Osce, Basel (2)

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

Acute chest pain:

• 1-3 hours  heart attack, unstable angina (NSEMI), aortic dissection,

pneumothorax (last for minute to hour, otherwise he will die!) First attack of GERD, diffuse spasm, trauma to chest.

• 3 days chest pain: o continuous:

1. Heart: Pericarditis 2. Lung: PE (based on size

presentation could be different. 3. Chest wall: herpes zoster

trauma to chest (musculoskeletal).

4. (Gastric cancer #10 in your list.) o Intermittent

CC OCD

PQRSTAA (and is it the first time?)

Associated symptoms (with the transition)

• Cardiac

• By system or by differential diagnosis ( pulmonary, GI, pericarditis

• Risk Factors: cardiac (5),

pericarditis (renal failure, recent heart attack, recent surgery, recent flu, malignancy, medication (TB),) pulmonary (recent travel, malignancy, CHF, ocp (for women)

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Knock, knock, knock Introduction:

As I understand, you are here because you have been having severe chest pain for the last three days, can you tell me more about that from the moment it started?

- How did it start? Gradually

- What were you doing at that time? I can’t remember. - Is it all the time or on and off? It’s all the time.

- Is it increasing or decreasing? It’s increasing.

- I can see you are in a lot of pain, bare with me for just a few minutes and then I’ll give you some painkiller.

- Is this the first time? Yes. - How do you feel it? Stabbing. - Does it shoot anywhere? No.

- On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain?

- Where you able to sleep last night? No.

- It must have been difficult, I’m glad you came here; hopefully we can figure out what’s going on.

- Is there anything that increasing or decreasing it like breathing or leaning forward? Did you try any medications?

- In addition to this, did you notice any other symptoms?

Constitutional symptoms:

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

Cardiac

: Any Nausea, vomiting, excessive sweating, loss of consciousness, dizziness, heart racing?

Lung:

Any cough, phlegm, shortness of breath, wheezing, chest tightness, coughing blood, recent flu like syndrome fever, night sweat?

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GI:

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

DVT:

Any recent trauma, redness and swelling in your legs, pain in calf, recent travel, prolonged staying in a position?

- Now I’m going to ask about factors that might put you at risk:

(Even though it looks like pericarditis, you still need to go for cardiac risk factors because you don’t want to lose anything.)

Cardiac: major (high blood sugar, high blood pressure, stress, diet, positive family history)

Pericarditis: …….

-And also pass medical history, family history and social history.

“A dream doesn’t become a reality through magic; it takes

sweat, determination and hard work” COLIN POWELL

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

1. Cardiac: stable Angina, unstable Angina Intermittent chest pain:

2. Pulmonary: __

3. GI: GERD, DES (diffuse oesophageal spasm

4. Panic attack: (patient can remember exactly how many episodes he had)

-As I understand you are here because you had chest pain for the last 6 weeks. Can you tell me more about it?

KKK

P: Yes, I’ve been having the pain for the last 6 weeks. It increased gradually, I’m concerned about it.

-I see, what is your concern? P: I started to have it at night.

-How about now, do you feel any pain right now? (Whenever patient says “I’m concerned” or “worried”, you should say “I can see you are concerned, what is your concern? Do you need any information? Are you interested in general information, or do you need any specific information?”)

-How did it start? Gradually. -What were you doing?

P: I was playing golf. (Playing golf has two important points. One would be because of the physical activity he’s doing; that might cause or aggravate chest pain, and the other would be bending during golf that might cause GERD.) -Is it increasing or decreasing?

-Is this the first time you have these symptoms?

-From that time until now, is the pain all the time or is it on and off? P: It’s on and off.

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-How many attacks have you had in the last week? (Frequency), how many in the beginning?

-Are these attacks, similar to the earlier ones?

-Are they more severe than before? How many blocks can you walk now? How many could you walk then? (What about having meal?)

-Can you show me where exactly the pain is? How does it feel like? Squeezing. -Does it shoot anywhere? My jaw.

-How about your shoulder, hand, and back?

-On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain?

-Is it in a particular time of the day? How about night?

-Is it related to activities, heavy meals, stress, breathing, cold air, change in position?

-Is there anything that increases or decreases your pain?

Constitutional Sx:

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

Cardiac:

Any Nausea, vomiting, excessive sweating, loss of consciousness, dizziness, heart racing?

Lung:

Any cough, phlegm, shortness of breath, wheezing, chest tightness, coughing blood, recent flu like syndrome fever, night sweat?

GI:

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

CHF symptom:

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

Panic attack symptoms:

excessive fear? sense of losing control, death or being crazy.

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-Because it is the first time I see you, I would like to ask some questions to see if there is any conditions that might explain your symptoms.

Risk Factors:

-Any history of high blood sugar, high blood pressure, high cholesterol, stress, and positive family history for heart disease?

-When is it diagnosed? Is it controlled?

-Do you smoke? How much and for how long?

-Have you ever considered quitting? (You have to be nonjudgmental.)

-I would like you to know smoking is harmful to your body, if you would like to, we can arrange a meeting to help you quit.

(And also past medical history, family history and social history).

“One important key to success is self-confidence.an important key to

self-confidence is preparation” . ARTHUR ASHE

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

counselling/clinic

Introduction

-As I understand you are here because you have been having chest pain for the last 6 weeks, during the next few minutes, I’ll take history, do some physical exams and hopefully toward the end of our session, we’ll reach our working plan.

-During the exam I might take some notes, is that okay with you? Do you have any questions at this start?

-When did your pain start?

P:It started 6 weeks ago and it’s improving and I’m very concerned. -What is your concern?

P: My dad died from heart disease in age 45.

-It is a very reasonable concern, I’m glad you came here. Hopefully we can figure it out together and deal with it.

-How did it start and how long did it last?

P:It started suddenly and lasted for a few hours. -Is it increasing or decreasing?

P: It’s almost the same as the beginning.

-From that time until now, is the pain all the time or is it on and off? P: It’s on and off.

- How long do they last? How about beginning? -How often do you have it?

-How does it feel? __ (patient refuse to answer this question) -Does it shoot anywhere?

-On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain?

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-Does it decrease or increase with exercises or changing positions?

-How did it affect your life, how did it affect you financially? You can refer the patient to social worker.

-Is there anything that makes it better or worse?

Cardiac: Any Nausea, vomiting, excessive sweating, loss of consciousness, dizziness, heart racing?

Lung: Any cough, phlegm, shortness of breath, wheezing, chest tightness, coughing blood, recent flu like syndrome fever, night sweat?

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

Risk Factors:

Cardiac: (5), CHF, GERD (repeated cough, change in voice, tight clothing position, diet triggers; like alcohol, chocolate, fat, obesity pregnancy and strogen.

PMH, FHX, SHX.

Counselling:

-I know you are here because you are concerned because of heart disease, this is quite reasonable to be worried about, as I told you.

Based on what we have done so far, the chance of having heart disease is low but because of smoking, positive family history, and diet, we still need to rule it out completely by doing some blood work, electrical tracing of your heart. Even -If they are normal, we still can’t send you for more confirmatory assessments, such as exercise test to be sure (EST), on the other hand, most likely your pain can be explained by a common condition called GERD. Have you ever heard of it? It stands for: Gastroesphageal Reflux Disease (always in concealing you should give the patient the name of the condition, then simply explain

pathophysiology and mechanism of the disease. Then talk about how to treat it and side effects of the treatment, and then mention about alternative option and complication of not treating.)

-When you eat food, it goes down through your feeding tube, or food pipe. In the lower part of your oesophagus is stomach which contains acid. There is a valve like structure between these two which prevent going acid up from

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are trying to do is preventing that from happening. It is a common condition that can be treated by modification of the risk factors.

-Is it reasonable? Wait control is important; I can refer you to a dietician. You need three meals and three snacks and also try to avoid having meals late before sleep and avoid these specific foods like alcohol, chocolate, avoid tight clothing and …..

It is also a good idea to raise the head of your bed about 6 inches (10 cm). Quitting in smoking is also important because you have been having symptoms while sleeping; it is a good idea to start some medication for you (proton pumps inhibitor). You have to take it for one month and we will see how it affects you. There is also some articles and brochures available here.

“

Open your arms to change, but don’t go of your values

”DALAI LAMA

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

Differential diagnosis: cardiac, GI, pulmonary, panic attack Introduction

As I understand ……….

P:Yes Dr. I have been having chest pain for the last 6 week. OCD, PQRSTAA

How did it start? Suddenly

What were you doing in that time? nothing How many attack did you have? Three

Dose it shoot anywhere? Are they the same or not? How does it feel? Not specific

On the scale from 1-10……….? 5-7, variable. Any increasing or decreasing factors? Not really

P:I am very concerned about that. I’m afraid from having another attack

Associated symptom:

Cardiac:

nausea+, vomiting, sweating+, dizziness+, heart racing+, loss of consciousness.

Lung:

SOB+, cough, whizzing, chest tightness.

GI:

difficulty swallowing+ (sense of lump in chest), heart burn.

Neurologic:

shakiness+, numbness, weakness, light headedness+, sense of losing control or going crazy+.

-Do you feel that things around you are not real? -Can you see yourself from outside from the attack?

-Sometimes whenever people have similar chest pain may lose control or feel that they’re going crazy or dying. Have you experienced it?

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-Is there anything that brings these attacks?

-Are you under stress? What kind of stress? How do you cope with it?

Co-morbidity:

GAD, OCD, PTSD, Phobia -Are you such a person that is worried a lot?

-Any fear from being in high places, or certain objects, or animals, or speaking in public (specific phobia)?

-Do you have repetitive intrusive thought that you feel you are not able to get rid of them (OCD)?

-Have you ever experienced in which personal and emotional safety and well-being is in danger?

-Any thinking, nightmares, flash backs about that?

-At that time, did you have tense period of sever fear for which you lose your control?

MOAPSS:

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

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

Counselling:

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

Explanation:

Imagine you are crossing a street and there is a car approaching you fast. How would you feel? At that time, you would feel afraid and your heart would go fast and your blood pressure would increase and you would be more alert and it is very important because it helps you to deal with a danger situation and this is related to a hormone called Norepinephrine.

Sometimes the same reaction might happen without any trigger and obvious risk which is panic attack. More than half of people will improve.

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We have 2 kinds of medications, first we start with benzodiazepine for the first 2 weeks. At the same time, we start other types of medication called SSRIs for 6 months. They are safe but because of some side effects, like abdominal

discomfort, nausea dizziness, we increase it gradually.

(In some patients improvement of energy might be faster than improvement of mood and it is important for those who have suicidal thought .in this situation they are told to contact their physician)

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

Abdominal pain Related to meal: mesenteric ischemia

,

Ischemic colitis, gastric cancer, pancreatic failure(bulky stool, shooting to back),GERD, cholecystitis Introduction

As I understand………

Patient is concern about having stomach cancer because his wife has died from stomach cancer.

When was that? How do you feel about that?

It is good you came here, now we can find what is the cause of your pain. Usually stomach cancer is not similar to flu; we don’t get it by infection. It’s related to food and the other risk factors but because you have been together for years, you have exposed to the same environment and some underlying risk factors.

OCD

PQRSTAA(increasing gradually-on and off-dull wage pain-no shooting) Is it related to anything? Any specific time in the day?

Any nausea, vomiting pain after meal, change in bowel movement? Did you lose weight?

Constitutional symptom

Risk factors:

for ischemic colitis: DM,HTN,FHX of heart disease (what kind? when? Are you under regular follow up? when was your last f/u visit? any intervention? Any treatment? any trigger?

(And For peptic ulcer and gastric cancer)

Wrap up:

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

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

Intermittent claudication:

1. Neurologic (increase pain when going down hills.) 2. Vascular (related to time, and increase going uphill.) OCD PQRST AA Local symptoms Risk Factors: 1. Cardiac 2. Neurologic, spinal PMH, FH, SH

As I understand you are here …. -Is the pain in one side or both? -Did you seek any medical attention?

-What makes you to choose to come today? My pain started last night. -What were you doing at that time?

-How often do you have it?

-How long does it last each time?

-What does bring the pain up? Is it related to any activities?

-How many blocks can you walk? (How many now? What about before?) -What do you do when you have pain?

-Do you have pain at rest? How about if you dangled your feet? -Have you ever wake up with this pain? (Alarming)

PQRST AA

-How does it feel? Crabs.

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-Did you notice you have you have more pain when you walk uphill or downhill? Does it make any difference?

-Is it related to time or related to the way you seat? Local symptoms:

In addition to your pain, do you have any numbness, tingling, weakness, burning sensation?

-Any color change, ulcer, hair loss, thickening of your nails, coldness? Back pain, back trauma

Constitutional symptoms: ...

Risk Factors: DM, HTN, high cholesterol, heart disease, smoking, medication (b-blocker), HX of peripheral vascular disease

-Sometimes some patients who have this pain, might note change in sexual desire or any difficulty with erection. What about you?

(If you have still time, check symptoms of heart and mesenteric ischemia) -How did it affect your life?

-I’m glad you came here today, we will do further steps to be sure.(ultrasound) I’ll give you a medical note for your work to modify your job.

“In order for you to succeed, your desire for success

should be

greater”

Than

your fear of failure”.

BILL COSBY

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

Introduction

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

-During - After

Causes: Medication (poly pharmacy)

Recent hypovolemia (decrease in take, recent bleeding, vomiting Diarrhea

PMH, FHx, Social history

4 setting in which you ask the patient “how do you feel right now?” 1) After the fall (did you hurt yourself? Does it still hurt? I’m going to take a

look after I finish my interview.)

2) The patient who couldn’t pass urine (Bear with me just for a few minutes, I will bring a surgeon to put a catheter for you.)

3) Hypoglycaemia and Arrhythmia (you are fine, I’m looking after you) 4) The patient who attempt suicide.

-As I understand, you are here because you had fell 20 minutes ago. Before I proceed, I’d like to ask you about how you feel right now.

-Did you hurt yourself?

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-Did you lose your consciousness? Yes, I was having a nap, when I woke up, I fell down on the floor.

-Where you alone? No, I was with my wife. -Did she accompany you?

-Did she describe what happened to you?

-If you don’t mind, after we finish, I’m going to clarify some point.

-Before you fell down, did you feel any dizziness or light-headedness? Any sense of spinning things around you?

-Did you fall down immediately, or were you able to take some steps?

-Before you fell down, did you feel hungry, heart racing, shakiness, sweating? (Hypoglycaemia)

-Any chest pain or heart racing? (ischemia- arrhythmia)

-Any weakness, numbness, difficulty finding words, change or loss of vision? (CVA)

-Any flashes, light, strange feeling? (Seizure) -How long were you unconscious?

-How did you regain consciousness? On your own or after intervention? (Hypoglycaemia)

-While you were unconscious, did your wife mention, if you were shaking or jerking moment? (One part, or all over the body? Did you bite your tongue, rolled up your eyes? Did you hurt yourself? Was there any loss in bladder, or bowel control? Where you breathing? Did you turn blue (seriousness)? After you gained your consciousness did you feel things around you are not familiar? (confusion)

-I’m going to ask more questions to see what would be the cause of your fall. -Do you take any medication? Do you have the list? Metformin, B- blocker, hydrochlorothiazide, Lipitor, ASA, B Complex, B12, benzodiazepine, Amitriptyline.

Ask about them one by one in Q2 exam and any recent change in medication in CE1 exam.

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How controlled where you?

When was the last time you saw your doctor? Do you measure your blood sugar?

Are you taking water pills? How long and why? Any new change in dose?

Why do you take b-blocker? For how long?

Why are you taking ASA? By prescription or on your own? Have you had recent bleeding?

You are taking two sleeping pills. Are they per scripted by the same doctor or a different doctor? Any recent change in dose?

What about amitriptyline? Are you depressed? How long are you taking it? Do you think about hurting yourself or the others?

Patient: I didn’t feel so good, so my doctor increased the dose of Amitriptyline. Did you have any diarrhoea bleeding, vomiting, …?

Constitutional symptoms, PMH, FHX, social HX. ( PE, was done  orthostatic hypotension)

Based on what you told me, most likely the reason of your fall is a condition called orthostatic or postural hypotension. Have you ever heard about that? Whenever we change our position from lying to sitting, or sitting to standing, the blood tends to pool in our legs. Usually, our body reacts to it by narrowing blood vessels to maintain blood pressure.

Sometimes because of age, medication , diabetes or combination of the body fail to react appropriately so the blood pressure drops and fails to reache to brain.

This condition may happen again so whenever you want to change your position, do it slowly or sit on the edge of the bed, also I would like to contact your psychiatrist in order to see if he wants to change the medication or adjust the dosage. Also ECG?

Life just does not hand you things. You have to get out there and

make things happen. EMERIL LAGASSE

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Heart racing

Case: male patient 37 years old, having palpitation for the last six weeks. Hx and counselling

Consequences of Atrial fibrillation: embolism, sudden death, heart failure Cause: age, coronary arty disease, valvular heart disease, heart failure,

hyperthyroidism in old patients, alcohol (holiday heart), lone AF ( only one time in 24 hours), COPD, medication ( digoxin), cocaine, any factor gives

tachycardia in right setting ( anaemia, ephedrine, chocolate, coffee,

antihistamine, decrease volume, beta agonist), any factor give enlargement of the heart

Differential diagnosis: pheochromocytoma, hyperthyroidism, panic attack Ask Sudden death in the family: 1. Hypertrophic cardiomyopathy 2. QT prolongation

Once the AF became continuous (48 H) the possibility of clot formation became high so we should ask to screen neurological problems: do you have difficulty finding words? Any weakness, numbness in your body?

KKKKKKKKKKK

Dr: Good afternoon, Mr. Douglas, I’m Dr. Miller one of the physician working in the clinic today. As i understand you are here because you have palpitation for the last six weeks, could you tell me more about it?

P: it is not improving and I’m getting concern about it. Dr: what kind of concern?

P: I have never had it before, I’m not sure is it serous or not.

(Whenever patient uses medical term we should clarify to make sure we are in the same line)

Dr: before I proceed I’d like to know, when you say palpitation what do you mean?

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(The patient might say my heart skipping beats or going fast, or my heart is bouncing in my chest)

P: my heart goes fast Dr: how did it start? P: I started suddenly

Dr: what were you doing? How long did it last at that time? From that time till now, is it all the time or on and off?

P: in the last 3 weeks it started became continuous and at the beginning it was attacks.

Dr: before that how often did you have it? What was the duration of these

attacks? What was the duration of the longest attack? Did you have any attack longer than 48 hours?

Dr: even during the night? How did it affect your sleep? (Because it is more than 24 hours we empathize with the patient)

Dr. Can you tap it for me? Dr: it sounds irregular to me.

Dr: is it the first time or did it happen before? P: no, it didn’t happen before.

Dr: with that did you notice any chest pain, chest tightness, any dizziness, light headedness, or loss of consciousness, sweating, nausea vomiting (cardiac symptoms)

(Because it is long and irregular and day and night it is not panic it attack.) Dr: Did you notice anything increase it? Anything decrease it? Anything brings it? Do you believe it related to coffee, chocolate, energy drinks, alcohol? Do you smoke (for extrasystoly) have you ever try recreational drugs (cocaine can cause arrhythmia)?

(If the patient says I fell I’m dying and it is scary we can say as empathy:

sometimes people feel like that with heart racing and I know that it is very scary) Transition: I’m going to ask you more questions to see what could be the cause.

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Dr: Do you have history of heart disease? Any history of thyroid disease? If you are in a place that everybody feels fine, do you feel hot? Do you have any weight loss and any shakiness? Do you have moist skin?

Anybody told you are pale? Any bleeding recently? Have you ever been

diagnosed with romatic fever? (if no) as a child did you have repeated attacks of sore throat? (if no) do you remember injection of penicillin or any antibiotic on regular basis?

P: yes, but I had allergy and they stopped it.

Dr: any repeated attacks of headache with the heart racing and excessive sweating? (pheo)

Dr: any diarrhoea? Flushing? (characinoid) Any family history of sudden death at young age?

Do you take medication? Have you ever been seen by a psychiatrics? In the last few weeks did you notice any difficulty finding words, weakness, numbness in your body?

Transition: as this is the first time I see you, any long term disease? Any high blood pressure? High blood sugar? Hospitalization.

How do you support yourself? Stress?

In the Ph.Ex don’t forget to tilt for mitral stenosis, use bell.

Ph.Ex: general exam, vitals, touch thyroid, cardiac exam, if have time neurological system.

Dizziness:

1. Panic attack

2. In older person deal with it as syncope, is it repeated or one time a. repeated: is it related to cough, urination, or emotional stress, vasovagal

b. once: is it related to change in position ( exclude everything related to event), medication, cardiac, neurologic, spinning

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General Physical Exam lessons:

Cardiovascular exam: Introduction, Vitals, inspection (general and specific), then palpation, then auscultation with 2 accentuating manoeuvres: sitting up and holding breath and in&out, bending forward. Then you go for peripheral related exams like JVP exam, finger nails.

Respiratory system: Introduction, Vitals, Inspection, palpation and feeling, tapping or percussion for resonance and dullness, auscultation and special tests (say 99, vocal and tactile fremitus, ego phony and whispered pectoroliqouy)

GI system: inspection, AUSCULTATION, percussion, superficial and deep palpation, some special tests like Mcburny and Row sing’s sign, DRE and pelvic exam.

MSK system: Introduction, Vitals, Inspection (SEADS: swelling, erythema, atrophy, deformity, scars), and palpation (TTC: tenderness, temperature, crepitus) Range of movement: active, passive and against resistance. In neck, back and hand do neurovascular. Shoulder mostly mechanical and knee mostly stability. Ankylosing spondylitis mostly mechanical. One joint above one below.

Neurologic exam: Introduction, Vitals, Inspection and orientation, Cranial nerves, upper and lower extremities, Coordination and gait and dysdiadocokinesia, end up with cortical sensation. Muscular exam: inspection, bulk, tone, power, reflexes and sensory. 5 feet: 150cm, 6 feet: 180, 5`6: 165, 220:100kg

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HAND TREMOR EXAM:

Hello, Good afternoon, Mr. Andros, I am Dr. Miller, one of the physicians working in this clinic today. As I understand you are here, because you have shakiness in your right hand. I have been asked to do a Physical examination, if you had any questions, Please do not hesitate to ask me.

If you want to do the V/S at the moment, it is fine, otherwise skip over it. Do not forget to ask about orthostatic hypotension (Parkinson disease).

1. Ask the patient to count from 10 to 1. The tremor did not disappear (even increased) which is consistent with Parkinson and rules out anxiety. 2. There is no fine tremors (rule out hyperthyroidism),

3. No flapping tremor(R/O liver and other internal organ failure).

4. Touch your nose and my finger repeatedly with arm change(R/O intentional tremor in cerebellar diseases).

5. Essential tremor is all the time and disappears with B-blockers or a shot of whisky and is familial.

In inspection the patient has tremor in his right hand and right arm and the patient does not have tremor in the left arm and if there is any pill rolling or head nodding, mention it. There is cog wheeling in the right arm and wrist and elbow, there is fine rigidity, I cannot assist any spasticity because the patient is rigid. There is no rigidity, spasticity, cog wheeling on the left side.

Now ask the patient to stand up, the patient has difficulty in initiating movement, having stooped posture, festinating gait, ask him to turn in blocks.

Pull the patient to the back (in Parkinson they continue to fall down and cannot control themselves).

Come and sit: check for mask face, decreased eye blinking and drooling, monotonous speech, articulation (normal or abnormal) micrographia and check for

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ACUTE BACK PAIN EXAM:

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

Do you prefer to be lying down or to be standing? Standing.

How did it start? 3 days ago I was lifting an object heavier than usual. How was the pain? Stabbing.

Were you able to continue? No. I had to stop.

From that time is it all the time or on and off? Increasing or decreasing? At certain time of the day?

Can you point or show me where your pain is? How does it feel? A sharp pain in my back. Does it shoot to anywhere? Yes, to my leg. Both or one? No, to the right one.

Which one bothers you more, your back or your leg? How is the severity of the pain if you want to grade it from 1 to 10? 7. That was very difficult I could not even sleep. Did you take any painkiller? Good you are here, hope we would be able to deal with that and help you. Anything that increase your pain? How about lying down, stretching your back, bending or moving?

Is it the first time you have such a problem?

In addition to your back pain, do you have any numbness, tingling? Any difficulty with your balance, any falls? Difficulty with passing urine or loss of control? Bowel

movement? Any numbness in the buttocks?

Any fever, night sweat, chills? Loss of appetite? Weight loss? Any trauma to your back?

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Long term diseases? Surgery? Burning sensation with urine? How did this affect you?

How do you support yourself financially?

Now I start the P/E, can you tell me the vitals please? Turn the patient to the way examiner can see.

May I untie your gown?

Normal cervical and thoracic curvature. No scoliosis, scars, atrophy. Feel your back, normal temperature.

I am going to press now. I reach lumbar area, if you have any pain please inform me. Do some movements for me please.

Try to bend as much as you can. Can you touch your toe with your fingers? Bend right and left. Can you cross your arms?

Walk towards the wall (hold your arms around him in order not to fall). Walk on your heels. He can. And on your toes, he will not be able to do it  There is normal L5 and impairment of S1. (Heel#L5, Toe#S1)

Please lie down. Do you need my help?

I am going to raise your leg, which might cause some pain, please inform me. (SLR test)

Then I go to the sensory, I am going to touch different parts of your toes:

Little toe: S1, Big toe (first web): L5, middle malleolous: L4, knee: L3, Mid Thigh: L2. Then check the powers.

Next step: Just relax. I want to check your reflexes, first the Knee, then the Achilles, you mention but do not do the Babinsky.

To examiner: I would like to do DRE. End up with the pulses.

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CHRONIC BACK PAIN:

Hello, Good afternoon, Mr. Anderson, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here due to the back pain since the last six months. I have been asked to do the physical exam. During my exam at any time if you had any pain discomfort or questions, please do not hesitate to ask me, also I will report my findings to the examiner, is that OK with you?

Can you tell me the Vitals, please? The patient is sitting comfortably with no signs of distress.

Would you please stand up?

If I wanted to do the history first or doing the physical exam of the Ankylosing

spondylitis, I would have started with my inspection (may I untie your gown?). Do you need my help?

From the side NL cervical and thoracic and lumbar curvature, no obvious scoliosis from the back view. No signs of scar, swelling, deformity or oedema, also no obvious muscle contraction.

I warm my hands. I am going to feel your back. NL temperature. I am pressing on the spine. Always identify C7 spinous process, then thoracic spine and lumbar area. Feel paravertebral muscles. Since it is chronic back pain, do Sacroiliac joints.

I’d like you to do some movements for me:

1. Can you touch your toes with your fingers without bending your knees? (Limited flexion)

2. Can you arch your back? Can you bend to the right and left laterals? 3. Can you slide your arm along your side?

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I am going to do a special test called Shober’s test: I am going to draw some lines on your back, which are washable:

Line 1: at the level of Sacroiliac joint and line: 2, 10 cm above it.

Try to touch your toes. The distance of 10 cm should increase to 15 cm or more.

Stand in front of the wall and touch the wall with back of your head, shoulders, hips and heels.

Then please walk. NL gait is seen. Walk on your toes: NL S1, Walk on your heels: NL L5.

I want to look at your eyes; there is no redness, pallor or yellowish discoloration of sclera. Ankle reflex is NL  S1.

Open your mouth, no ulcers.

I am going to take a look at your hands No pitting changes in the nails. No clubbing, no psoriatic changes or skin rash.

Would you please lie down? Cover him. Do SLR.

Do Patrick’s test.

Listen to his heart for murmur or regurgitation. Then mention digital rectal exam.

If time is left, mention power and sensory, too. Do the chest expansion test.

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Neck pain exam (short introduction):

Hello, good afternoon, Mr. Douglas, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here because of the neck pain for the last two weeks, and I have been asked to do a physical exam. During my exam if you had any pain or discomfort, or any other concerns to stop, please do not hesitate to inform me. Taking the vitals. Based on the vitals, the patient is stable and I am going to proceed (report any abnormality in the vitals). (If they don’t provide you the vitals you have to do them. If they don’t give you even 1 of them you have to ask for it).

The patient is sitting comfortable without any signs of distress.

Go to the back of the patient. I want to have a look at your neck. May I untie your gown? Normal cervical and thoracic curvature from the side. No scars, or deformity, muscular atrophy or swelling or erythema.

Warm the hands. I am going to feel: 1. Temp. Is Nl.

2. Feel the vertebrae, spinous processes till the middle of the thoracic spines? 3. Feel Para vertebral muscles.

4. Feel and exam Trapezius and Sternocleidomastoid muscle. 5. Then feel the mastoid process.

6. Then check for the lymph nodes.

I want to feel the back, if you had any pain, please inform me. Cervical spines are not tender.

I’d like you to do a swallow for me. No enlargement in the thyroid gland.

Go to the front. I want you to do some movements for me. Please touch your chest with your chin. Can you look to the ceiling? Can you turn your head to the right? To the left. Any pain?

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Can you touch your shoulder with your ear on the right? How about on the left? Can you cough for me? Any pain?

Then valsalva manoeuvre, can you press against my hand? Any pain?  Neck pain is not associated with any muscle spasm.

Part of my exam is to look at your upper extremities. Please roll up your sleeves. Deltoid, biceps and triceps are normal and symmetrical. Forearm, thenar and hypothenar muscles of NL bulk.

Check the tones in Stroke Pt.

Start to move the hands. No cog wheeling at the wrist, elbow and there is no lead pipe rigidity. And there is no clasp knife spasticity (there is a click and then relax in stroke like Chaghoo-zaamendaar) (velocity dependent). (Tremor is on top of cog wheeling, but not with lead pipe)

Can you touch your shoulders with your hands? (Support his arms with your hands). Do the sensory (peace of cotton and closure of both eyes) and exam the reflexes (biceps and brachioradialis: 5, 6- Triceps: 7, 8) then do the power (if you do biceps, triceps and deltoid it’s more than enough).

I like to stretch your arm on the painful side, and then Turn your head to the opposite side, electric shock shows irritation of the nerve (It is equal to SLR in the legs). Check all the powers in hands, wrists, fingers and forearms and arms.

Ask the patient to stand. Can you walk some steps for me? Check the gait. Say that you want to do the clonus.

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UNCONSCIOUS PATIENT, STROKE, P/E:

Knock, knock, knock,

Do the introduction to Rule out the locked in syndrome also to confirm the unconsciousness of the patient.

Hello, Mr. Douglas, Mr. Douglas, I am Dr. Miller one of the physicians working in the ER today. Can you open your eyes? Can you hear me? The Pt. is not responding. I want to open your eyes and shine the light in your eyes? Report the pupils now (dilated or constricted or round) If you hear me move your eyes up and down. Ask for Vitals:

1. Look for bradycardia and HTN or Cushing triad. 2. Look at the pattern of respiration and report it. 3. Feel the body and pay attention to the temperature.

Check the GCS (3-15). In intubated Pt. 10+T  If no response then ask for intubation. Check the cranial nerves while unconscious:

1. CN2 with Ophthalmoscopy to see retinal haemorrhage,

2. CN3,4and 6 the eyes are deviated or not and the movement of the eyes and their symmetry.

3. CN2, 3 for papillary reaction, 4. CN5and7 corneal reflex. 5. CN9&10 gag reflex.

6. CN7 with facial expression also drooling and nasolabial folds.

Then we go for upper extremity for inspection, check tone and reflexes, then the same for lower extremities report any spasticity or rigidity, dragging of leg is Nl.

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Then do the reflexes and Babinsky.

Look at the examiner and ask if neck x-ray is clear Then I have to do meningeal signs: kerning in knee, brudzinsky in the neck and neck stiffness unless in trauma. Are there any brain stem reflexes. Then you have to mention oculocephalic tests and cephalocaloric test (just verbalize it).

GCS: not in primary survey. In primary survey ABPU: alert... pain, unresponsiveness Verbal: talking normally: 5, short inappropriate sentences:4, inappropriate words:3, incomprehensible sounds:2, nothing:1.

Motor: can you move your arm: 6. Press on sternum and localizing: 5, if withdraw: 4, flexion: 3or decorticate, extension: 2or decerebrate, none: 1.

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CRANIAL NERVE EXAMINATION:

12 pairs of cranial nerves:

1. CN1. (Kallman syndrome) : Just to be done in Quebec exams. Coffee and ammonia (Rule out malingering).

2. Start with the Optic nerve. It has 5 steps. In 2 of them you shine the light inside the eyes for fundoscopy and pupillary reaction. 3 of them the patient looks for visual fields, colour vision and visual acuity.

3. Then go for CN 3, 4 and 6 by extra ocular movements. (Pupillary reaction is 2&3.)

4. Then you go for 5thCN.The CN5 has sensory and motor components. For motor: clench your teeth and corneal reflex.

5. CN7 is mostly motor.

6. The CN8 is hearing, do Rhinne and Weber in Manitoba and Newfoundland exams.

7. The CNs 9th and 10th

8. The CN11 has 2 steps (sternocleidomastoid and shrugging the shoulders). have 5 steps.

9. Stick your tongue in CN12 exam. Knock, knock, knock (short introduction)

Hello, good afternoon, Mr. Douglas, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here because of having head ache, and I have been asked to do the cranial nerve exam in the next 5 minutes. During my exam if you had any pain or discomfort, or any other concerns to stop, please do not hesitate to inform me.

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I am going to do the 2nd

1. Is it your best vision or you need eye glasses? Cover one eye with one hand and read the chart, middle line then jump down, and vice versa with the other eye do the same.

N. Exam:

2. Ask about the colour both sides and in between. 3. Check the visual field.

4. I am going to shine the light into your eyes. Check for direct and indirect (consensual) reflexes (swing test). Afferent is 2, efferent is 3. Both pupils are round, symmetric and reactive to light, not dilated, not constricted.

5. I want to do fundoscopic exam. Why? I am looking for disc oedema and 2-3 signs of HTN (flame shape hemorrhage, AV nicking, exudates, cupper wire) and 2-3 signs of D.M. (hard exudates and neovascularisation).

I am going to exam 3rd, 4th and 6th

1. By Inspection both eyes are symmetrical, no deviation, no nystagmus, no head tilting, no ptosis. (Head tilting in cases of 4th N. palsy that the patient wants to put his gaze at the same level, so adjust their head to see straight, like Alexander who had syphilis neuropathy and head tilting)(Ptosis is for 3

N.: (Corneal reflex is 5&7).

rd

2. Look at the tip of this pen and follow it with your eyes. At any time you had double vision, inform me, please. (H shape)

. N.).

Now we go the 5th

Now we go to the 7

N. (Trigeminal N.): Pay attention to temporal wasting, and clench your teeth (for masseter’s muscle). Check the sensory with piece of cotton with closed eyes in 3 sites vertically and bilaterally.

th

1. By inspection face is symmetrical, Nl. Nasolabial folds, no drooling, and no deviation in the angle of mouth.

. N.:

2. Now I’d like you to copy me and do some movements for me, can you raise your eyebrows, wrinkle your front or forehead, can you close your eyes and don’t let

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me open it. Can you puff out your cheeks, can you show me your teeth and smile, can you whistle

3. To the examiner: I’d like to do corneal reflex.

CN8: Go to the back of the patient, Whisper house and horse and ask the patient to repeat them after you and do the wiggling fingers closing to ears, bilaterally.

Now we go to 9 and 10. Give me a swallow, please. No hoarseness, NL voice, say AA, soft palate is symmetrical and uvula is central  To the examiner: I’d like to do gag reflex.

Now the 11th

1. Please shrug your shoulder while I press down, Nl.  Trapezius muscle. N.:

2. I’d like to turn your head to the right side against my hand and to the left side the same  Nl. Sternocleidomastoid muscle.

Now we reached the 12th

1. Would you please open your mouth, there is no fasciculation, there is no tongue atrophy.

N., Hypoglossal N.:

2. Would you please stick out your tongue, tongue is central, no deviation, turn it to the right and left, normal movement.

3. Press your tongue against your cheeks. Tongue deviation is to the same side as the lesion. For face and uvula is opposite.

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Shoulder exam:

Hello, Good afternoon, Mr. Walter, I am Dr. Miller one of the physicians working in this clinic today, as I understand you are here because you have pain in your shoulder for the last 2 weeks. I have been asked to do the physical exam. During my exam if you had any pain or discomfort, please do not hesitate to inform me. Also if you had any questions please do not hesitate to ask me. Also I will report my findings to the examiner, Is that OK with you?

Can you give me the Vitals, please? V/S is stable; the patient is sitting comfortably with no signs of distress.

I want to look at your shoulder; may I untie your gown?

In my inspection, both shoulders are symmetrical; both clavicle and scapula bones are at the same level, Normal muscle bulk bilaterally, no signs of scars, erythema, atrophy, deformity or swelling. Normal cervical curvature.

(Warm your hands)I want to feel your shoulder now. Temperature is Normal. I am going to press. Sternal notch is not tender, both sternoclavicular joints and both clavicles are not tender, acromioclavicular joints and acromions both are nontender.

I am going to continue my exam on your left shoulder. Spine of Scapula is not tender also middle aspect and tip of scapula are not tender.

When I am pressing on your spine in the neck do you have any pain? No sign of bursitis.

I’d like you to relax. Move the shoulder up and down, no pain or tenderness in rotator cuff area. Glenohumeral joint is not tender.

Check the sulcus sign to check Glenohumeral laxity. Check for cripitation in circular movement of the shoulder.

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Would you please put your gown back and stand up and face me, do you need my help?

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

shoulders.

ROTATOR CUFF INJURY:

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

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KNEE PAIN:

QEII patient in this case is usually young.

Hello, Good afternoon, Jack, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here due to the knee pain for the last week. I have been asked to do the physical exam. During my exam at any time if you had any pain

discomfort or questions, please do not hesitate to ask me, also I will report my findings to the examiner, is that OK with you?

Can you tell me the Vitals, please?  By general Inspection, The patient is sitting comfortably with no signs of distress.

Would you please stand up? Do you need my help? Can you put your gown a little bit up?  Both knees are symmetrical. NL joint alignment. No genu valgus or varus. Would you please walk to the wall? NL gait, no limping. No bulging in the popliteal fossa, no limping, NL gait.

Turn and lie down. I am going to drape you; by inspection both quadriceps muscles have the same bulk, no scar, atrophy, oedema, erythema or swelling.

Warm hands. I am going to feel your knee. Temperature is NL in both patellae and colder than the other parts of knee joint. If patellae and knee have the same temp, it means inflammation, doesn’t need to be warmer. Both knees are symmetrical with no local fever. Supra patellar pouch.

Press and swing the patella to R/O chondromalacia.

Then go to the large tendons and end up with tibial tuberosity(R/O Osgood-Schlatter). Lateral and medial collateral ligaments and press to the back.

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Bend your knee and feel up, down, middle. Feel lateral and medial tibial condyle. Check medial and lateral meniscus. Check crepitus and effusion.

Patellar tapping and bulging sign or milking test.

Range of movements: bend your knees, check flexion and extension. Check Power, push against my hand.

Exam stability of knee. Anterior and posterior cruciate ligament by anterior posterior drawer tests the same test is Laschman’s test but in 15 degrees, medial and lateral collateral ligaments by varus and valgus stress test in 15 degree.

Other knee exam and check the pulses.

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HIP PAIN EXAM:

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

Can you tell me the Vitals? Temp.: 40 and the patient is febrile  The Pt. is sitting comfortably and not in distress.

Would you please stand up? Do you need help?

If he cannot, exam him in lying down position with turning to the left side.

I’d like to have full inspection, can I have full exposure? (If no: mention that hips and symphysis are deep seated joints and we cannot get a lot of information by inspection or palpation, however I am looking for any obvious swelling, erythema, tenderness or deformity.

Lumbar curvature is NL. Gluteal folds are at the same level and both hips are symmetrical.

I am going to feel the local temperature.

I am going to press over the hips. Feel sacroiliac joint, posterior iliac spine, iliac crest and superior iliac spine.

Would you please walk towards the wall? NL gait, no limping.

Do Trendelenburg test? (To see the weakness of Gluteus Medius) Can you stretch your right leg towards the back, while you are holding the edge of the bed? I hold you from the back for support.

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I’d like to have full inspection and feel the inguinal ligaments, head of the femur and greater Trochanter also Symphysis Pubis. Check the R.O.M. and bend your knee as much as you can. Then you do internal, external rotation, flexion and extension, adduction and abduction.

2 special tests: Patrick’s test and Thomas test.

Up to 1 inch difference is accepted for the difference between the lengths of legs. Check the power. Press against my hands, up, down, in and out.

Patrick’s (Faber’s) test: would you please bend your knee and put it above the other knee. I press on the knee to R/O sacroiliitis. If you bring the bent leg to touch the bed, it will check piriformis syndrome. (Please check these 2 tests on YouTube, too) The people with Osteoarthritis cannot have full extension. Hold one knee and stretch the other knee is Thomas test. If the stretching leg is elevated from the bed shows ileopsoas tightness.

Ankle exam:

For ankle exam mention no open fracture, obvious swelling and bruises in trauma cases and SEADS in medical cases.

In the case of pure physical exam, you can have long introduction. In cases of both history and physical exam, introduction would be shorter. Suppose that examiner is blind, so you have to verbalize as much as you can.

They want to see how you react to stress or in difficult conditition. Really care about to find the Drape for the patient, even on the floor. First cover then put up the gown. Warm your hands (usually my hands are cold and I am going to warm them). Then warm your stethoscope with your coat. Always warn the patient before any movement. Can you show me where you have pain? Sympathize and do empathy. Tell him whatever you want to do on him, and ask him to do them.

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Cases:

Cardiovascular cases:

1- 65 y/o with essential hypertension for the last 30 years, do P/E. 2- 35y/o with high blood pressure, do focused cardiovascular exam. 3-25y/y recently diagnosed with high blood pressure, do relevant P/E. 4-60y/o with cuff muscle pain, take history and do P/E.

5- Take history and do P/E for a patient with palpitation in 35y/o patient 6-Patient with cardiac Murmur

7- 70 y/o man having surgery 3 days ago, not passing urine for 4 hours, next 10 minutes do physical exam.( volume state exam)

8- Pt. had a surgery 3 days ago, now having shortness of breath for the last 2-3 hours, next 5 minutes do P/E.

9-Pt. had a car accident, or fracture or surgery 24 hours ago, now comes with S.O.B. (think of fat emboli or pulm. Emboli or athelectasis) do P/E for the next 5 minutes. 10-Pt. with S.O.B. for the last 3 hours after surgery 3 days ago in the next 10 minutes do focused P/E.

11-Pt. having history of Heart failure for the last 10 years. 3 days ago he has developed S.O.B. In the next 10 minutes do P/E?

Respiratory cases:

1-Pt. has cough for the last 3 days. In the next 5 minutes do P/E?

2-55y/o Pt. has a history of breast cancer 5 years ago with mastectomy, received

chemotherapy and radiation, now she is having cough or S.O.B. for the last 3 days, do a focused P/E. (primary fibrosis)

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GI system:

A. Abdominal Pain:

1-24y/o female with lower abdominal pain for the last 24 hours, do P/E in 5 minutes. 2-35y/o woman came to the ER for severe abdominal pain for the last 2 hours, do P/E. 3-22y/o girl with the history of crohn’s disease for the last 5 years came with abdominal pain for the last 24 hours, do P/E in 5 minutes.

4- 30 y/o male with abdominal pain for the last 24 hours, do P/E in 5 minutes. B. GI bleeding:

1-61 y/o, well known alcoholic patient came to the ER with vomiting blood in next 5 minutes do P/E. (liver failure).

2-25 y/o Female Pt. with nasal bleeding, systematic and ENT exam. (Search for bruises and petechia)

Neurological cases:

1-HIV patient with head ache since the last week, do cranial nerve exam in 5 minutes 2-Pt has difficulty in his vision, 40y/o, in next 10 minutes take history and do P/E 3-Pt with crooked face (Bell’s palsy) do relevant P/E.

4- In Newfoundland Pt. is coming with hearing loss.

5- Pt. with weakness in the right or left hand, look for power, tone and reflexes

6-Pt. with diabetic foot do neurovascular exam. (If 5 minutes: no Monofilament test, if 10 minutes they want it)

7- Unconscious patient, do neurological assessment 8-Pt. with back pain, do P/E

MSK system:

1- Do all the joints, except elbow

2- Shoulder exam 3- neck exam 4- hand laceration and carpal tunnel syndrome

5-hip exam 6-knee trauma and c heck anterior and posterior cruciate ligament, medial and lateral collateral ligament and medial and lateral meniscus

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7- Osteoarthritis of the knee based on the age

8- Ankle sprain P/E or counselling, be careful to R/O fracture and ligament tear 9- Pt. who had acute back pain regardless of the age

10- 67y/o man with acute on chronic back pain for the last 6 months, 3 days ago started with severe back pain since 24 hours ago (Think of metastatic fractures, Prostatic malignancy or breast cancer or osteoporosis in old age)

11- Chronic back pain: If young think about Ankylosing spondylitis, if old think about spinal stenosis or osteoarthritis or facet joint

Then we will go to the joints and related cases one by one which are all mentioned above.

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Mr Walter coming to clinic because of difficulty in swallowing for last 6 weeks, next 5 min take history

(In 5 min cases you don’t need to give diagnosis)

DDx: oesophageal cancer, scleroderma, strictures, web, rings and diffuse spasm. First see if it is intermittent or progressive.

A) If intermittent  ask if it’s for solid/ fluid or both. 1. Solid and liquid  spasm.

2. Solid  ring or web.

B) If progressive  ask if it’s for solid/ fluid or both.

1. Did it stuck both or fluid first? Achalasia or scleroderma, 2. Started with solid food, think of cancer (mechanical factor).

Stroke/MS in brainstem affects coordination (whenever I eat foot, it comes out from my nose).

Approach:

first clarify (what do you mean?), second analyse (where? Intermittent vs. Continues, solid vs. both) and then go to associated symptom, risk factors and R/O other possibilities (in young patient think of HIV), PMHx, FHx and finally Social Hx. KKK,

Hello, good after noon Mr Douglas! I am doctor Miller, one physicians working in the clinic, nice to meet you.

D: As I understand you are here because you have difficulty swallowing for last 6 wks, can you tell me more about it?

P: Yes doctor for the last 6 wks I have difficulty swallowing, it’s not improving. When you say difficulty swallowing, what do you mean?

P: Doctor whenever I eat, it is difficult! Food stuck.

Can you show me where do you feel it stuck? Did it start suddenly or gradually? Gradually

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From that time till now, is it all the time or on-off? All the time Getting all the time. Solid or fluid? Solid food (meat)

Were you able to flush it down? When you drink, did it help? Yes or no!!!! Is the first time or happened to you before?

I am going to ask some questions to see if you have any symptoms related to that? Do you have any chest pain? Tightness? Do you vomit? Do you bring up undigested food? Any cough/ repeated chest infection/ change in your voice? Any abdominal pain/ distension/ change in bowel movement (constipation/diarrhea). Did you notice any blood in your stool or vomit blood?

Constitution symptom:

fever, night sweat, weight loss, lumps and bumps. How much weight loss over how long?

Any nausea vomiting, abdominal pain, tiredness (he is repeating)

Go for metastasis

: do you have any yellow discoloration, itchiness, pale stool and dark urine?

Any back pain?

Risk factors: do you have any history of GERD?

1) If yes  when was that? How long was it? Did you seek medical attention? Did you ever have any studies done? Did they ever put any camera or light in to your chest? Did they ever tell you that you have a condition called Barrette esoghagitis?

2) If no  ask for the symptoms; heart burn, acidic taste in your mouth, use a lot of pillows for sleeping?

Do you have history of smoke? Drink alcohol? Any family history of esophageal cancer? P: Yes my dad died of esophageal cancer.

When and in which age?

Any history of swallowing acid or alkaline? Chest surgery (not sure), chest radiation?

DDx:

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

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PMHx:

Hx of stroke, weakness, numbness, difficulty finding word, DM, any medication? +/- HIV?

Social Hx:

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

35 y/o male patient having fever for the last 6 weeks (history) *Think of HIV, Hepatitis, malignancies and spleenectomy.

* Start with introduction then analyzing fever then go for constitutional symptoms and DDx (head to toe). Pay enough attention to liver; symptoms and risk factors. End up with PMHx, FHx and Social Hx.

KKK,

Hello Mr Hutson...

As I understand, you are here because you have fever for the last 6 wks, can you tell me more about it? Yes doc. ...

How did it start? Suddenly or gradually? At that time did you have any flu/illness? Did you seek any medical attention before?

–NO  What motivated you to seek medical attention today? Maybe he say I started to have skin rash....

Increasing or decreasing? All the time or on-off?

Did you measure it? How often do you measure it? How do you measure it? What was the highest measurement? Any variation or special pattern? Did you try and

medication? Anything decrease/increase it? Is it the first time you have this or have had it before?

Constitutional symptoms

...

I am going to ask you more questions to see if you have any other symptoms:

Start with CNS; do you have any headache, nausea, vomiting, bothered by the light, neck pain, neck stiffness?

Any pain in your ears, discharge in your ears? Runny nose? Any pain in your face? Sore throat? Difficulty swallowing? Any tooth problem?

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Any heart racing (IE)? Chest pain? SOB?

Cough, phlegm, wheezing, chest tightness, contact with TB patients, have you ever been screened for TB (skin test)?

Abdominal pain? Distension? Diarrhea? Change in bowel movement?

Any flank pain, burning sensation, more go to the washroom, change in your urine? Any joint pain, joint swelling, Skin rash, ulcers in your body or mouth, red eye? Have you ever you or any of your family member been diagnosed by conditions called autoimmune disease? Like RA, SLE...

Any history of liver disease, have you been screened for liver disease/HIV? Have you been vaccinated for hepatitis? Do you have any yellow discoloration, dark urine, pale stools, itchiness, increase in size of your abdomen(pants), any bruises and swelling in your legs?

I am going to ask you some questions to see if you have exposed to liver disease without being aware of that, some of these questions might be personal but it is very important to ask them. I’d like you to know that whatever you tell me here is strictly confidential; I wouldn’t release any information without your permission unless I am requested by the law:

1. Any travel outside Canada recently? 2. Any raw fish/food, new restaurant?

3. Any history of hospitalization/ surgery, receiving blood, donating blood (screen)? 4. Any tattoo, piercing?

5. Do you smoke, drink? Have you ever tried recreational drugs? If yes; ask about IV drugs/needle.

6. Sexual Hx:

With whom do you live? Wife. How long have you been with your wife? 3 years. Before being with your wife did u have any sexual partner? Yes, from which age you become sexually active? 18

From that time till now how many partner have you had? 13

Did you practice safe sex always, I mean did you use condom in every single time? What is your sexual preference? Men, women or both? What type of sexual activity do you practice? Oral, anal or vaginal?

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Within the last 3 years have you had any other sexual partner in addition to your wife? Yes, when was the last time? Did you use protection?

Do you have any discharge, any lumps in groin area, and any ulcers in genitalia? How about your wife, does she have any symptoms, fever, and discharge?

Whenever you have fever, discharge, jaundice and lymph nodes, you need to ask good sexual history.

How do support yourself financially? Have you ever been exposed to blood or bodily fluids at work?

PMHx

: cancer, medications, allergies...

6

Giving the Lab test result to the patient:

1-Introduce yourself

2- Why/where/who ordered it? 3- Explain the result

4- Consequences; symptoms of liver disease 5- Causes of liver disease

6- PMHx 7- FHx

Abnormal liver function test (ALT>AST):

As I understand you are here to get the results of your blood work which was done 2 weeks age and I have the results and I am going to discuss it with you in a few minutes but because it’s first time I see you I am going to ask some Questions to help me get better understanding of these results.

What’s the reason for doing this test? Insurance

Is it the first time or have done it before? If yes...when? And what was the result? Don’t need to go through the SPIKE, it is not that much bad to have elevated liver enzyme!

Your results show that there is an elevation in one of the markers that use to assess function of your liver; we call it liver function test. If it’s elevated means there is an injury in the liver’s cells and they are different causes for that. Before talking about the causes I’d like to see if you have any symptoms related to that.

Acute symptoms; any recent of yellow discoloration, itchiness, dark urine, pale stool, sever flu like symptoms with joint pain and muscle ache. Any change in your appetite, hate taste of cigarettes, N/V

Chronic phase; did you notice any increase the size of your abdomen/belt, bruise, swelling in your ankles, vomiting blood and change in your memory.

Have you ever been diagnosed/screened with/for liver disease before? Have you ever been vaccinated for HBV/HAV before?

7

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

PMHx: blood disease, medication FHx: liver disease

8

Problem with drinking (elevated liver enzymes or change in behaviour):

First start with drinking habit then find impact in his life (medical, social, familial or psychiatric)

Abnormal liver function test (AST>ALT):

I can see you are upset, can u explain to me why you are upset? P- Did you cancel my insurance?

D- Definitely not, I am not aware of what insurance you are talking about, usually insurance companies determine whether to approve your application or not, from my prospective you are here to discuss your blood work which is related to liver. I am not sure if it’s related to your insurance company or not, most likely this the reason they cancelled your insurance.

If the patient insists  I can see how much you are frustrated and understand how it is important for you. I can assure you again it is not me who determine that’s done in insurance company you can talk to them, however, since you are here there is

something important to discuss and that’s your liver! The result of your blood work could be concerning to us.

Is it the first time or have done it before? If yes...when? And what was the result? Your results show that there is an elevation in one of the markers that use to assess function of your liver; we call it liver function test. If it’s elevated means there is an injury in the liver’s cells and they are different causes for that. Before talking about the causes I’d like to see if you have any symptoms related to that.

P- Doctor! Why don’t you repeat my test?

D- Mr... whenever we do blood test and we find it abnormal we double check, if you would like to repeat that we can do that but usually it’s accurate. Not only that, based on history if you have any abnormalities in your liver we need to do further

tests/assessments.

Acute symptoms: any recent of yellow discoloration, itchiness, dark urine, pale stool, sever flu like symptoms with joint pain and muscle ache. Any change in your appetite, hate taste of cigarettes, nausea, vomiting?

Chronic phase: Did you notice any increase the size of your abdomen/belt, bruise, swelling in your ankles, vomiting blood and change in your memory.