes.
3. Check visual acuity with the Snellen eye
chart.

how many fingers do you see? Then can you

cover the other eye plz. Thank You.

4.Check the pupils for symmetry and reactivity

to light.(light reflex-accommodation)
5. Perform a funduscopic exam.
Ears:
1. Conduct an external ear inspection for
discharge, skin changes, or masses.
2. Palpate the external ear for pain (otitis
externa)
3.Examine the ear canal and the
tympanic membrane using an otoscope.
4.Whisper test
5.Rinne test
(Normal is AC>BC) positive Rinne
(CHL is AC<BC) negative Rinne
(SNHL is AC>BC) positive Rinne
6.Weber test(ONLY done in UNILATERAL
hearing loss ) as normally shows no
lateralization(same when pt has bilateral
Hearing loss)

Now Im looking at your eyes for any

abnormalities plz look up, down for me.
Thank you
Can you follow my index finger without
moving your head. Thank you
Could you plz cover your Rt.eye and tell me
{I need to look in your eyes, Can you plz
look straight at my ears? Thank you
Now I need to take a deeper look in your
eyes ,Thank you

Now Im looking to your ears for any

discharge, skin changes or masses
Now,Ill pull up & down at your ear gently, just
let me know if you have any pain. Thank you
Now I need to check your ears with this device
for any abnormalities. Thank you
Can you hear my fingers from this side? how
about the other side?
This tuning fork is gonna ring and Im gonna
put it at the back and in front of your ear, let
me know when you hear it and when you
dont,. Can you hear that?
Now Im gonna put it on top of your head? tell
me which side you hear it louder or they are
the same.

Nose(Use light source without a cone)

I need to look into your nose. Can you plz look up for me
Throat:
Now I need to check your mouth and your throat With this light:
Plz open your mouth wide. Can you stick your tongue out and say AHH. Thank you

Examine Chest & Heart Simultaneously At One Setting.(I need to examine your heart
and lungs, May I untie your gown? Thank You.
2- Pulmonary exam(Full examination in chest case) otherwise auscultate only
Posterior Chest(Percussion/Auscultation/TVF) I need to check your lungs, Thank you.
Anterior chest(Inspection/Palpation):I need to lower your gown , plz
1-Inspection:Now Im looking at your chest for any abnormalities. It looks normal
2-Palpation:I need to press on your chest, if you have any pain or discomfort, plz let me know
3-Percussion:Now Im gonna tap gently on your chest
4-Auscultation:I need to listen to your lungs ,Can you please take a deep breath through your
mouth? again,again,again,one more time(4 times only).In the 2 nd time ask pt, are you Okay?
5-TVF: Now Im gonna put the side of my hand on your back, Plz say 99 , again(4 times) .
3-Cardiovascular exam:
(Ill examine your hearts in a sitting and then lying down positions.)
Sitting Up:
1-Heart&Lung auscultation: I need to listen to your heart and lungs plz. May I untie your gown.
Thank You. For women, tell her could you plz lift up your breast , Thank you.
2-Pulse:I need to check your pulse in your arms and legs(Radial Dorsalis pedis).Thank you
3-Leg edema:I am gonna examine your legs for any swelling. Is that okay with you? Thank you
Lying backNever ever forget to pull out the leg extension (You can do this with
the abdominal examination if there is any , related to the case)
Could you lie back plz, Let me pull out leg extension to make you more comfortable .
1- JVD: plz look to the left. I need to take a look at your neck vessels for any visible pulsation
2- Carotid Bruit: I need to listen to your neck vessels , Can you hold your breath for a
moment , please? do it Bilateral. Thank you
4. Abdominal exam: I need to examine your belly/stomach
1-Inspection: Let me take a look at your belly for any abnormalities. It looks normal.
2-Auscultation:Now I need to listen to your bowel sounds.
3-Palpation: Ill press gently on your belly then I ll press more deeper , Please let me know if
you have any discomfort. Thank you.
4- Percussion: I need to tap gently on your tummy. Thank you
5-Rebound tenderness: Now I need to press in, on your tummy, plz tell me if it hurts when I
press in or when I let go? (Do it on the opposite side of the painful side).Thank you.
6- Murphy sign: Im gonna press deeply on this area, I need you to take a deep breath& tell me
if you have any pain
7-CVA tenderness: Im gonna tap on your back gently. Plz let me know if it hurts. Thank you.
5. Neurologic exam:
A.Mental status examination: Orientation, concentration, memory. Almost not done(Need time)
except in psychiatric case even its the only exam the you will do 1st to be done
1-Orientation: to PPT(Person place- time)
I would like to ask you some questions about yourself ,is that okay?
Can you tell me your full name?
Do you know where are you now?
What is todays date?
2-Memory: (You Can ask it only and substitute the MMSE)-Now I would like to ask you some questions to check your memory.
I will name three objects for you, and I want you to repeat them immediately,
okay? Apple, pen and chair. (Tests immediate memory.)

I will ask you to repeat the names of these three objects after a few minutes.
Do you remember what you had for lunch yesterday? (Tests recent
memory.)
When did you get married? (Tests distant memory.)
Now, can you repeat for me the names of the three objects that I mentioned
to you? (Tests short-term memory.)
3-Concentration: Can you spell world forward and backward.

B. Cranial nerves: Now Id like to check your brain nerve functions, is it okay?
1. III, IV, VI: Extraocular movements. Plz follow my finger without moving your head. Thx
2. V: Im going to touch your face lightly-do you feel my fingers ?
Can you bite down tight(Clench your teeth)? Thank you
3. VII: Can you raise your eye brows?./plz smile big and show me your teeth. Thank you
4. VIII: Can you hear my fingers (Finger rubbing)
5. XI: can you Shrug your shoulders.Thank you
6. XII: Now plz Stick out your tongue, and move it from side to side. great
C.Motor system: I need to check the strength of your muscles in your arms& Legs, is that ok?
1. Active motion: {All movements are against resistance}
Upper Limb*Hands: Can you plz squeeze my fingers tight? Thank you
*Shoulder& Arms: Can you plz (push out=abduction),(pull in=adduction);Thx
*wristsCan you plz (move down=exion),(move up=extension),(Move to both sides);Thx
Lower LimbMay I left your drape
*Thigh: Can you push up against my hand . Thank you
*Leg : Can you (kick out= Knee extension), (pull in= knee exion). Thank you
*Ankles: Can you push up and down (against my hands)?. Thank you
D.Reexes: I am going to check the reexes in your arms and legs is that okay?
UL: Biceps, brachioradialis,
LL: knee, Achilles
Babinski (If needed):Now I need to check the reflex at the bottom of your foot , its gonna feel
like a tickle .please bear with me for a while.
E.Sensory system: Now Id like to test the sensations in your arms & your legs. is that okay?
This is Sharp and this is dull ,So plz close your eyes and tell me what you feel? Twice per
each limb then say is this like that in each limb?
Vibration, position sense(Only in Peripheral neuropathy. e.g DM)
*Vibration: Ill placing this tuning fork on a part of your body (best is base of big toe), please
close your eyes. Did you feel the vibration? Thank you , you can open your eyes now.
*Position: Now Ill be moving your big toe up &down. This is up, and this is down. Plz close
your eyes and tell me which direction I am moving your big toe.
F.Cerebellum: any one of these is okay
*Finger-to-nose: Plz touch your nose with your index finger , then touch mine
*Heel-to-shin: can you take the heel of your foot and RUB It against your shin like that? and the

other one as well (demonstrate it if needed)

*Romberg sign: Can you stand up for me with your feet together, plz? Do you want any help?
Can you put your arms straight out with palms up, and close your eyes (demonstrate this)-Ill
be standing beside you to support you. Thank you
*Gait: Can you walk back& forth for a couple of steps, please? You can sit down. Thank you
G.Meningeal signs: Now Im gonna do a couple of tests to check for any irritation of the
membranes which covers your brain
*Kernig: I need to uncover your leg. Im going to bend your knee and then straighten it. Plz
Tell me if it hurts. Thank you
*Brudzinski: Im going to gently bring your neck forwards towards your chest and will stop if
there is pain , just relax while I do this . Thank you
6. Joint exam:(Check The Injured Joint 1st Then if you have time the adjacent ones)
1- Wrist pain:
Inspection: let me take a look at your wrist
Palpation: I know you have pain on this side, so let me start with the normal side first.
Now let me check the other side.
ROM(Passive: Now Ill move your joints gently, plz let me know if you have any discomfort)
(Active: Can you move your hands up and down to the left and to the right .Let me start
with the one that does not hurt so I can compare whats normal and what is not )
Muscle Strength SensationsReflexes : Same As Above
Pulses: I need to check your pulse in your arms , is that okay?
Special test for Carpal tunnel evaluation:
Tinnel test: I need to tap on your wrists. Let me start with the one that doesnt hurt. Thank you
Phalen test: Can you do like this, Plz ,Let me know if it hurts. Thank you
2- Shoulder Pain:
Inspection: let me take a look at your shoulder
Palpation: I know you have pain on this side , so let me start with the normal side first. I need
to feel around your shoulder-start from the scapular blade if anything hurts, plz let me know.
-Now let me do the same on the other side. Thank you
ROM: Now I need to check on your shoulder movement. We will start with the normal one:
*Can you put hands behind your (head/back with your thumb up) like that.
*Can you stretch your arm out in front of you? Then do it all the way backwards , like that?
*Can you move your arm to the side all the way up to the top, like that?
Now with the other hand, go only as far as you can. Can you Do this Do this. Thank you.
Muscle Strength(Shoulder shrug/flexion/Abduction against resistance) Sensations Reflexes : Same As Above
Pulses: I need to check your pulse in your arms/legs , is that okay?
3- Lower Back Pain:(After Listening to heart & lungs)
Inspection: let me have a look at your back & other joints
Palpation: I m gonna feel around your back, if anything hurts let me know.(Use both thumbs)
ROM: Can you lean forward Plz, can you go to the side, can you twist to the Rt., to the Lt.
Thank You. If you have any difficulty with these let me know?
Please stand up for me, Can you bend forward & touch your toes, Thank You.
Muscle Strength SensationsReflexes : Same As Above
Babinski :Now I need to check the reflex at your feet sole. Plz bear with me.
Straight leg test: Now Id like to lift your leg straight up, is that cause you pain? I apologize for
the discomfort.
Gait : I need to see how you walk. Let me pull out the footstool. May I help you down? Please
walk to the other side of the room and back . Ill be nearby. Thank You.

Pulses: I need to check your pulse in your arms/legs , is that okay?

4- knee pain:
Inspection: let me check your knees for any swelling or deformity. Okay.
Palpation: Now Im gonna feel around your knee to see if there is any water , I know you have
pain on this side , so let me start with the normal side first. If there is any pain, let me know
ROM: Can you plz lie back for me. Can you bend your knees for me. How about the other one
can you go as far as you can..Thank you
Alright: Now Im gonna move the normal one around, Do you feel any pain.
Anterior/Posterior drawer sign: can you bend your knee , Now Im gonna push in & pull out./
Collateral strain: Now I need to push in & out From the side on your knee, Is there any pain?
Muscle Strength Sensations- Reflexes-Pulse : Same As Above
5- Ankle painBetter to be done when pt is lying back
Inspection: Now Id like to take a look at your ankle to compare both feet
Palpation: Now I need to press on your feet, Plz let me know if you have any pain
ROM: Id like to move your foot in a couple of directions plz relax. Can you push it up& downmove it in and out
Muscle Strength Sensations Reflexe(Achilis-Babiniski) : Same As Above
Pulses: I need to check your pulse in your feet
(Closure)
1) Briefly summarize
2) Brief explain your D/D
3) Explain Tests
4) Reserve management discussion (until we are sure what the problem is)
5) Avoid alarming the patient
6) Ask if the patient has any question
7) Thank the patient for coming
8) Reassure the patient that you will be careful and will do everything you can to help
9) Shake the pt's hand and say take care.
10) Leave the room
1- Thank you Mr.., for your kind co-operation, Ive finished my examination,
2- According to the information you have given me and the physical exam, I am
considering a couple of possibilities), It could be (probable diagnosis in medical
expression with explanation) or possibly a problem with your(if you have only one
diagnosis in your mind say another relevant one in your DD even its not clear enough).
(If the pt has a serious problem pointing ahead, you can say , According to the
information you have given me and the physical exam, I am really concerned about
your symptoms as it might be a serious illness like caner or it could be a problem with)
(If the pt comes for follow up and found out a complaint ,According to the
information you have given me and the physical exam, I think your problem could be
due to..or )
(If you didnt have other than one diagnosis: According to the information you
have given me and the physical exam, I think you could have .which is.
3- So, I need to run some blood tests and take some pictures (for echo or doppler use the
word: sound wave pictures) of your.. to find out exactly what the problem is and rule

4567-

out any serious illness

Once I receive the test results, we will meet again to discuss the final diagnosis and the
treatment options (Management plans), Does this sound good?
Okay Mr. / Ms..., Do you have any other questions or concerns For me?
*If s/he asks you..answer it and ask did I answer ur question/address your
concern?
It was a pleasure meeting you ,--Shake Hands
Have a great day. Goodbye.

Notes On Examination
1-Any bleeding& Dizziness: order orthostatic studies/full neuro or cardio exam(Acc to cause)
2-DM: Fundoscopy, test sensation and vibration, pulses, auscultate carotids, examine feet
3-(Any Chest pain): check sinus, do a complete chest and cardio exam
4-(Any Pure Cardiac case):Complete cardiac exam in two positions/Auscultate carotids, leg
edema, Pulses.Ususally do Head & neck as it will be a case of dizziness or light headedness
5-Palpitations: check thyroid, extremities tremor, DTRs
6- (Any Joint pain): Auscultate Chest & Heart + Complete Joint Examination
7-Remember to use funduscopy in : HTN, DM, headache, confusion and visual complaints
8-Insomnia: check thyroid, DTRs
9-Any Pure psychiatric case: MMSE + (Neuro or Chest& Heart exam)
10-Confusion, forgetfulness: auscultate carotids, MMSE, funduscopy
11-Headache: Head& Neck / Chest& Heart / Neuro
RECOGNIZING RESPONSES TO THE SP :
Remember every action of the SP is PURPOSEFUL.
1- Mr. Smith: I see youre coughing, do you want a cup of water/a tissue?
2- Mr. Smith: I see a lesion in your face, what is that? Can you tell me what happened?
3-Mr. Smith: I see youre holding your chest, are you in pain? Then ask if there is anything
you can do to help him/her feel more comfortable.
4- Mr. Smith: Yawning - "You look tired Mr. Smith, did you sleep well ?.
5-Mrs Smith, I see that you put the drape on your lap , are you cold?
6- Shivering SP: Could mean fever or also could mean the room is too cold .right ? so first do
ask the SP if the room temperature too cold for him/her.
7-If the patient is sad, "this must have been a difficult time for you, can you tell me about it?"
8-If he is wearing glasses , so something wrong with his vision. Or if hes wearing a hat ,
maybe hes hiding something underneath the hat. Be Picky
Very Imp Notes
1- If during any test, pt complains of any pain say " I am sorry, I need to do this test to know
what actually is the cause of your problem. Next time i will be gentle." (never avoid any test
fearing that it may cause pain to the SP. Just explain him the importance of the test)
2-Remember if you dont remember the SP name you can say: Sir/ Madam
3- Never write anything while the SP is speaking. It's so important to write afterwards as you
will never remember what the pt said to you due to the stress of the exam and the time limit
of the pt notes.

3-Be careful with the pts that have Hearing Problems: dont ask questions while youre
washing your hand because theyre not going to be able to hear what youre talking about.
Also never speak at the back of the pt unless you keep an eye contact
4-When after 10 min during the encounter ; when they do the announcement it may
interrupt you. Don't show any frustration then. Just wait till the announcement is over and
then carry on. Keep your smile and cool here. Don't ever show that you are tensed or
frustrated at any point in the exam.
5-Also while doing the physical never ever touch the gown of the patient. Your duty is to
just tie or untie the gown. Lowering the gown is done by the SP. Ask Now I am going to
examine your chest. For this I want you to lower your gown. Let me help you to untie your
gown."
6-If the CC is not related to CVS or RESPIRATION then only auscultate the heart and lungs.
No need to do more than that
If the CC is related to heart or lung ,Here you do a detailed Chest examination.
Physical examination will take a maximum of 3 min 40 sec including the washing of your
hands. Practice in such a way that you will not need more than 4 min for physical
examination in any case.
{time limit of examining Heart and Lung . You will just need 15 sec for heart auscultation
(3sec X 4 areas of the heart and 3sec for neck auscultation) and 20 sec for Lung auscultation
(2 places in front & 2 places at the back for 5 sec each ( auscultate for one full respiration
and then move to the other place.}
7-If the pt is sensitive to light , offer to pull down the shades or dim the lights.
9-Remember to get points for the checklist; I mean that dont exhaust yourself in trying
getting the actual diagnosis and omitting asking about other items in (e.g social history ,
Cig,EtoH,Illicit, work,Travel At least),so get every point as much as possiple.
10-Remember the rule right-right-right (ophthalmoscope in examiners right hand
patients right eyeexaminers right eye) and the rule left-left-left (ophthalmoscope in
examiners left handpatients left eyeexaminers left eye)
11-(Dont forget to use a new speculum for every patient for examining Ear)
12-Its perfectly appropriate to ask questions about the history during the physical exam.
(Allow 4 to 6 mins for it)
13-You dont need to say what exactly you are looking for, unless they ask you - rather begin
with , like if you were looking up the eyes for pallor and icterus you could go:
Could you look up for me - arrite..and now could you look down please.....that looks fine"
14-Never ever after washing your hand or putting your gloves on to touch anything other
than the pt , (Not your face or the white coat not the pen or clipboard to write something
that you asked during PE Not your white coat ) Only The pt & the stethoscope. Make sure
that while you turn the knob of the sink off; don't do it with your hand but use a tissue to
turn the knob off after washing your hands.

15-Now before touching the Sp, place your hand on him and ask if s/he feels your hand cold
(if yes rub your hands and ask again )
16-Word choice is important.2 words which repeatedly get doctors into trouble are (feel and
Good) after performing a physical exam maneuver ,the patient might take it to mean that the
exam was normal. During the history ,if you say good after a patient answers your
question, it may come across as judgmental that you agree with her behavior. Use Thank You
or Thanks Or Simply Nod.
17-The word feel is appropriate to use in the history.{How does that make you feel} is
perfectly acceptable.
18- You may encounter a case in which the examinee instructions include the results of a lab
test. In this type of patient encounter the patient is returning for a follow-up appointment
after undergoing testing.
19- it is critical that you apply no more than the amount of pressure that is appropriate
during maneuvers such as abdominal examination, examination of the gall bladder and liver,
eliciting CVA tenderness, examination of the ears with an otoscope , and examination of the
throat with a tongue depressor.
20- Immediately after each patient encounter, you will have 10 minutes to complete a patient
note. Note: If you leave the patient encounter early, you may use the additional time for the
note.
21- If you have a case for which you think no diagnostic workup is necessary, write "No
studies indicated" rather than leaving that section blank.
22- You will not receive credit for listing examination procedures you WOULD have done or
questions you WOULD have asked had the encounter been longer. Write only the
information you elicited from the patient through either physical examination or history
taking.
23- When you are listening to breath sounds , Never ever lift the stethoscope while the pt
is taking his breath. And give time when you are listening to the heart (like count 1,2,3 then
move it to the next cardiac area till you are done with the 4 areas of the heart)
24- If you dont know the answer of the challenging question, try to escape the answer by
logic way (as you are not required to give him/her accurate answer)
25- Practice PE so well that u can do them at any given time even if u have only 2 min left u
should be able to do something at least wash and check eyes so that youll get credit for it
26-There is no diagnosis called depression, Its called and written(Major depressive disorder)
27-Important correlations:

Paediatric cases: Sepsis or hidden infection is 1st in your mind

Gynaecological cases: Thyroid disease is a must
Anything related to the head: Head trauma must be in your mind

Any bleeding: Think about bleeding disorders and Drug induced(v.v.v.imp)

Any female or old pt: Abuse must be in your mind

28-Be careful of the time as almost always one system will be enough(the main one),as if
you did more than one and you are behind the 1st alarm(5 mins remaining),you will not close
the case nor counsel the pt, so better to focus on the main system and do the other things.
29- Dont writ WNL OR NORMAL in pt nots as they are not preferred but write down your findings
which are normal but write them down.

General Rules for PN:

a. Practice , practice , practice writing patiently within 9 minutes
b. Broken English is fine , like Google keywords ! Grammar can take a back seat
c. D/Ds don't have to be 5 in number ! You could write even 2 or 3 but its EXTREMELY IMPORTANT
that you arrange them in the order of relevance / possibility to the SP that you saw !
d. Treatment, consultations, or referrals NEVER to be in your work-up plan.

e. If you choose to write your patient note by hand, DO NOT touch the keyboard at that
station, because doing so will generate a blank patient note. If you accidentally touch the
keyboard, notify a proctor immediately.
Best Protocol to write PN:

1st- DD (1st one is the most likely one),(2nd one is another thing related to the same system)
(3rd one is something related to the age of the pt)(4th one is something related to the sex of
the pt.),(Last one is the least likely one )
2nd- Investigations (make a mental note of ordering the following according to relevance)
a- CBC w/diff-lytes (IN ALL CASES, First Investigation)
b- Pelvic/Rectal Exam.(2nd in OB/GYN)
c-X-ray/CT/MRI(picture investigation)
d-Hormonal investigation (TSH, free t4,Testosterone,Prolactin,etc)
3rd- Physical findings.(Write only what you did) 2-3 lines max.to save time then come back
4th- History (its very tricky to manage the space for History, so practice it well to avoid
writing in a clumsy way), as it takes mostly half of the time so you wanna earn points.
Please stick to this order, even if you start getting confident with your timing, because there
will always be a case where you run out of time, so always get as much points as possible
"The patient note is considered a communication tool; poor legibility or spelling errors that interfere
with the patient note reader's ability to comprehend the note may have a -ve impact on your score.

In Paediatrics: you also have to write at the start about the informer.
The source of information is the patients mother. at the start of HPI.
Q. Can we write technical terms on patient notes while describing history.?
A. Except for the chief complaint - which must be in the patient's words, the rest MUST be
medical as you wont have time and this is completely permissible as PN will be assessed by
doctors(e.g my period become lighter& longer = hypomenorrhea/oligomenorrhea)

Q. I am confused about the order of diagnostic workup. USMLEWORLD recommends

listing most specific first, in order of priority, but FA recommends listing most
simple and straightforward first. Could you clarify this for me?
A. I don't think that really matters - all relevant ones must come in the picture.
Order may be more important when you list down the Differential Diagnosis and I would
calibrate my order of Investigation list as per my D/D list.
Q: How about the telephone encounter:
A: leave the physical examination section blank ...or perhaps a better idea would be to write "Will be
done when Damian arrives at the hospital"

Advil
Aldactone
Allegra
Augmentin
Bumex
Celex
Coumadin
Lexapro
Lipitor
Lopressor
Maalox

Mylanta
Nardil
Nexium
Paxil
peptobismo
l
Plavix
Prilosec
Prozac
Synthroid
Tylenol
Zantac
Zocor
Zoloft
Zyban

Ibuprofen
spironolactone
Fenoxifenadine(aller
gy relief)
Amoxcillin +
Clavulanic Acid
bumetanide
citalopram
warfarin
escitalopram
atorvastatin
Metaprolol
Antacid (Aluminum
Hydroxide and
Magnesium
Hydroxide)
Antacid (Mg. OH
and Ca. Carbonate)
Phenelzine(MAOI)
Esmoprazole
paroxetine
antidiarrheal
clopidogrel
Omiprazole
fluoxetine
levothyroxine
Acetaminophen /
Paracetamol
Ranitidine
simvastatin
sertaline
Bupripion
(Antidepressant +
smoking cessation )

ACEI:
Altace=ramipril
Monopril=fosinopril
Accupril=Quinapril
CCB:
Norvasc=amlodipine
Procardia=nifedipine
Calan or isoptin = verapamil
Cardiazem=diltiazem
Ask about what for if you dont
know the drug(Not wrong)

HERBAL MEDICINE
Cranberry: UTI
Echinacea: URTI
Garlic: High cholesterol
Ginger: Motion sickness for N&V
Saw Palmetto: BPH

yo
year-old
M
male
F
female
b
black
w
white
L
left
R
right
hx
history
h/o
history of
c/o
complaining of
NL
normal limits
WNL
within normal limits

without or no
+
positive
negative
PPD
Packet per day
NSVD normal spontaneous
vaginal delivery
UTD
Up-To-Date
NKA
no known allergies
NKDA
no known drug allergy
SH
social history
FH
Family history
ETOH
alcohol
cig
cigarettes
q
every(as in Periods)

A&O Alert and oriented

Abd
AP

BS

abdomen
antero-posterior

Bowel Sounds

f/u = follow-up
LAD
lymphadenopathy
FBS
fasting blood sugar
NC/AT { Normocephalic,
Atraumatic}
PA
posteroanterior
BUN
blood urea nitrogen
minutes mins
CBC
complete blood count
CCU
cardiac care unit
CHF
congestive heart
failure

CP

chest pain

CVA
cerebro-vascular
accident or costovetebral
angle
CVP
central venous
pressure
CXR
chest x-ray
DM
diabetes mellitus
DTR
deep tendon reflexes

PMI
RBS
RRR

(Point of maximal intensity)

random blood sugar

(regular rate& rhythm)

months mos

KUB
kidney, ureter, and
bladder
LMP
last menstrual
period
LP
lumbar puncture
MI
myocardial
infarction
MRI
magnetic resonance
imaging
MVA
motor vehicle
accident
NIDDM non-insulindependent diabetes mellitus
HCTZ
hydrochlorothiazide
NSR
normal sinus rhythm
PERLA pupils equal, react
to light and accommodation
po
orally
PT
prothrombin time
PTT
partial prothrombin
time
TIA
transient ischemic
attack
U/A
urinalysis
URI
upper respiratory
tract infection

LE

lower extremity

HEENT head, eyes, ears,

nose, and throat

SEM
systolic ejection
murmur
HTN

hypertension
IM
intramuscularly
IV
intravenously
JVD
jugular venous
distention
N/V/D
nausea/vomiting/diarrhea
GI
gastrointestinal
GU
genitourinary
ED
emergency department

SOB

EOMI
intact

Ext
UE

shortness of breath

extraocular muscles

extremity
upper extremity

m, r, g (murmurs, rubs, gallops)

NT,ND Non tender, Non
distended
B/L
Bilateral
CTAB clear to auscultation
bilaterally IBS
Inflammatory

bowel syndrome
G1P1(gravid once/have one baby)

Ginko: For improved blood flow people worried about stroke, CAD
Ginseng: For increased memory , anti stress people worried, or afraid
of getting Alzheimers
St. Johns Wort: Depression

Physical exam
GA: Pt is conscious and oriented and ( in no acute distress/leaning forward/fatigued&
anxious/holding tissue with blood in it)
VS: copy vital signs or the main thing related to the case
HEENT: { No bruises No LAD nor JVD}
Head : NC/AT
Eyes : EOMI , PERRLA, Fundoscopy no papilledema no retionopathy , No visual field defects , Conjunctiva: No icterus,
nor pallor
Ears : Canals w/o abnormalities, TM clear , Auricle or peri-auricle :No tenderness , no stigmata of infection,
Weber test no lateralization; Rinne test (revealed AC>BC)
Nose : Nasal turbinates not congested
Neck : supple , no thyroid enlargement , no LAD , no limitation of ROM, (-) JVD, no carotid bruits.
Throat : no tonsillar enlargement , erythema , exudates , vesicles.
CHEST:
Palpation:(-) tenderness to palpation
Percussion: Clear to percussion Bilat.
Auscultation: Clear lung fields. (-) rales, rhonchi, wheezes
TVF: WNL
Heart:
Inspection/Palpation: PMI not displaced
Auscultation: S1, S2 / RRR / (-) m, r, g
ABDOMEN:
Inspection: (-) scars (e.g CS scars) or skin abnormalities
Auscultation: (+)BS in 4 Q / OR hypoactive BS
Palpation: Soft , NT , ND , CVA tenderness (+/-)
Percussion: Tympanic to percussion in 4 Q / (-) organomegaly or masses
Special maneuvers : (-) rebound , Murphys , psoas
NEURO:
A&O x3 , Concentration, Memory good
CN: II-XII : intact
Motor strength: 5/5 throughout except for /LE or RE ( 3/5 if he can move the limb)
Sensation: intact to sharp &dull
DTR : 2+ intact& symmetric /or Brisk reexes.
Cerebellar : finger to nose: intact, Gait : Bradykinetic, takes small steps, Romberg: ve
Special tests : Plantar reflex: Normal / Kernig or Brudzinski (-)/ Straight leg raising ve bilaterally
LUMBOSACRAL:
Inspection: No obvious deformities or signs of trauma
Palpation: No spinous process or paraspinous tenderness
ROM: No limitations in movements
Motor: 5/5 LE B/L(Lower extremity / Bilateral)
Sensation : intact to sharp & dull.
DTR: 2+ patellar , Achilles
Pulses :2+ symmetric , DP, PT(dorsalis pedis posterior tibial)
Extremities:
UL: No clubbing, cyanosis, or edema. No tremors, rash or excoriations.
LL: No pedal edema,
All other items of the lumbosacral system.

Medical Term
Abatement
abcess
abdomen
ABDOMINAL
abduction
Abortion

Abscess
Abuse
Adjuvant Therapy
alcohol
alopecia
Alzheimer's Disease
amenorrhea
Anal fissure
anemia
Angina
Angiodysplasia
Anticoagulant (heparin, etc)
anus
appendectomy
Appendicitis
appendicitis
appendix
Appetite
Arrythmia
Asthma
Atrophic oral
Axilla
Bipolar disorder
Bronchoscopy
carpometacarpal joint
cervix
Cholecystitis
cholelithiasis
chrons disaese
claudication
Clavicle
colitis
Colonoscopy
Conjuctivitis
Connective tissue
constipation
convulsions
CT - head

Layman English
A decrease in the severity of a pain or a symptom
cavity with pus
Stomach, Belly, Tummy
Pertaining to body cavity below diaphragm which contains stomach,
intestine, liver, and other organs
push out / to take away from, like to "abduct" someone
(1)Induced abortion: is a procedure done to end pregnancy.
(2)Spontaneous abortion= miscarriage: is a naturally occurring abortion.
3)Therapeutic abortion: is an induced abortion required to save the life or
health of the mother.
A swollen, inflamed area where pus gathers.
Do your parents(boyfriend/girlfriend, roommate, husband /wife)treat you
badly?
therapy provided to enhance the effect of a primary therapy
liquor
hair loss
A brain disorder characterized by memory loss and behavioral changes due
to abnormal, age-related breakdown of nervous tissue in the brain/ age
related memory loss
absence of menstrual periods=missed periods
tear in the anal canal
having less than normal number of blood cells
Chest Pain due to Reduced Blood Supply to the Heart
swollen and weak vessels
blood thinner
back passage
surgical removal of your appendix
Inflammation of the appendix
an inflammation of a tiny structure of your intestine that we call appendix
Your appendix is a finger-shaped pouch that projects out from your colon
on the lower right side of your belly
Desire for food intake
It is a disturbance in the rhythm of heart beats
repeated episodes of difficulty breathing due to some allergens and
irritable airways
decrease in size of a mouth
Armpit
Ups and downs in your mood
A thin tube connected to a camera to look into your respiratory airways
knuckle
neck of the womb
inflammation of the Gall Bladder which is a sac under your liver
gall stone in biliary tract
chronic inflammation of digestive tract
limping
Collar bone
infection of colon
Visualize your bowel using a scope passed through your bottom and we
can take a sample from any masses there
Inflammation/infection of outer layer of your eye
is tissues between bones and muscles
Passing hard stools or unable to pass any stools
sudden, jerky movement of limbs that are out of control of the patient
serial x-ray of the head and brain

If you nd yourself obliged to use a medical term that the patient may not understand, try to offer a quick
explanation. Dont wait for the patient to ask you for the meaning of a term, or you may lose credit IF S/HE asked
you what does this mean.

General Scheme for Writing the History

You must write it down before knocking on the door to arrange your items and make it easy
for you to write the PN , and not to forget anything when you are out
HPI
O nset
L ocation
C ourse(sudden/over time)
I intensity
C ontext(circumstances)
Q uality
C onstant or intermittent
R adiation
P rogression(worse or better) A lleviating
D uration
A ggravating
F requency
A ssociated(ROS)
ROS(Part of the associated symptoms)
1- System related Qs(e.g rest of GIT
Questions)
2- DD related Qs.

DD
1- Most common one.
2- Related to the same system
3- Related to pts age.
4- Related to pts sex.
5- Least likely one.
PMH
P (Episodes/HTN,DM,CHOL)
A (Meds/Food/Else)
M (Meds/OTC/OCP)
H (+/-)
S (+/-)
F (Alive,well/ + or - )
O (If relevant)
S (Active or not/e whom)
S (Cig/EtOH/Illicit)(Job/Travel/ stress/
living conditions)

General Scheme for Writing the Patient Note

General History:

Pediatric History:

HPI:

HPI:

ROS: -ve except for the above

ROS:

OB/GYN: (Only In Female & Relevant Cases)

Allergies:

Allergies:

Medications:

Medications:

PMH:

PMH:(Disease & ttt)

Birth history: uncomplicated NSVD

PSH:

Dietary history:

SH: Cig-EtOH-Illicit drugs-sexually active or not

Immunization history: UTD

FH: (+ only ) or write non contributory

Developmental history: Last checkup- WNL

Physical Exam:

GA:

VS:
HEENT:
Chest:
Heart:
System Specific: (Abdomen/Neuro/Lumbosacral): Each one in detail

Mini Cases
Headache:(As any pain analysis)
1-Migraine (Aura=sensory-auditory)
2-Tension & cluster headache (Specific time
every day/runny nose during attack)
3-Eye disorder(Refractive errors)- Temporal
arteritis(proximal Joints/loss of vision)
4-Sinusitis (URI=Runny nose-cough)
5-Teeth(dental caries-abscess)
6-Head trauma(Falls= Very imp)
7-Meningitis (Fever-Neck stiffness)
8-Increased ICP (SAH-tumor)- N,V, Weakness
waking from sleep/Speech difficulty.
9-Pseudo tumor cerebri: OCP
9-Hypertension.(Uncontrolled/Fx)
Depression:
1- Adjustment disorder with depressed mood/
2-Normal bereavement(Any stressful event)
3- Major depressive disorder(Fx)
4- Abuse***(woman-elderly=Very imp.)
5- Dysthymic/ Cyclothymic disorder(mood
swings- Ups & Downs over years)
6- Hypothyroidism.
7- Substance-induced mood disorder
8-Schizoaffective disorder. (Hallucination +
Depression)

Confusion/loss of concentration& memory

loss:
1-Repeated Hypoglycaemia } (dizzy-light headed)
2-Arrhythmia (passed out/racing heart/chest pain)
3- Alzheimers disease(Most Common-dementia Q)
4- Vascular dementia(Neuro Q)
5- major depression with pseudodementia(feeling sad).
6- Hypothyroidism (Temp.-skin-hair-voice)
7-Chronic subdural hematoma}Falls (Very imp)
8- Normal pressure hydrocephalus(mem-urine loss-gait)
9- Intracranial neoplasm(headaches-N/V-weakness)
11- Alcohol withdrawal syndrome (sudden quitting )
12-Neurosyphilis(STDs).
Psychosis/Visual-Olfactory hallucinations
1-Schizophrenia(Fx- Auditory hallucinations)
2-Brief psychotic or Schizophreniform disorder (1st is for
<1month ,2nd is between 1 month & < 6 months)
3- Psychotic disorder due to a general medical condition
(Brain tumor/encephalitis: Headache-N/V-fever-neck
stiffness +Neuro Qs-Visual or hearing problems)
5- Substance-induced psychosis
6-Narcolepsy(daytime sleeping-naps-trouble
sleeping Qs)
7-Seizure(Describe-witness/Before-during-after/Fx)

Dizziness vs light-headedness(Find
out What does s/he mean by dizziness)
As itll be cardiac/neuro case or Ear case
{ (Falls hearing loss/tinnitus) URI}
1-Mnires disease(HL+ vertigo>20mins)
2- Labyrinthitis (HL)& Vestibular neuritis:
No HL (Both after URI)
3- Acoustic neuroma(HL+V,VII,IX&X )
4- Benign positional vertigo=canalolithiasis: Secs
5-Orthostatic hypotension due to dehydration(e.g
diarrhea/drug)(sudden sitting or standing up)
6-Vertebrobasilar insufficiency (vision/ICT)
Hearing Loss:(To all sounds or not)
1-Presbycusis(SNHL-old age-AC>BC)
2. Cochlear nerve damage due to loud noise(Can
you locate the source of sound)
3. Otosclerosis(CHL-old age -AC<BC)
4.Otitis externa/media(Unilat. CHL)
4. Mnires disease(d.t endolymphatic
disruption in inner ear from syphilis)
5. Acoustic neuroma(Neuro Q/Speech
understood or not)
6. Ototoxicity(aminoglycosides/aspirin)
Weakness/Numbness(CNSEndocrine Psychological causes)
1-Transient ischemic attack (TIA)
2-Stroke
3-Seizure -Todds paralysis.
4-Multiple sclerosis(eye/different lesions
5-Hypoglycemia
6-Diabetic/Alcoholic Peripheral
neuropathy
7-Megaloblastic anemia(Vit B12 def)
8-Guillain-Barr syndrome
9-Polymyositis
10-Myasthenia gravis
11-Horners syndrome
12-Conversion syndrome

Loss of consciousness(LOC)=Blackout
1-Seizure(Before:sweaty-sounds-flashes-racing
heart/During:shaking-bite
tongue-loss
bladder/
After: confusion-concentration)/vision
2-Syncope(vasovagal-dehydration)stress/diarrhea 3TIA or Stroke (Hge-Weaknessspeech- gait)
4-Cardiac arrhythmia(dizzy-palpitation-tachycardia)
5-Severe aortic stenosis/MI(Chest pain)
6-Pulmonary embolism (SOB/LOC/Fever)
7- Hypoglycemia(N/V-dizzylightheaded-Belly pain)
8-Substance abuse/overdose(LOC 1st then fall)
9-Head trauma (Any history of recent trauma)
Blurry vision:
1-Catarct.(Old age)
2-Macular degeneration(How is your night vision)
3-Closed angle Glaucoma.(wear glasses or Contacts)
4-DM(Excessive thirst late/need to drink more)
5-Hypertensive retinopathy(history of LOC/seizures)
6-Temporal arteritis(Complete loss of vision at any
time/headache/weakness/joint/jaw pain)
7-Brain lesions(Headache-N/V-weakness).
8-If unilateral (Trauma /FB/or infection to the eye)(discharge
-Halos around light-eye pain/red/swollen)
Tremors: what context did your hand shake the
most?
1-Physiological tremor: (made worse by, stress
,hyperthyroidism (Temp-racing heart-Diarrhea-wt)
2-Postural tremor: (absent at rest, present on
maintained posture- affects hands/head,) Causes:
*Benign essential tremors: Fx., improves with alcohol.
*Thyrotoxicosis.(vision changes-nervous-palpitations)
*Alcohol withdrawal syndrome. (seizures-hallucinations)
*Drug-induced(B-agonist ,valproate, lithium)
3-Tremor at rest: Idiopathic Parkinson's disease (PD)
(Dementia Qs /Depression esp. memory&
concentration -urinary changes/ Gait instability +
changes in voice or handwriting / constipation)
4-Intention tremor: cerebellar dis. (MS,TIA,Stroke)
Neuro&CVS Qs(occur only with movement &subside
with rest)
5-Epilepsy(Hx of seizures)

Insomnia(Difficulty sleeping):
1-Stress-induced insomnia as in Generalized
anxiety disorder or Hyperthyroidism (SweatingIrritable-bowel changes-weight change)
2-Caffeine-induced insomnia(shaking handsracing heart)
3-Obstructive sleep apnea(snoring-daytime
sleeping- naps)
4-Insomnia with circadian rhythm sleep disorder
(jet lag or shift work)
5-Insomnia related to major depressive disorder
(Sadness-Early spontaneous awakening)
6-Adjustment insomnia(stressful event)
6-Diseases that interrupt sleep(Cardiac or Resp.,
Arthritis: pain/Restless leg syndrome

Fatigue=loss of energy=Not himself:

1- Depression-PTSD-Adjustment disorder(In full)
2-Hypothyroid(Temp-skin-hair)/(menstrual changes)
3- Sleep disorder(Obstructive sleep apnea: snoringdifficulty falling-staying asleepearly awakeningdaytime sleeping)
4- Domestic abuse. (safe at home)-Very imp
5- DM-DI (1st diagnosed or uncontrolled-Urinary
symptoms)
6-Chronic Infection anywhere(Fever-chills)-e.g HIV/TB
7-Any Cancer-paraneoplastic Syndrome(GIT symptoms /
stool color black/red/clay - Chest symptoms)
8-Anaemia (feel weak-racing heart-vomit blood)
9-Chronic fatigue syndrome(sore throat-myalgiaarthralgia-headaches-generalized weakness)

Frequent Falls:
1-Cerebellar disease (gait/speech).
2-Parkinsons disease(memory problems)
3-Diabetic neuropathy(urinary/sexual
problems)
4-Brain tumors(shaking movements).
5-Inner ear disease(Meniere-labyrinthitis)
6-Fractured hip(any broken bones before
from falls/living conditions)
Sore throat:
1-Viral(EBV/Common cold/Adenovirus/HIV} or
bacterial(strept./Gonococcal) pharyngitis
(General Qs+URI Qs+Ulcers+fever+LN)
2-Tonsillitis(Muffled voice/pain go to ear)
3-Infectious mononucleosis (EBV) (Ill contacts
+glandular fever, rash +generalized
fatigue+ Abd pain spleen+ Hepatitis
Jaundice/stool &Urine+GIT Q
4-Acute HIV infection (risky pts: sex/drugs)
Cough/shortness of breath
1-URI-associated cough mainly viral(General
Qs/runny nose-sore throat/fever)
2-Bronchitis (Acute-Chronic) (Chest Qs)
3- Asthma (Fx-Pet or animal exposure).
4- Pnumonia( Urine Legionella antigen,
serum Mycoplasma PCR, PCPAIDS)
5- TB(Exposure to TB specific/last PPD)
6- Lung cancer-Abscess(weight/Appetite)
7-ILD(dry -wt loss-progressive dyspnea)
8-Wegners granulomatosis(URI/LRI/Renal)
9-GERD(heartburn/cough at night+GIT Q)
10-Heart failure(Fatigue-edema-gradual)

Jaundice
1-Extrahepatic biliary obstruction:{Pancreatic cancerCholangiocarcinoma} (General Qs/Itching)Choledocholithiasis -Cholangitis(GIT Qs)
2-Viral hepatitis (Eating-Travel-Blood-Sex-Drugs)
3-Alcoholic hepatitis(Stool, urine color, belly pain)
4-Primary biliary cirrhosis(Fx-Itching)
5-Acetaminophen liver toxicity(Especially if alcoholic)
6-Hereditary Hemolytic diseases e.g sickle cell (Blood Qs)
Night sweats:
1-Chronic infections:
A-Tuberculosis(General Q + Chest Q).
B-Acute HIV infection.
C-Subacute bacterial endocarditis(SBE)-Cardio Qs
2-Cancer( Lymphoma Leukemia)=Any swellings/
Feeling weak )
3-Hyperthyroidism
4-Menopause(Pain with sex-hot flashes)
5-Drug-induced ( GnRH agonists, antidepressants)
Chest Pain:
Cardiac causes:
1-Angina/MI-(Cardio Qs-Cocaine use)
2-Pericarditis(past URI, pain when you breath in)
3-Valvular HD(MVP)
Lung Causes:
4-Pleurisy(Unilat.-abrupt&sharp-lower lat. Chest)
5- Pneumonia-TB(fever&chills-tachypne-cough)
6-Pneumothorax- PE(LOC-racing heart-dry cough)
Other Causes:
7- Muscle(strain-costocondritis) (painful to touch)
8- Esophagitis/Esphageal spasm.(GIT Qs)
9- GERD/Peptic ulcer dis.(postprandial pain)

Palpitations:
1-Hypoglycemia(related to meals/sweating
confusion/fine tremors)
2-Cardiac arrhythmia(dizzy-LOC-confusedfatigue)
3-Heart disease{Angina(chest paindifficulty breathing)or valve dis. MS/MVP}
4-Hyperthyroidism(hot intolerance)
5-Anaemia(Tired-pallor-weakness)
6- Pheochromocytoma(sweating-anxiety)
7- Carcinoid(belly pain-diarrhea-wheeze)
8-Excess Caffeine intake
9-Panic/anxiety attacks(facial flushing-SOB)
Weight gain(Obesity)
1-Pregnancy(N/V,Breast-urinary changes)
2-Hypothyroidism(cold intolerance-dry
skin-falling hair-constipation-voicemenstrual irregularities)
3-Familial obesity
4-Cushings syndrome(mood changes, prox.
weakness, bone pain, high BP,BS)
5- Polycystic ovary syndrome(Infertile/extra
hair growth anywhere)
6- Drug-related obesity(Steroid-OCP-lithium
7- Smoking cessation
8- Causes of generalized edema (CHF-RFCLF)chest & heart general Qs
9- Atypical depression(sad-tired-sleep)
10-Eating disorder(binge eating):food type
Nausea/Vomiting
1-Pregnancy(test-relation to meals)
2-Any GIT infection(Gastritis/GE/appendicitis/
IBS/(abd. Pain-food poisoning)
3- Renal disorders (UTI)(fever-loin pain)
4- Increased ICT (due to mass effect/Infection):
(headache, stiff neck,vertigo,weakness)
5-Acute labyrinthitis/Meniere disease (Ear Qs)
6-Acute angle closure glaucoma (Eye Qs)
7- DM=DKA(Urinary Q)
Constipation:
1-Diverticulosis(Diet vegetables, fruits)
2- Colorectal cancer(GIT Q/sense of
incomplete evacuation)
3-Bowel obstruction(Abd cramps/pain)
4-Anorectal disease(fissure,rectal prolapse)
5-Hypothyroidism(Skin-Hair-Voice-Cycle)
6-DM(diabetic gastropathy)(Cardio/Urine)
7-Neurological disorders(Stroke/
Parkinson /scleroderma)
8-Medication- induced(iron-opiates)Imp
9-Functional(1ry) constipation.(no abd pain)

Weight loss
I-With increased appetite
1-Hyperthyroidism(anxious, sweating ,racing heart,
shaking hands, skin, voice, hair, period changes)
2-Uncontrolled DM
3-Pheochromocytoma
II-With decreased appetite
4-Malabsorption(changing diet/GIT Qs)
5- Chronic infections{HIV infection(Sex-Blood)-TB-SBE}
6- Cancer(Rash-bruises-blood in coughing , urine or
stool-any swollen glands-H,N.V)
7- Anorexia nervosa/Depression(Feel sad/body image)
8-Drug induced:diet drugs/laxatives/amphetamines
Dysphagia(To water-food which 1st or both)
1-Esophagitis (Candidiasis, CMV, HSV, pill-inducedcorrosive liquids accidently or intentionally-GERD)
Painful or not
2-Systemic sclerosis(skin changes/GIT Q)
3-Esophageal cancer (Smoking/Alcohol)
4-Achalasia(any chocking sensation)
5-Plummer-Vinson syndrome(Feeling tired,/racing
heart)
6-Esophageal spasm(Chest pain)
7-GERD(heartburn/cough)
8-Neuromuscular disorders(CVA/myasthenia gravis) (any
weakness/Fatigue/painless dysphagia /problems
with chewing or choking).
Upper GI bleeding:(Hematemesis)
1-Bleeding peptic ulcer(Gastric-duodenal)
2-Gastritis/Oesophagitis.
3-Mallory-Weiss tear
4-Esophageal varices
5- Cancer(Oesophageal/gastric)
6- Medications: NSAIDs, anticoagulants, steroids,
thrombolytics. VERY imp
Abdominal pain(Fever or not/generalized or
localized)
Upper:
1- GERD
2-Gastritis /Gastric Cancer(Heart burn/melena/belching
3-Peptic ulcer (disease / Perforation)-Relation to food
4-Functional or non-ulcer dyspepsia(most common cause
of chronic dyspepsia).
3-Cholecystitis/choledocholithiasis/ Ascending or Sclerosing
cholangitis-Types of food that exacerbate the pain
4- Acute viral hepatitis-itching/tired-travel/blood/sex
5-Acute/ Chronic pancreatitis-fever/tachy/jaundice /
alcohol

Diarrhea
1-Infectious diarrhea (gastroenteritis)
bacterial(Salmonella/shigella,C.jejuni
Yersinia) Viral(Hep A, Rota virus, HIV),
parasitic (ascariasis , giardiasis), protozoal
(Amebiasis) {fever-sick contact }
2-Food poisoning (S.aureus- B.cereus)
3-Travelers diarrhea(travel-E.coli)
4-Pseudomembranous colitis (Antibiotics)
5-Hyperthyroidism(Anxiety-hot intolerance
-tremors-racing heart-Cycle)
6-Tumor(VIPoma)
7-Bloody diarrhea(Ischemic colitis/IBD/
Cancer/ Diverticulitis)
Alternating Constipation & Diarrhea
1-Irritable bowel syndrome(Not emptying
your bowel)
2-Inammatory bowel disease(CD,UC) (General
Qs/Blood in stool/Tenesmus)
3-Malabsorption{Celiac disease(feel bloated
-Chronic pancreatitis(Chronic belly Pain)}
5- GI parasitic infection

6- Rib fracture-trauma/falls
Lower:
1-Volvulus or other intestinal obstruction/ perforation
2-Gastroenteritis(fever/N,V,D)
3-Mesenteric ischemia/infarction(Heart Qs)
4-Diverticulitis (Fever/abd. Distension/mass)
5-Inflammatory bowel disease(CD/UC) (wt loss/diarrhea)
6-Appendicitis(rigidity/localized pain/+ve signs)
Back:
1- Nephrolithiasis(severe&sudden/agitated/Urinary
frequency with dysuria &hematuria)
2-Pyelonephritis
3-cystitis(Dysuria-Nocturia-frequency-fever)
4-Renal cell carcinoma
GYN/OBST Causes
7-Ruptured/Torsion ovarian cyst(sudden,fever)
8-Ectopic pregnancy(Amenorrhea/vaginal bleeding
/urinary frequency)
9-PID(metrorrhagia,fever,chills,urinary discomfort )
10-Endometriosis(pain with
menses=dysmenorrhea /with intercourse/
increased with defecation)

Hematochezia(Blood per rectum):

(blood before, during, or after
defecation)
1-Diverticulosis(Diet, alternating
Constipation& diarrhea, abdominal Pain
relieved by defecation)
2-Anal fissure(pain with defecation)
3-Hemorrhoids(mucus)
3-Inflammatory bowel disease: UC/CD
4-Infectious diarrhea (Travel- fever/chills Abd pain)
5-Ischemic colitis(bloody diarrhea-severe
cramping disease)-Heart Qs
6-Colon cancer(Fx., fatigue wt loss)
7-Bleeding disorders(rash-easy brusingbleeding gums- Fx)

Erectile dysfunction(ED)(on a scale from 1 to 10

being 1 is flaccid&6 is adequate for penetration)sexual desire
1-Organic ED {HTN-DM-hyperlipidemia-Leriches syndrome(angina, leg claudication, diminished pulses, hair loss,or
thin)-*Endocrine: Pituitary Hyperprolactinemia-

Hypogonadism *Trauma: local / surgery(Prostate)

*Drug-related:Cimetidine-HCTZ-Propranolol-Amitriptyline
*(Alcohol-Smoking)-induced ED
*Peripheral neuropathy(Neuro Qs/orthostatic BP
2-Psychogenic ED (depression-PTSD-Performance
anxiety) =stressful events/nocturnal or morning
erection/ premature ejaculation/conflicts with
partner -is she satisfied?
3-Peyronies disease(curved penis)=painful erection

Dark Urine:
Must ask about :
*If the bleeding varies in severity
between voiding.
*If it's worse at the beginning, middle,
or end of urination.
*Presence of clots or not
1-Foods:Beets,Blackberries
2-Drug-induced (rifampin/Penicillin/
cyclophosphamidecytoxan)
3-Hematuria causes
4-Rhabdomyolysis (exercise/accidents)
5-Paroxysmal nocturnal hemoglobinuria
6- Chest symptoms for Pulmonary renal syndrome

Any Joint Pain(Limb Pain)

*Constitutional Qs: fever-chills-wt loss
*Eye(Dry-red-decreased visionsensitivity to light): {Sjogrens syndromeSLE-Ankylosing spondylitis-Temporal arteritis}
*Rash- ulcers oral-genital
*Resp Qs
*Blood in urine
*Neuro Q(Weakness/drop){SLE-Behcet} Focal numbness/weakness/headache
{Polymyositis/dermatomyositis}
*GIT Qs(Diarrhea or dysuria/STD
gonorrhea) {Reiters} -UC/CD{ankylosing
spondylitis}
*Travel: History of recent tick bite
*Occupation
*Ability to function (dressing/ grooming /
writing/ walking)
*Smoking worsens RA
Wrist Pain:
1-Domestic violence
2-Carpal tunnel syndrome(intermittent
paarathesia-Pain worse at night & with
repetitive movements-Job- Phalen
&Tinnel:+ve)
3-Tenosynoviitis(pain worse on radial
aspectPain at snuff box-Finkelstein+ve
4-Arthritis
5-Fracture
6-Sprain or strain
3-Radiculopathy of nerve roots C6
and C7 in cervical spine (Any neck pain)

Hematuria:
1-UTIPyelonephritis-Cystitis-Urethritis-Prostatitis
(fever,chills,N/V, painful ejaculation,terminal
hematuria,scrotal swelling)
2-Stoneskidney-ureteric-bladder-Urethra (loin/scrotal
pain Fx- possible bladder distension)
3-GN(Post infectious: URI/Gastroenteritis )recent
4-Pulmonary renal syndromes (Wegner granulomatosis/Good
Pastures Syndrome SLE) Chest Qs-painless hematuria
4-Polycystic kidney disease (Fx-HTN)
5-Trauma(abd or flank /vigorous exercise)-Very imp
6-BPH(obstructive symptoms: Hesitancy-terminal
dribbling-poor stream-strangury- sense of
incomplete bladder emptying)/(Irritative symptoms:
urgency, dysuria, frequency, nocturia)
7-Tumours(Bladder-Kidney-Prostate-vaginal)-gross
hematuria/ clots
8- Bleeding disorders(e.g sickle cell anemia:
rash/easy bruising/severe abd pain)
1-Shoulder(Arm) pain
1-Shoulder Dislocation----------}Both have limitation
2- Fracture.(Humeral-clavicle)-}in all ROM
3-Rotator cuff injury/Frozen shoulder.(Increased pain on
elevation of arm or on all movements)
4-Tendonitis(Max. pain at acromion/difficulty
sleeping at affected side)
5-Adhesive capsulitis(Progressive restriction of
movements-no tenderness on palpation)
6-Sprain.(Falls/LOC)
7-Elderly abuse.(Living conditions)-Very imp
8- Arthritis. (Other joint affection/MSK Qs/
constitutional symptoms)
9-Refered pain
A- Angina/MI/Dissecting aortic aneurysm (Cardio Qs)
B- Acute pancteatitis- Cholecystitis- Cholelithiasis
(Abdomen Qs)

Hand Pain(Fingers Pain):

1-SLE(Non destructive/small joints)
2-Rheumatoid arthritis(MCP/PIP)
3-Psoriatic arthritis/ Parvovirus B19 infection(Small joint
affection)
4-6Carpal tunnel syndrome
5-Osteoarthritis(DIP)
6-Disseminated gonorrhea(unprotected sex with
Multiple partners)

Hip Pain:
1-Hip dislocationtraumatic
2-Hip fracture (History of repeated fallsNeuro Qs)
3- Pelvic fracture(History of accidents)
4- Osteoarthritis(no constitutional
symptoms- Overweight)
5-Avascular necrosis(SLE-oral ilcers-rash)
6-Bursitis
7-septic arthritis

Heel Pain:
1-Plantar fasciitis most common
cause(time of max. pain)
2-Calcaneal Stress fractures- (Previous
fractures or trauma to heel or ankle)
3-Achilles tendinitis
4-Arthritis(Reiters -RA-osteoarthritis-Gout)
5-Ankle sprain(twisted-falls)-Very imp
6-Foreign body-Spurs (warmth, erythema,
pain, indurations, or a uctuant mass)
7-Osteomyelitis(Constitutional Qs)
8-Foot deformities(flat foot/ Ingrowing
nail/Hammer toe/Bunion)
9-Tarsal tunnel syndrome.
Leg Pain:
Bilateral:
1-Peripheral vascular disease (intermittent
claudication-rest pain)
2-Lumbar spinal stenosis(pain in lower back
/controlling urine or stool)
3-Osteoarthritis(knee-ankles) obesity
4-Diabetic polyneuropathy(urinary changes)
5-Thromboangiitis obliterans.(Hidden cancer)
Unilateral:
6-Supercial venous thrombosis (any skin
changes -dilated painful warm veins)
7-DVT(trauma to leg-Fever-Chest Qs)
8-Bakers cyst rupture(Any leg swelling)
9-Myositis{Polymyositis/Inclusion body
myositis}Any trauma/injury to leg/statin
10-Cellulitis(red-swollen-warm to touch)
11-Radiculopathy from herniated disc

Knee pain:
1-Trauma (fall-sport-elderly abuse)-(Cruciate
ligament/meniscal ) injury
2-Arthritis:
A- RA(other joints involve /Rheumatologic Qs)
B- Reiters $ (GIT-Dysuria)C- SLE(Oral ulcers/photosensitivity/rash/mood)
D- Osteoarthritis(no constitutional-only local)
E- Septic arthritis (Gonococcal/ Non-gonococcal)
(Constitutional Qs/sexual partners )
4-Gout.
5-Pseudo gout.
6-Ruptured popliteal cyst
Neck Pain(Cirvicalgia): Circumstances
1-Prolonged postural (falling asleep on sofas&chairs)
2-Tension Headache-Stress/strain(Most common)
3-Trauma: acute (flexion, extension)-car accidents
4-Degenerative arthritis: cervical spondylosis
5- Neurological: cervical prolapse Meningism
(Meningitis-SAH) Infection Qs/All Neuro Qs
6- Inflammatory: RA-polymyalgia rheumaticaankylosing spondylitis (Full Rhematolgy Qs)
7-Metabolic:osteoporosis-osteomalacia
8-Referred pain: shoulder/tempromandibular or
acromioclavicular joint or MI (heart &chest Qs)
9-Malignancy:secondaries (Weight changes)
Lower Back Pain:
Context (moving furniture, bending/ twisting,
trauma)/Timing(disturb sleep)
1-Disk herniation(Urinary or fecal incontinence/leg
weakness)
2- Vertebral compression (tumor fracture)(Trauma/Abuse)
3-Lumbar muscle strain (lifting-relieved by analgesics)
4-Lumbar spinal stenosis(Aging-relieved on leaning
forward or pushing carts)
5-Degenerative arthritis.(Osteoporosis-osteomalacia)
5-Ankylosing spondylitis (Fx/stiffness in the morning)Very imp
6-Renal (UTI-Stones) (Fever, night sweats)Very Imp.
7-Malignancy:
*Cancer metastases(Prostate=difficult urination
/Breast=masses-discharge-skin change) *Multiple myeloma (other bony pain-hypercalcemia
constipation, excessive thirst & urination
repeated infections)
8-Women Causes:
*Endometriosis(cyclic pelvic pain)
*PID(Vaginal discharge-fever)
*Ovarian Cyst(Abd pain- urinary frequency)

The DD depends on the main complaint

of the pt.
Hypertension Follow Up:
1- Drug induced ED.
2- Hypogonadism
3- Major depression.
4- ED caused by vascular disease(HTN/
DM/Hypercholesterolemia)
--------------------------------------------Disease analysis
1-Onset(when you were diagnosed with)
2-Checkups(Regular or Not/Last one)
3-Home monitoring/Last reading.
4-Diet Monitoring(+Weight changes)
5- Current status(How do you feel today)
6-Complications:
a-Visual(any problems)
b-Neurological(Headache-Weaknessnumbness-sexual problems)
c-Renal(Urinary Q)
d-Vascular{Leg pain- Feet care(itching/
white spot)/Aneurysm SOB/CP}
Fever:(When/How high/Did the fever
disappear, only to reappear later)
1-Infection&inflammatory disorders
associated signs for every system.
2- Neoplasms (prolonged fever-night
sweats-wt loss-LAD-palpable masses)
3-Thermoregulatory dysfunction(sudden
&high anhydrosis-hot flushed skin-LOC
decreased-low BP-Tachypnea/cardia
4-West Nile encephalitis(Headache-myalgiarash-neck stiffness-low LOC)
5-Drug-induced started new(anticholinergics/
chemotherapy/ MAO inhibitors/toxic
doses of salicylates or TCA
6- Transfusion reactions
7- IV drug abuse
8- Long steroid use (Suppress immune
system)
9- Heat (exhaustion/stroke):did you go to
extreme temperature places?
=========================
Hoarsness of voice:
1-Laryngitis(Acute:URI or acute stress
/Chronic:chronic voice strain/Cig/EtoH)
2-Singers nodule
3-Laryngeal carcinoma
4-Hypothyroidism
5- Retropharyngeal/ Peritonsillar abscess

which is due to DM complications or due to drugs

side effects
Diabetes Follow-up:
1. Insulin-induced hypoglycemia.
2. Peripheral neuropathy (Diabetic-Alcoholic).
3. Multiple myeloma.
4. Diabetic autonomic neuropathy, vascular
disease, or medication-induced erectile dysfunction
-------------------------------------------------------Drugs=treatment analysis (Same for drug refill)
1-Name:What are the medication you are on?
2-Amount: How much do you take?
3-Frequency: How often do you take them?
4-Compliance: Do you take them regularly?
5-Side effects (Complications): Have you experienced
any side effects from the drugs? As The most
common side effects of this drug are:

Rash:(Describe it-itchy or not/analyze as pain)

1-Acne vulgaris
2-Bacterial infection(Impetigo-folliculitis-Rosacea)
3-Dermatitis(nummular-atopic)
4-Eczema.
5-Psoriasis
6-Drug-induced(anabolic steroids /androgens /
bromides/ corticosteroids / dactinomycin/hormonal
contraceptives/iodides / isoniazid /lithium
/Phenobarbital/phenytoin / trimethadione)
Itchy=Pruritis
1- Biliary disease(Jaundice/abd pain/fever-chills)
2- Infestations: Pediculosis(Capitis-Pubis)
3- Fungal: Pitryasis rosea
4- Scabies
5- Urticaria

===============================

Amenorrhoea:(Must ask about FMP)

1-Pregnancy(Have you missed a period/
breast swelling or weight changes)
2- Hypothyroidism(Cold intolerance-skin &
hair changes)
3- Hyperprolactinemia(Breast discharge)
4- Polycystic ovary
syndrome(Urinary/weight /excess
hair/voice deepining)
5-Anxiety-induced amenorrhea(stress/ Eating
& exercise habits)-sleep/constipation
6- Pituitary tumor(Headache-vision)
7- Ovarian or adrenal malignancy (hair thining
/Acne/excess hair/enlarged abdomen)
8-Premature ovarian failure- Menopause (For
both:hot ashes=flushes=night sweatsvaginal dryness-bone problems)
Vaginal discharge:
1-Bacterial vaginosis Thin, green or grayish
white, foul-smelling discharge
2-Vaginitis(candidiasis White, curdlike,
profuse discharge with yeasty, sweet odortrichomoniasis Frothy, greenish yellow, and
profuse foul-smelling)

3-Cervicitis (chlamydia Yellow,

mucopurulent, odorless, or acrid
discharge-gonorrhea Yellow or green,
foul-smelling discharge )

4-Foreign body (retained tampons, swabs)

5- Malignancy (cervical/endometrial)
The STDs:
1-Trichomonas/Chlamydia Trachomatis
2-Gonorrhea/Syphilis/HSV-HPV-HIV
Urinary Incontinence:
1- Genuine Stress incontinence.(weak pelvic
muscles + Increased intra
abd.Pressure ,coughing-sneezingstanding-laughing)
2- Detrusor instability =Urge incontinence (did
you ever notice a sudden urge to
urinate immediately-frequent
urination ,pass large amounts- day&
night)
3-Mixed incontinence(Do you wear
absorbent pads)
4-Overflow incontinence(spinal cord injury/
trauma to back/DM)-dribbling
5-UTI(burning urination fever)
6-Atrophic vaginitis (Bleeding/ Hot flashes/
discomfort during intercourse/mood)
7- bladder cancer (weight changes-blood

Vaginal bleeding:
1-Dysfunctional uterine bleeding/Anovulation(Cycle Qs)
2- Hypothyroidism(Temp-Skin-Hair-Voice changes)
3- Molar /Ectopic pregnancy
4- Spontaneous-septic abortion/Endometritis(fever)
5- Atrophic vaginitis(Most cause in 80% -Mood swings
- hot ashes-discomfort during intercourse)
6- Cervical (polyp/ laceration)(Persistent intermenstrual
postcoital bleeding &Pain+ Pink-foul smelling
discharge),Back pain,leg swelling/UrineQ)
7- Endometrial ( polyps/fibroid) (Postcoital or post
douching bleeding that becomes heavier&
frequent Clotting& Anemia)
8-Cancer (Cervix-endometrium)
9-Coagulation disorders (VWD-hemophilia-hemolytics)Brusies
Dyspareunia(Pain during sex)
1-Atrophic vaginitis(Bleeding-hot ashes-vaginal
dryness during sex - Thin, scant, watery white
discharge)
2-Endometriosis(pain with menses/defecation)
4-PID{Cervicitis(vaginal discharge-back or abd.
pain-)/Acute salpingo-oophoritis/ Tubo-ovarian
abscess (TOA)}-Fever/N,V
5- Vulvovaginitis
6-Vaginismus(timing/ Anxiety /Hx of sexual abuse)
7- Domestic abuse(feel safe at home)-very imp
8- Depression(sexual desire/conflicts with partner history of sexual trauma=abuse or rape)
9-Pelvic tumor(Pressure symptoms-urinary/abd Qs)

Positive pregnancy test:

1- Normal pregnancy(N/V, Fatigue, weight gain, and
breast engorgement& discharge, Urinary
frequency).
2-Ectopic pregnancy.(Be aware of Light vaginal
bleeding/ Lower abdominal pain/ Cramping on one
side of the pelvis/Dizzy)if any aggravates, call 911
3-Molar pregnancy(severe nausea and vomiting,
new-onset hyperthyroidism, Anemia, High
BP,Vaginal discharge of grape-like cysts or Dark
brown to bright red vaginal bleeding during the
first trimester).

in urine)
8-DM(excessive drinking/thirst)
9-Excessive caffeine or alcohol
In all pediatric cases, we will ask all
Child with fever
1-Neonatal sepsis
2- Meningitis
3-Acute otitis media
4-URI / Pneumonia
5- Gastroenteritis (viral, bacterial, parasitic)
6- UTI
7-Roseola infantum (Infant Measles)
8- Viral exanthema: Measles(Rubeola)
/Mumps(German measles) / Rubella
9- Fifth disease(Parvovirus B19 infection)=
(slapped cheek appearance)
10- Varicella(Chicken Pox Virus)
Child with diarrhea
1-Viral diarrhea : Rotavirus
2-Bacterial diarrhea (Shigella, Salmonella,
Campylobacter jejuni, and Yersinia)
3-Malabsorption(Cystic fibrosis -Milk
intolerance)-abd distension/chest Qs
4-UTI or Pyelonephritis.
5-Intussusception.(vomiting bile or faeces)
6-Bacteremia/sepsis

Child with constipation:

1-Functional=1ry constipation(after 2 yrs)
2- Hirshsprung diseae.(at birth-His 1st BM)
3- Diet-induced constipation(diet analysis)
4- Dehydration(enough water/milk)
5-Anal fissure(is there any cracked skin
around anus/fear of using other Toilets)
6- Hypothyroidism/DM. (Changes with his
skin/prolonged jaundice after birth /
urinary changes)
7- Medication-induced constipation(iron/Ca)
8- Stress-induced constipation(new school or
problems at home)

System Qs and focus on the main complaint.

Behavioral problems in childhood
1-Temper tantrum(breath holding spells pass out
harm himself parents response seizure
(Before& after the attack) depression/autism
2-Attention-defi cit hyperactivity disorder (ADHD)(place of
attack / easy distractibility /hard time
concentrating /memory status/problems organizing
ideas/difficulty taking decisions)
3-Oppositional defiant disorder
4-Conduct disorder(No sense of guilt-indifferent to
actions)
5-Adjustment disorder(stressful event)
6-Substance (intoxication/abuse/dependence)
Epistaxis:(Analyze blood/Uni or Bilateral)
1-Trauma-fracture football)
2-Foreign body/Nasal picking
3-Allergic rhinitis
4- Hereditary haemorrhagic telangiectasia (blood comes
out With sneezing/Blowing nose-in puberty)
5-Bleeding disorders=leukemia/aplastic anemia(Bruises/
fever/fatigue-body aches/recurrent infections)
6-Chronic intranasal drugs use (Cocaine=cardio Qs)
7-Nasal tumours (tired/loss weight)
8-Drug-induced (Aspirin-warfarin)
9-Chronic disease(uncontrolled HTN-Liver disease)
Child with jaundice: (Stool+ Urine color)
1. Physiologic jaundice(age of child)
2. Breast-feeding jaundice(Timing & frequency)
3. ABO or Rh incompatibility(Your own blood group and
the blood groups of your husband and baby/ Other
pregnancies and miscarriages before)
4. Neonatal sepsis(TORCH) (Awake and responsiveSucking and cry-ill contacts-General Qs)very imp
5. Cephalohematoma
6. Familial neonatal hyperbilirubinemia
Late-onset neonatal jaundice (after one week):

1-Breast milk jaundice.

2-Biliary atresia.
3-Metabolic disorders: Hypothyroidism,
Galactosemia, or hereditary hemolytic disorders
such as Spherocytosis or G6PD deficiency

Child diagnosed with diabetes

1. Type 1 DM
2. Type 2 DM
3. Secondary causes of diabetes (such as
Cushings- cystic fibrosis,
hemochromatosis and acromegaly)
4.Prader-Willi Syndrome.(Obesity)
5.Maturity onset diabetes of youth.
Child with noisy and strange
breathing/Stridor:
1.Sudden(Foreign body aspiration) muffled cry
/Best heard on inhalation or exhaling air
2.Infection{Viral(Croup-LaryngitisBronchiolitis) or
Bacterial (Epiglottitis/tonsillitis/Pertussis) =
drooling/ Blueness of skin}
3. Retropharyngeal/ Peritonsillar abscess
(Hoarsness of voice)
4. Chronic (Laryngomalacia)=snore nightly
5-Asthma
6. Angioedema. (Fx of allergies)

Child with Bed wetting

1.Monosymptomatic primary nocturnal enuresis.(Family
problems/Stress/other children)
2.Secondary enuresis:UTI/DM(dysuria-excessive fluids)
4. Functional bladder disorder(Fx-any neurological
problems-shaking movements)
5.Sleep apnea/Sleep terror disorder(Wake up in night)
6. Constipation(GIT Qs)
7.Congenital anomalies(ectopic urethral orifice)Fx
Child not eating (Picky eater)-why do you think
so/OCD/Frequency
1-Habitual eating disorder(What is his/her favorite food
? /How many meals/snacks does your child eat
each day? Does he watch TV before mealtime?)
2-Iron deficiency anaemia
3-Lead poisoning(What kind of house/moving
recently)
4-Fiber-lack diet(GIT Q)
5- Parasitic Infections
6- Depression(Social Qs-mood swings)
7- Parental influence: Have you ever punished or
rewarded him to change his/her eating behaviors?/
do you follow a set schedules of meals?/Do you
often offer dessert along with the routine meals)
8-Slow growth rate(small stomach than others)
9-Genetic: related to the number of taste buds

*Do you know anything which may have

caused it?
*Is s/he able to breath, cough or talk
(Choking)?
Child with Hematuria
1-Congenital anomalies(obstructive uropathy and renal dysplasia)=pregnancy& birth history
2-UTI
3-Polycystic kidney.
4-Hematologic disorders, ( vitamin K deficiency, hemophilia, and hemolytic uremic syndrome;
5-Tumors (Wilms tumor, bladder cancer, and rhabdomyosarcoma);
6-Allergies; foreign bodies in the urinary tract;
Important Investigations(All in brackets is single investigation)
Sepsis:

(CBC with differential, blood culture, UA and urine culture)

(In Children) add Titers for CMV, toxoplasmosis, and rubella(If required)

Meningitis:

(CBC, Electrolytes)-ESR-(LP,CSF analysis) / (CT head or MRI brain)

Sleep:

Ambulatory nocturnal pulse oximetry Polysomnography

Ear Infection:

Audiometry- Tympanometry - Brain stem auditory evoked potentials

Dix-Hallpike maneuver(BPPV) (VDRL/RPR)
(In Children) Pneumatic otoscopy Tympanometry

Eye Infection:

Tonometry - Slit lamp examination-discharge culture

Sinusitis:

CT sinus

Throat:

(Throat swab for culture& ASOT) - (Monospot test & Anti-EBV Abs).

Thyroid:

TSH / US

Chest:

ABGs CXR(PA and lateral) CT chest (Sputum exammicroscopy, Gram

stain, AFB smear, Culture, Cytology) PPD Direct laryngoscopy(FB)
Bronchoscopy with BAL (hemoptysis-cancer-ILD) - Spirometry
(Asthma/COPD/GBS/ Neuromuscular disorders)- PFTs
For PE: Doppler U/S legs D-dimer
ECG Stress test ECHO(TEE/TTE) Cardiac enzymes(CPK-MB, troponin)
- Cardiac catheterization(MI) +/- Cholesterol &TGs levels

Heart:
Abdomen
&Pelvis:

General: AXR - US(CT abdomen& pelvis) (Rectal exam, Anoscopy).

Esophagus& Stomach: 24 hour pH monitoring - Upper endoscopy
Noninvasive H. pylori testing=urea breath test ( for peptic ulcer disease)
Bowel: FOBT - (Stool leukocytes, culture, ova and parasitology,and pH )Electrolytes(Esp in diarrhea) Colonoscopy - Procto-sigmoidoscopy
(In Children) Rotavirus enzyme immunoassay(imp.)
Liver: (AST,ALT,ALP,bilirubin )-Viral hepatitis serologies (PT/PTT )(MRCP/ERCP)----(esp.for PSC)
(In Children) Blood type + Direct Coombs test
Pancreas: (Amylase, lipase) / D-xylose
DM: Serum glucose - (UA, urine microalbumin) ( HbA1c )- Islet cell Abs
Kidneys: UA/ Urine culture-cytology / (BUN,Cr) / US(main)/ Cystoscopy
Adrenal: Dexamethasone suppression test 24h urine free cortisol/US
Genital organs: Urine hCG / Genital or Pelvic or Breast exam
*STDs: (Wet mount, KOH prepwhiff test) / Cervical GC DNA testing/Pap
*PCO:(LH/FSH) (Testosterone/DHEA)
*(Ectopic pregnancy PID-Endometriosis -Pelvic cyst): Laparoscopy
*(Impotence) :Testosterone , prolactin level-TSH-Doppler US penis

Bone :

X-Ray(AP&Lat)DEXA scan(Osteoporosis)Bone scan (Osteomylitis/Cancer)

MRI(For ligaments &Tendon injuries) PSA(For suspected mets.)

Rheumatology *(SLE/Rhematoid arthritis): (ANA, anti-ds DNA, RF, ESR )

*(For Gout/ Pseudogout /Septic arthritis): Arthrocentesis and synovial uid
analysis(cell count, culture, crystals , Gram stain)
Myositis
Dermatology:

(Aldolase, CPK), Muscle biopsy

{In Neuropathy-Weakness}: anti-acetylcholine receptor antibodies,
(EMG/Nerve conduction studies)
(Fungal) Woods light Fungal culture
(Allergy) Patch test
(Any colored lesion ):Skin biopsy

Anaemia:

(CBC with differential) (Serum iron level, TIBC, ferritin,B12 level)

Pyschiatry:
Drug abuse

Mental status exam - Urine toxicology TSH (CBC ,Electrolytes, calcium,

glucose) - BUN/Cr
Urine toxicology - Mental Status Exam

AIDS:

HIV antibody and viral load

Abuse:

Skeletal survey