Taiwanwalker CS note
Section 1 General History/PE
Regular history pg 2 Challanging Questions pg 4 Difficult Questions pg 6 Common Counseling pg 7 Associated symptoms pg 8 Physical Exam pg 10
Section 2 Case Discussion
Gastrointestinal pg16
Abdominal pain/ Diarrhea/ Constipation/ Nausea&Vomitting/ Blood in stool/ UGI bleeding/ Jaundice/ Dyaphagia
Eyes and ENT pg22 Blurred vision/ Sore throat/ Loss of hearing/ Hoarseness Respiratory pg23 SOB&Cough/ Hemoptysis/ Asthma drug refill Cardiovascular pg25 Chest pain/ Palpitation
Neurology pg26
Dizziness&vertigo/ Headache/ LOC/ Numbness&weakness/ Frequent falls Seizure/ Tremor/ Confusion&memory loss
Urology pg30
Hematuria/ Obstructive symptoms/ Buring urination/ Incontinence/ Flank pain /Increasing urination
Rheumatology/Musculoskeletal pg32
Low back pain/ OA/ Heel pain/ knee pain/ Unilateral&Bilateral leg pain Shoulder pain/ Elbow pain/ Wrist pain /Polymyagia
Obstetrics/Gynecology pg36
Dyspareunia/ vaginal bleeding /vaginal discharge/ Hot flashes positive pregnancy test/ Amenorrhea
Pediatric pg38
Fever/Jaundice/ diarrhea/ DM/ stridor/ behaviour problem/ picky eater /bed wettin Phychiatry pg43
Anxiety+SOB/ Depression /Insomnia/ Phychosis Abuse/Assult pg45 Constitutial Symptoms pg46 night sweats/ Fatigue/ Weight gain/ Weight loss Others pg48
DM drug refill/ HTN drug refill/ Erectile dysfunction/ terminal cancer/ MVA Pre-employment medical checkup/ HIV drug refill/ Alcoholism/ Rash
Section 1 General History/PE
Regular history#Begin
Knock on the door(wait 2 seconds)
Hello Mr/Ms.XYZ nice to meet you,(shake hands) I am doctor Lin the duty doctor today, and I am here to ask you a few questions.
Let me make you more comfortable(drape the patient)
So, What cause you to come in today?-->I am sorry to hear that Can you tell me more about your problem?
#HPI: LQQ OPERA, ask PDF alone with O, or LIQURAAA Location:Where's the location of the pain?
Quality:Can you describe your pain? -->for example, sharp/dull/burning/or pressure like? Quantity:On a scale of 1-10, with 10 being the worst, how would you rate your pain? Onset:When did it start? How did it start?what were you doing when it started)?(Past: Did you experience the same problem before?
Duration:How long does it last?Frequency(timing):How often does it occur? Is the pain constant or intermittent ?
Is it getting better or worse? what time in a day does it usually present?
Precipitation: Do you remember anything that might have caused it? Is there any relationship with food and the pain(in epigastric pain case)? any relationship between the position and the dizziness?
Excerbation:Do you know anything can make the pain worse?
Relieving(Radiation): Do you know anything can make the pain better?The pain move to somewhere else? Have you tried anything to help?
Associated symptoms:Do you have other symptoms right now? -->Is that all the symptoms you have? #PHM: PAM HUGS FOS EAST SODA .
Begin with transition sentence:
I need to ask you few questions about your health in past, is that okay? I need to ask you few questions about your family health, is that okay? Can I ask you about your about your sexual and personal life, It'll be
confidental--> if no answer: I would like to know the whole pictures of your health condition and your infomation can be very helpful,(pause) is that Ok?
Past medical history: Do you have any illness in the past?any operation?any trauma?(Dizziness, pain cases, headache) ,Easy bleeding(In any bleeding case),DM/HTN/Hyperlipedemia(In limbs weakness/ numbness,erectile dysfunction)
Allergy:Are you allergic to anything?
Medical:Medication:Are you currently taking any medication including over-the counter medication and prescribed medication?Side effect?
Procedure: Any blood transfusion?(in anemia cases), when is your last PPD?(if suspected TB) , Have your colon been examined with any device?(colonscope in jaundice/blood in stool case )
Hospitalization: Have you been admitted to hospital before?
Urinary:Do you have any urinary symptoms ? Do you have trouble urinating ?
Is there any change to your urine habit? Is there any change to urine color?
Is there any change to stool color?
Sleep:How's your sleep recently? If not good->see insomnia
Family:Is there any illness in your family?
Ob/Gyn:When was your last menstrual period?(ask in detail if needed)
OB:(GPA+complications)How many times you have been pregnant?how many children did you give birth to? Have you ever had miscarriage?abortion? In which trimester?Any complication during pregnancy?
GYN:Symptoms:Do you have vaginal discharge/bleeding?Pain during intercourse? Any problem controlling bladder Past problem :Did you performed Dilation&Curettage, Did you have uterine infection (in Amenorrhea case), Did you use Intrauterine device? (in abdominal pain/vaginal
discharge case)
MP:MP Description:When is your first menstrual period? How often is your menstrual period? How long does it last? How many pads do you use in a heavy day?
MP complications: Is there any changes to your menstrual period? Have you ever bled between cycles? Do you have abdominal pain with your period? (in dyspareunia)
Pap smear:Have you had a pap smear? What's the last time you did a Pap smear?What's the results of the Pap smear?
Sexual:Are you sexually active?(In details: How many sexual partners do you have in last 6 months? Men, women or both?
-->Men specific:(Condom/impotence) Do you use condoms? Is there any change in your sexual function lately (if suspect impotence)
-->Woman specific(Condom/Contraception): Does your sexual partner use condom? do u use any birth control pills?
-->If high risk sexual behavior:(STD/HIV)Have you had sexually transmitted disease?
Have you been tested for HIV? (Also ask STD in lower abdominal pain/UTI/joint pain case) Exercise:Do you get any exercise?
Appetite(Also Diet and Weight):Is there any change in your appetite?What's your diet? Is there any change in your body weight?
Stress/support system(Also mood): Do you have any stress? Do you have anyone who can support you? (in physiological problem)
How's your mood?
Travel: Travel:Have you travelled recently? Did you have any immunization before travel?Any picnic/ camping(If GI case)?
Expose:Have you been exposure to animal? Have you been bite by insects?Have you been in contact with sick people?(If GI/URI/TB)?
Smoking:Have you been smoking? How much? Occupation:What's your job? Is your job stressful?
Drug:Have you been using any recreational drugs? (Heroin cause constipation, cocaine cause MI) How do you take it? How often do you take it? When was the last time you took it?
Alcohol:Have you been drinking alcohol? if yes->how much do you drink, how long have u been drinking ->If drink a lot-> ask CAGE
Cut:Do you feel that you need to cut down on your drinking? Annoyed:Does anyone complain about your drinking?
Guilt:Do you feel guilty about your drinking? Eye-opener:Do you drink alcohol in order to get rid of a hangover?
#Conclusion:
Summarize history:Right now I would like to summarize your history(Ex: you have chest pain for 5 days , it's progressing and it's burning. Also you have nausea and vomiting, is that right?)
Summarize PE:
Explain Diagnosis and Lab to do:(Ex:According to your history and physical examination, you might have a a inflammatory process of the esophagus, but we are not sure yet, so we would run some blood tests and we will do an image test to see the anatomy of your esophagus (also explain pelvic exam/rectal exam in low back pain/abdominal pain case)
Counselling:Also as a concerned physician, I would like to talk about your smoking/alcohol/unsafe sex/DM /HTN/current problem
Ask questions: Do you have any questions or concerns? Challenge questions:Do I have XYZ/ Do I need OP?There's possibility, but before I can answer your question, I would like to run some tests, I will study the results carefully, and we will sit down and discuss it all over again, I will make sure you are conformable during the examination.
If still have time:Can you think of anything that you want to tell me and I forget to ask?
Ending: Thank you verry much, Mr.Green, I will try my best to help you to get better, Please take care for now. Challanging Questions
Patient tells a lot of stories
Mr. Smith, sorry that I interupt you, but right now I want to focus more on your physical condition, I will try to find another time and you can tell me more about your trip, is that OK?
Patient says not interested to talk
Ms Green I understand it's really a tough time for you, but your condition could be cause by some medical problem, I will try my best to help you to feel better, can you try to answer my question?
Just give me some pain killer
Ms Green, I understand that you are in pain, but I need to ask a few questions to understand your pain, then we can give your safe treatment for your pain.
I want refill before the lab test
I will try to contact with the doctor who prescribed you medication to give you 1 or 2 days extension You are a good doctor so that’s why I come for refill
I am flattered, but I have to evaluate you again to study the safety of the medication, it’s my commitment to be careful.
Why are you asking so many questions?
I would like to know your general health as a whole to find out what’s wrong to give you the right treatment, so can you tell me more about ...
Do I have AIDS?
Will my insurance company going to pay for the test?
I am not sure, but I will refer you to a social worker to find that out, also I can write a letter to your insurance company to show how important is the test.
Can I go back to work?
It’s seems like work can worsen your condition, also I can write a letter to your employer to explain your condition.
Am I going to die?
Your condition raise my concern, most of the people will have symptoms improve after the treatment, however, no matter what’s happening, I will be at your side and I will try my best to help you
I need to go home for my child
I understand your concern, but according to your situation it’s your best interests to stay in the hospital,we have wonderful social worker who can solve your problem
Why do we have to live?
Life could be challenging, but I will try my best to make you feel better, is there any specific things on your mind which is bothering you?
Will I get better?
It’s hard to tell at this point, but most of the people would feel better after the treatment. I am in abdominal pain, can I have some water?
I am sorry I cant give you any water right now in case you need an emergency operation. I am afraid of OP
It’s very common to have the feeling for operation, however, I will make sure you are comfortable during the process.
Have HIV/STD, do I have to tell my wife? (Do you think he is cheating on me)
I know it’s difficult, but you should discuss with her in person, it’s important to have you both evaluated and treated at the same time if the result is positive.
It’s just because I am getting old.
Age could play a role in your problem, but we still have to rule out other causes like..., so I have to run some test on you and I will study it carefully.
What is ultrasound/EKG(Explain first, don't wait till they ask) Ultrasound:A machine using sound wave to detect your internal organ EKG:A machine detect electrical activity of heart
CT/MRI :special imaging test to detect your organ
Endoscope:A tube connected to a camera to see into your bowel/respiratory tract TSH: blood test for your thyroid activity
Pap smear: A test to collect your cervical cells to see if there’s abnormality Is this tumor malignant?
I cant answer your question until I get pathology report, I will read the results carefully and we’ll discuss it all over again, no matter what’s happening I will try my best to help you
Where have you been, I am waiting for a long time
I am very sorry you had to wait so long, but now I am here and will totally focus on your concern My mother has cancer, does it mean I will have it too?
The risk is increased, but doesnt mean you will get it, so regular screening test is very important. Losing pregnancy in vaginal bleeding?
The risk is increased, but doesnt mean you will lose it, so regular checkup is very important. Tubal ligation get pregnancy?
The risk is small, but there’s still possibility I heard herbal therapy works.
I heard that herbal therapy could be helpful to many disease, let me know the name of herbal therapy and I will study carefully about it’s safety and efficacy
HRT cause breast cancer?
It’s appears to be true, so that’s why HRT is only used with limited time to relief hot flashes
Crying:Tissue + touch shoulder: It must be very difficult for you, would you please tell me more about it Compliment on cloth/hairstyle, ask about your personal life
Thanks for the interests, but right now I would like to focus on you in order to help you. Change subject when ask about sex/drugs:
I’ve notice that you changed subjects while asking, I’ll try my best to help you, please tell me what’s your concern?
Difficult Questions
Urinary: irritative symptoms:screening with "Is there any change to urinary habits?
Urgency:Do you feel like you have to go to toilet right away once you feel the urge? Frequency:Do you feel like you have to urinate all the time?”
Nocturia:Do you need to get up in tthe night to urinate?
Obstructive symptoms: screening with "do you have any trouble urinating?(HIS Dimished PI)
Hesitancy:Do you Need to wait for the stream to begin? Intermittency Is the stream starts and stops intermittently?
Straining: Do you need to push hard during urination and only little urine comes out? Diminished stream:Have you noticed any weakness in your stream?
Postvoid dribbing:Any dribbling of urine after urination?”
Incomplete bladder emptying: sensation of not emptying your bladder completely after finishing the urination??
Bowel: Decrease stool caliber Do you feel the size of the stool is decreasing?
Tenesmus:Do you feel the need to pass stool even you just finish bowel movement?
Straining: Do you need to push hard during bowel movement and only little stool comes out? Derma: Rash questions:Description(Can you tell me more about your rash?),Onset( when did it start?) Progression(Is the rash progressing?From where to where?)
Ob/Gyn:Primary/secondary Amenorrhea: Did you have mensural period before? Galactorrhea:Is there any nipple dischage?
Hirsutism/Virilization:Did you notice any increase of body hair? is there any voice change? Douching: Did you use any advice to rinse your vagina?
Others: Impotence severity: On a scale of 1-6 ,as 6 is adequate for penetration, how are you going to rate your problem.
Secretions Questions(Vomitus/Diarrhea/Urine/Vaginal discharge/vaginal bleeding) :Content
/Color/Blood(and mucous in stool)/amount(A cupful, a teaspoon, or a tablespoon?) /odor Medication questions:Dosage, compliance, side effect, Control(HTN,DM), last HbA1C(DM)
Insulin:Site of injection, Insulin injector, Compliance with insulin, Schedule of insulin Common Counseling
Smoking
1.damage your heart and your lungs.
2.can use Nicotine patches or Gum to help reduce those withdrawal symptoms 3.we even have a professional team to help you deal with it better.
4. Feel free to contact me anytime if you decide to quit. Alcohol
1.Excess alcohol consumption raises your risk of high blood pressure, liver problem, car accidents
2.Avoid drinking before or when driving
3.We have a professional team that can help you deal with it better. 4.Feel free to contact me anytime if you decide to quit.
Unsafe sex:
1.use condoms regularly in order to reduce sexual transmitted disease
2. watch for unusual discharge, sores, redness, or growths in genital area, or pain while urinating.
3.blood test for HIV DM:
1. Follow regular exercise and diet instructions that will be provided to you 2. make a habit of using soft footwear whenever you walk
3. Be regular in blood-sugar monitoring so that dose adjustments can be done on time.
HTH:
1.regular exercise 2. reduction of weight 3. limiting salt
4. take regular health maintenance examinations to help control your blood pressure.
Hyperlipedemia:1.take the medicine regularly,
2.low fat, low salt diet, prevent things like egg yolk and fatty meat. 3.do some moderate exercise 30 min a day
1.weight reduction in patients with DM and HTN could eliminate the symptoms completely without medications.
2.We have a very good dietary specialist here in the clinic
Associated symptoms(Remember it well) Pediatric:URI:Runny Nose, Ear Discharge ,Ear pulling
LRI:Coughing, Rapid breathing, wheezing(Chest pain)
GI: Vomitting , Diarrhea/Constipation, Difficult swalowling, abdominal distension, (Abdominal pain)
CNS: Shaking, (Headache) Skin: rash jaundice
Others:Fever, tireness,crying Adult: URI:Start with asking cold symptoms
Ear:Ear pain, Ear discharge,Nose: Runny nose, postnasal dripping, Others: Painful swelling glands, facial pain/headache, sore throat
LRI: Chest pain, SOB, Cough, Wheezing
CV:Chest pain, Palpitation, SOB(nocturnal), peripheral edema, orthopnea CV+LRI: Chest pain, SOB, Cough, Wheezing, Palpitation, peripheral edema GI:Nausea/Vomiting, Diarrhea/Constipation,Abdominal pain
CNS:H:Headache, Head trauma, Lose of consciousness, neck stiffness EENT: Speech difficulty, vision change, Dizziness(light-headedness), Limbs: Limbs weakness/sensational change, Fall, (Gait problems,seizure Incontinence)
Onco: Swelling glands, Coughing, Bowel habit/stool color change,difficulty swallowing, itching Constitutional symptoms
Endo:hypothyroid: cold intolerance,weight gain (screening question), fatigue, depression, hair/skin change, constipation,voice change
hyperthyroid:Heat intolerance, weight loss(screening question), palpitation, tremor, nervousness
Uro:Irritative symptoms: Urgency, Frequency, Nocturia
Infection symtoms: Buring sensation, dysuria, flank pain
Obstructive symptoms:(HIS Dimished PI) Hesitancy, Intermittency ,Straining, Diminished stream , postvoid dribbling, Incomplete bladder emptying
Others:leaking urine, hematuria/urine color change Ears:Ear fullness/pain/discharge, vertigo/hearing loss/tinnutus
Eyes: eye discharge, halos around the light, the pain in the eye, headache Rheumatology:Mnemonic CITRUS HPT and other joint symptoms
Chest pain/ cough, Insect/tick bite,
Trauma/travel, Rash, (SLE.STD,Psorias) Ulcer in mouth(SLE) Stiffness in morning Hair loss, Photosensitivity(SLE)
Temperture cause finger color change (Raynaud's phenomenon) Joint: Joint redness/swelling, Joint trauma, morning stiffness,
Others: constitutional symptoms, cold temperture causing problems to finger (Raynaud's phenomenon), red eye/urethal discharge(Reiter syndrome), vaginal discharge(STD), rash(SLE.STD,Psorias,ask SLE questions) diarrhea(IBD, reactive arthritis), focal numbness/weakness(nerve injury)
SLE related :oral ulcer, photosensitivity, Rash, CNS(seizure/limbs weakness,headache), system review problems
Ob/Gyn:Menopause symptoms:Common :Hot flashes, Urinary irritaive symptoms, joint pain
Sex symptoms:vaginal itchness/dryness, pain when intercose/low libido, Others:mood change, Sleep distubance
Others:Constutional: Fever/Chills, Night sweats, Weight loss, fatigue, loss appetite
System review:Fever/Chills,CNS: Headache,dizziness Chest:Chest pain, Short of breath, cough, Abdomen:abdominal pain, Nausea/vomitting, Diarrhea/Constipation,
Urinary: any urinary problems Extremties:weakness /numbness Pituitary tumor:Headache/decrease vision, Galactorrhea/Amenorrhea,
Anorexia nervosa: Amenorrhea, Cold intolerance, body image
CNS symptoms after trauma:Head and neck: Headache(ask with Nausea/vomitting),stiff neck Memory loss (Change in personality,Confusion)
ENT:Change in vision, Discharge from the ears/mouth/nose , Dizziness
Limbs:Weakness or numbness in the extremities, shaking (convulsions)
Seizure: bit tongue, confusion after regain consciousness, incotinence during seizure, body shaking Jaundice: skin/urine/stool color change, pruritis,constutional symptoms
Colon cancer:Decrease in diameter of stool, bowel habit /stool color changes,straining/ bloating/ tenesmus
TB:cough, SOB, hemoptysis, pleuritic chest pain, constitutional symptoms Mononucleosis:sore throat, rash, jaundice, abdominal pain, swelling glands
Pregnancy symptoms:GI:Abdominal pain, Nausea/vomiting, Bowel habits change, Urine:Urinary habits change (frequent urination)
Constitutional:Fever, Fatigue, Appetite changes,Weight changes Others:Backpain/headache, Shortness of breath,
Skin changes, vaginal bleeding, Pulmonary embolism: Shortness of breath, Chest pain, Fever
DM complication:Visual: Visual change, Heart:chest pain, palpitation ,
Pulmonary:Cough, SOB, CNS: Headache, dizziness, , Abd:nausea/vomitting Urinary:urinary change( polyuria, dysuria, hematuria), impotence
Ext:limbs weakness/sensational change, foot infection
DM constitutional symptoms:Urinary habit changes(frequent urination) Abnormal thirst or extreme hunger, Weakness or fatigue, Weight changes, tireness
HTN complication:Visual: Visual change, Heart:chest pain, palpitation, edema, Pulmonary:Cough, SOB, CNS: Headache, dizziness, nose bleeding,
Urinary:urinary change, impotence Ext:limbs weakness/sensational change ADHD symptoms: cant concentrate, easily distracted, Have trouble sitting still ,moving all the time , talk too much, interupt games/conversation, has trouble waiting his turn. has trouble enjoy activities quietly, Not seem to listen when spoken to
Mnemonic:MS.WC(Used in Fatigue/Weight gain/Weight loss/amenorrhea/Confusion& memory loss/depression )
Mood change(if depressed asked FACE SLIPS and abuse) Sleep/snore/Stress/Support
Weight/appetite change(if low ask Oncology symptoms)
Physical Exam
Asbefore start:I will do some examinations on you, is that Ok? #HEENT:
Head: Palpation::I need to press lightly on your head/face
Eyes: Inspection: I need to check your eye, can you look up for me
Fundoscope(pupil):I will turn off the light and will shine a light and see your pupil Now I am going to see the back of your eyes
Visual field:Can you see the finger moving?
EOM:Can you follow my finger, dont move your head Ear: Inspection: I need to check your ears
Palpation::I need to press on your ear, I need to pull up your ear now. Otoscope: Right now ,I am going to look into your ear.
Rinne test: I'm going to put the fork behind your ears, say "now" when the noise stop Weber test:I'm going to put the fork on your forehead, tell me which side
it's louder or it's the same?
Whisper into ear:can you tell me what you hear? Nose:Inspection: I need to check your nose
Palpation on nose and sinus::I need to press on your nose/face Otoscope: Right now ,I am going to look into your nose .
Throat: Otoscope: Please stick out your tongue and say, ah. Can you lift your tongue ? Neck: Thyroid:I need to check for swelling glands, I need you to swallow
Lymph node:I need to check for swelling glands #Pulmonary exam (plus regular cadiovascular) Anterior
Inspection:first, let me look at your chest Palpation:For local tenderness
Tactile fremitus:Can you say 99 for me please?
Percussion:I am going to tap on your chest (4 points bilateral)
Auscultate: I need to listen to your lung now, can you take deep breath through your mouth for me? (3 points bilateral)
Posterior
Palpation again Tactile fremitus again Percussion again
Auscultate again ,(And listen to heart while telling patient breath in normally) Also remember to check hands for for cyanosis or clubbing
#Cardiovascular (plus regular pulmonary) Sitting
Palpation:I am pressing on your chest to feel your heart->(press on PMI , if chest pain case also palpate for local tenderness)
Auscultation:I need to listen to your heart(4 points)->(listen to posterior lung while pt's sitting) Lying
Neck:JVD:Please look to your left, I need to check your neck (shine light with otoscope,patient lie 45 degree, pull out extension) Carotid bruits:I am going to listen to your neck (use bell) Carotid pulse:I am going to check the pulse on your neck.
Also remember to check Pulse(quickly check radial/popliteal/posterior tibial),and Edema(called swelling) #Abdomen exam
Inspection:let me look at your belly
Auscultate:let me listen to your belly(2 side and midline)
Percussion: I need to tap on your belly(4 quadrate, and liver span if suspect hepatomegaly)
Palpation:I am going to press softly/deeply on your belly, is that causing any pain? Do you feel any pain when my hands let go? Liver/spleen palpation:I am checking your Liver/spleen
Signs:Murphy sign:Can you breath in for me?(while pressing RUQ, do with Liver palpation) Psoas sign: Can you raise your knee? is that causing any pain?
Obturator sign:Is that causing any pain?(flexion and interal rotation of hip) Rovsing sign(will know while LLQ tenderness while pressing)
CVA tenderness:I am going to knock on your back, is that causing any pain?(do it with psoas sign) Remember to mention Rectal exam/Pelvic exam at the end
#MMSE. Used in non-focal-deficit CNS Cases like Dementia/Delirium/Depression/Delusions/Confusion/ Schizophrenia
Begin:I would like to ask you some questions to test your memory and thinking,is that Ok? Orientation:Where are you now? Can you tell me your name? What day is today?
Registration :I would like to let you remember 3 words to test your memory, it's red/bicycle/happy, can you repeat after me?
Attention/Remote memory: Who's the president of United states? Can you spell "WORLD" backward? Recall:Can you tell me the 3 words I want you to remember?
If running out of time, just ask orientation
#Neurological exam:(CM RS CM, Can Mom Really Sing Country Music?)
Cranial nerves:
CN 2: Can u count this? (5 fingers with 1 feet in front)
CN3/4/6:Don't move your head, please move your eyes to follow my fingers
CN5-Can you clench your teeth like this? Can you close ur eyes and tell me where do you feel the touch. CN 7-Can you smile for me?
CN 8- I am going to rub my finger, tell me which side you hear it?Is both side equal? CN 9/10 Can you say ahhh(and look into mouth)
CN 12-Can you stick out your tongue? and try to move it left and right? CN 11-Can you do like this? (Shrug your shoulder and press resisting power) Muscle Power :
Upper extremities:Can you do like this?Dont let me move you, can you raise your wrist up ..and down,
can you spread your finger apart, can you squeeze my fingers real hard? Lower extremities:Can you raise your knee?and down ,Kick the leg out, and bring it back. Can you push your foot down,
Reflex: Right now I am going to check your reflexes ,Babinski:I need to tickle your feet.
Senses: can you close your eyes, tell me is it sharp or dull,(3 points each limbs) Positional(diabetic):This is up and this is down, tell me which direction I am moving your big toe. Vibration(diabetes):I'm going to put this on your feet, tell me can you feel anything?
Cerebellar:FNF:can you put your finger on your nose? and pointed to my fingertip? and back to your nose? Ok, the other hand. (Or can do shine to heel, rapid alternative movement)
Gait:Can you get down and walk to the sink ...and back
Romberg+Pronator drift:Can you put your palms up like this and close your eyes. I will protect you from falling down
Meningeal sign: Kernig:Please let me know if that hurts (flex the hip+extend the knee)
Brudzinski: I am going to lift your head up, please be relaxed.(flex the neck) Dix-Hallpikes test:(if you have time and BPPV is strongly suspected):Head extends looking 30 degree left and lie down see if there's any vertigo, and sit up wait 20 secs do it at the right side. #Joint exam(IPRPMRS,Interesting People Rarely Persisently Mention Routine Subjects)
Inspection:I am going to look at your feet/shoulder/hands
Palpation:Is that causing any pain?(check for tenderness, joint effusion) start with the painless side ROM:II am going to move your joint to see if there’s limitation
Pulse:I am going to check your pulse
Muscle strength:Do this, dont let me move you Reflexs:I need to tap on your arm/legs
Sensory:Light :Can you feel this? Does it feel the same?(Sharp/Dull: This is sharp and this is dull, now close your eyes, tell me it's sharp or dull?)
Shoulder pain: impingement symdrom (bring the arms across the chest or bring the arm around), Rotator cuff injury(drop arm test)
Wrist pain: +Tinel sign+Phalen test+Adson test
Tinel: I am going to tap on your wrist,(and extend the wrist while tapping) Phalen:Can you hold your hands like this? Is there's any numbness or pain? Lower back pain:+Gait+SLR+Hip exam
SLR: I am going to raise your legs, is that causing any pain(raise extended legs+ dorxiflex the foot for more than 60 degree)
Knee pain: Anterior/posterior drawer+Medial/lateral collateral ligament, McMurray test,Patella McMurray test:I am going to check (external rotate and extend the knee->then internal rotate and flexed the knee)
Anterior/posterior drawer test:I am going to check knee tendon(put thumbs on tibal plateau, hands holds tibia and push anterior then posterior)
Medial/lateral collateral ligament: is that causing any pain? (and bring the legs inward and outward)
#When to order breast, pelvic, rectal, genital exam?
Constipation/diarrhea, Lower abdominal pain: rectal exam, pelvic Amenorrhea: breast exam, pelvic
Erectile dysfunction, Urinary problem,Hematuria: genital, rectal
Pregnancy, viginal bleeding/discharge, dyspareunia, sexual abuse: pelvic Nausea/vomitting, low back pain: rectal exam
Bed wetting: genital exam #Rinne/Weber test
Normal:Rinne both ears AC>BC ,Weber without lateralization
Weber lateralizes left Weber lateralizes right Rinne both ears AC>BC Sensorineural loss in right Sensorineural loss in left
Rinne left BC>AC Conductive loss in left Conductive +sensorineural loss in left Rinne right BC>AC conductive+sensorineural loss in right Conductive loss in right
Conductive loss in left: Weber lateralizes left , Rinne left BC>AC
Sensorineural loss in left: Weber lateralizes right, Rinne both ears AC>BC
Conclusion:Abnormal Rinne(BC>AC), it’s conduction loss, otherwise it’s sensorineural loss Normal physcial:
no acute distress. VS: WNL
HEENT: Head no tenderness
Eyes: EOMI, PERRLA, normal fundus. (no icteric sclera, pale conjuntiva.) Ears/Nose/throat/mouth:WNL
Neck:Supple, no JVD, no LAD , normal thyroid ,carotid no bruits/2+ pulses Chest: Bilateral Clear BS,.
Heart: PMI not displaced, RRR; normal S1/S2; no murmur, rubs, gallops. Abdomen: Soft, +BS, ND/NT ,no Organomegaly, no masses
Neuro:CN2-12 intact. Motor 5/5 throughout. DTRs: 2/2 throughout, Babinski (-) bilateral Intact to light touch. Romberg (-) ,finger to nose normal,Gait: normal.
Extremities: No clubbing, cyanosis, edema. Bilateral 2+ perepheral pulses Back: No deformities or bruises. No tenderness. ROM normal .
Skin: no rash, no lesion
In detail depends on what is examined(red:abnormal PE CSA people can make) no acute distress.(anxious and in acute distress, in severe pain)
VS: WNL(except T:105F) Head:
Inspection:NC/AT,
Palpation:no tenderness (tenderness over right temporal area) Eyes:
Inspection: EOMI, no icteric sclera,no pale conjuntiva. (Lid lag nystagmus, visual loss,) Fundoscope: PERRLA , normal fundus.(photophobia)
Ears
Observation: no discharge Palpation:no tenderness
Otoscope:no cerumen, TMs with light reflex, no sign of infection
Weber Rinne:Weber test no lateralization, Rinne test AC>BC both side.(Decreasing hear ing acuity on left ear, Weber test lateraization to left, Rinne test AC>BC on left side) Nose:
No nasal congestion/discharge. Throat:
No tonsillar erythema, exudates, or swelling. (enlarged tonsil) Mouth:
no lesions, Moist MM, good dentition Neck :
Inspection:no JVD
LAD palpation: Supple, no LAD ,
Thyroid palpation: normal thyroid (thyroid bruits)
Carotid auscultation/pulse: carotid no bruits, 2+ pulse (carotid bruits) Chest:
Palpation: No tenderness(ribs tenderness)
Percussion:Clear to percussion Bilateral tactile fremitus WNL.(Increase tactile fremitus) Auscultation:Clear Breathing sound (wheezing, decrease breathing sound)
Heart:
PMI not displaced, RRR; normal S1/S2; no murmur,(rubs, gallops) Abdomen:
Inspection:(C-section scar) Auscultation:+BS
Palpation: Soft, ND/NT ,no Organomegaly, no masses ( tenderness, guarding, rebound, CVA tendernes, Psoas+,murphy+,Rovsing+, obturator+)
Neuro:
AAOx3(not oriented to time)
Able to spell backward (cant spell backwards)
Distant memories normal, 3/3 registration and recall x3(can’t recall 3 subjects) CN2-12 intact.
Motor 5/5 throughout.(motor 5/5 throughout except 3/5 in right arm) DTRs: 2/2 throughout, (DTR:3+ right,1+ left, brisk reflexs)
Babinski (-) bilateral. ( babinski+)
Intact to light touch. (impaired to light touch on left upper/lower ext) finger to nose normal(post-pointing and intentional tremor)
Romberg (-) ,(romberg+)
Gait: normal. (bradykinetic, takes small steps, walk with back slightly bend forward) Extremities:
Inspection:No clubbing, cyanosis, edema.(cyanosis, tremor on outstreched finger tips, right side swollen than left side, ulcer, pigmentation,erythema)
Palpation:(right side is warmer compared to left, pitting edema,tendrness)
ROM:normal(restricted ROM on flexion/entension of left knee compared to right knee) Pulse: Bil 2+ perepheral pulses (doralis pedis/posterior tibialis/brachial/redial)
Other:(Homer’s sign+,patrick test+, tinel sign, rotator cuff ,impingement sign+, ) Back:
Inspection:No deformities or bruises(deformities or bruises) Palpation:No tenderness(tenderness)
ROM normal(Limited anterior ROM) SLRT(-) (SLRT+)
Skin: no rash, no lesion(redness, jaundice, spiders/telangiectasias/palmar erythema) Useful scales:
Reflexes (0–4), with 0 being completely arefl exic: 1: Hyporefl exia.
2: Normal refl exes. 3: Hyperrefl exia.
4: Hyperrefl exia plus clonus (test the ankle and the knee).
Strength (0–5), with 0 representing an inability to move the limb: 1: Can move limb (wiggle toes).
2: Can lift limb against gravity.
3: Can lift limb with one-fi nger resistance from the examiner. 4: Can lift limb with two-fi nger resistance from the examiner. 5: Has full strength.
Pulses (0–4), with 0 representing pulselessness: 1: Weak pulse.
3: Increased pulse. 4: Pounding pulse
#Normal MSE(Only write when you have time) Appears well groomed
Mood/Affect is euthymic. Not hostile,cooperative AAOx3
able to spell backward (or 5/5 on serial 7s. )
Distant memories normal, 3/3 registration, 3/3 recall x3 Speech is fluid and goal directed
No abnormal perceptions No suicidal/homicidal idea Judgment/insight intact #Abnormal MSE
Apperance:Appears: (well groomed, disheveled, or unkempt).
Mood and affect:Mood is (euthymic, depressed, euphoric, angry, anxious ,apathetic). Affect is consistent with mood.
Behavior: (cooperative, uncooperative, hostile, guarded, suspicious, regressed, Inattentive, poor eye contact) Schizophrenia :catatonia, Stereotypies, Abnormal movements,disorganized behavior
Side effects of antipsychotic medication:akathisia, tremor or dystonia
Parkinson's disease, dementia or delirium: psychomotor retardation, akinesia or stupor) Neurological disorder: choreiform, athetoid or choreoathetoid movements may indicate a neurological disorder
Cognition: (alert, stuporous, or lethargic) and disoriented to person, place or time.
Attention and concentration:(able/unable) to spell WORLD backward (or 1/5 on serial 7s. ) Memory: Distant memories normal (impaired), 3/3 registration, 3/3 recall at 3 times.
Speech:Speech is fluid and goal directed Mania or anxiety: pressured speech
Depression: prolonged speech latency , speak slowly Schizophrenia halting and tangential, Disorganized speech
Perceptions: Doesn't have abnormal perceptions ( hallucinations, delusions, or paranoias) Thoughts:
Schizophrenia:Delusions of control, passivity experiences, thought withdrawal, thought insertion, thought broadcasting,Poverty of thought,suspicious beliefs ,suicidal/homicidal idea Mania:Flight of ideas
Depression: inhibited thinking, depressive beliefs ,fearful beliefs , Poverty of thought,suicidal/homicidal idea
Dementia:Poverty of thought, suicidal/homicidal idea Judgment/insight (intact or impaired).
Section 2 Case Dicussion
Introduction#Symptoms Lab test generally ordered
Differential diagnosis 1
Differential diagnosis 2>Lab test specifically used in that differential diagnosis
Differential diagnosis 3
◄ :commonly seen differential diagnosis
History:system related symptoms,other symptoms(Other: commonly forget history) PE: HEENT/neck/chest/CV/P/Abd/Neuro/Ext
Counsel: related to specific symptoms #PE Abbrevieation I use in this note :
(dont have time for orthostatic vital sign /blood pressure of both arms, don't even bother)
CV(Auscultation):CV, CV(Auscultation+Palpation):Full CV
Pulmonary(Auscultation): P, Pulmonary(Inspection, Auscultation, Percussion, Palpation):Full P Abdomen(Palpation):abd, Abdomen(Inspection, Auscultation, Percussion, Palpation):Full abd Neuro(Cranial nerve, muscle power, Reflex, Sensory, Cerebellar): Full Neuro
Extremities: Ext
Gastrointestinal
#EPIGASTRIC PAIN Rectal Exam, CBC/electrolytes/AST/ALT/bilirubin/Alk-P/Amylase/lipase, CT abdomen, Endoscopy with H pylori testing
Pancrease
Pancreatitis, Acute / Chronic ◄ Pancreatic cancer
Gastric
Peptic ulcer disease ◄
Peptic Ulcer Perforation ->Upright CXR
Gastritis ◄ Gastric cancer Funtional dyspepsia Gall Bladder
Cholecystitis ◄ >HIDA scan
Vascular
Abdominal Aortic Aneurism
Mesentery ischemia◄ >ECG
History: abdominal symptoms,constitutional symptoms,,LRI ,Jaundice symptoms ,chronic pain, black stools or blood in the stools , early satiety
(Others:Abdominal pain relation with food, history of OP/PUD/NSAID use)
#RUL PAIN: Rectal Exam, CBC/AST/ALT/bilirubin/Alk-P/viral hepatitis serologies, U/S abdomen
Gall Bladder
Cholecystitis◄ >HIDA scan
Bile duct
Ascending Cholangitis ◄ >MRCP,ERCP,blood culture (rule out sepsis)
Choledocholithiasis◄ >MRCP,ERCP
Sclerosing Cholangitis >MRCP,ERCP
Liver
Hepatitis ◄
Fitz-Hugh-Curtis Syndrome◄ ->Laparoscopy
History:abdominal symptoms,constitutional symptoms,jaundice symptoms (Others:history of gallstone)
PE: HEENT(Eye for jaundice,mouth), CV+P,
Full Abd(Murphy sign, Liver palpation)
#Male has LOWER ABDOMINAL PAIN Pelvic/Rectal exam, CBC/electrolytes, AXR/CT abdomen,U/A+ culture
GI
Appendicitis ◄ Diverticulitis ◄
Inflammatory Bowel Disease ◄ Uro
Nephrolithiasis ◄
UTI◄
#Young female with LOWER ABDOMINAL PAIN Pelvic/Rectal exam, CBC/ESR, urine hcG/ UA/culture, CT abdomen/U/S pelvis
GI Appendicitis ◄ Uro Nephrolithiasis UTI Gyn Endometriosis >laparoscopy◄ PID > cervical culture◄
Ovarian Torsion >Doppler U/S pelvis, laparoscopy◄ Ruptured Ovarian Cyst ◄
Ob
Spontaneous Abortion ◄ Ectopic pregnancy ◄
History:Urinary infection/irritation symptoms , abdominal symptoms,constitutional
symptoms,Weight change,,Vaginal spotting/discharge,heartburn (Others:STDs, history of OP/stone, LMP, detail ob/gyn history) PE:No HEENT ,CV+P+CVA ,Full Abd(Psoas, Obturator, Rovsing),ext
#LUL PAIN Rectal Exam, CBC/electrolytes, CXR/U/S abdomen/CT abdomen, Splenic Splenic Rupture◄ Splenic Infarction ◄ Others: Pneumonia◄ Kidney stone◄ Rib fracture◄
#CRAMPING ABDOMINAL PAIN Pelvic/Rectal exam, CBC/electrolytes, AXR/CT abdomen
Mechanical
Intestinal obstruction ◄ >Lactate, ABG
Hernia
Volvulus of the bowel ◄
Small Bowel or Colon Cancer ◄ Functiional
Mesenteric Ischemia / Infarction >Mesentetic angiography
leus ◄
Irritable Bowel Syndrome Infection
Gastroenteritis ◄ Food Poisoning ◄
#Acute Diarrhea Rectal exam, CBC/electrolytes, stool(leucocyte, culture, parasite antigen), AXR
Infection
Food poisoning ◄
Pseudomembranous colitis◄ >C difficile toxin
Traveler’s Diarrhea ◄ Infectious diarrhea ◄
#CHRONIC DIARRHEA Rectal exam, CBC/electrolytes/TSH, stool(leucocyte, parasite antigen, osmolarity, fat), AXR, colonscopy/barium enema
Diarrhea+ constipation
Inflammatory Bowel Disease◄ >small bowel series for chohn's disease, CT abdomen/pelvis
Irritable Bowel Syndrome ◄
Colorectal cancer◄ >CT abdomen/pelvis
Diverticulitis◄ >CT abdomen/pelvis
Infection
Infectious diarrhea ◄ Whipple's disease Bowel wall
Lactose intolerance ◄ >hydrogen breath test
Celiac Disease◄
Carcinoid >urine 5-HIAA, CT chest/abdomen
Small bowel lymphoma Endocrine+Exocrine Hyperthyroidism◄ >TSH
Chronic Pancreatitis ◄ Medication
Laxative abuse
History:hyperthyroid/ URI symptoms /colon cancer symptoms, abdominal symptoms,constitutional symptoms,Weight change, cough
(Others: diet/fluid intake/specific food related, HIV risk factor, mucous in stool history of OP/pancrease disease, stress for irritable bowel, ill contact/travel ) PE:HEENT(eyes, mouth for dry oral mucosa),Neck(thyroid), CV+P, Full abd, Ext(edema)
#Constipation Rectal exam, CBC/electrolytes/TSH , urine toxicology, FOBT, CT abdomen/ pelvis
Only constipation Depression ◄
Substance Abuse (Heroin) Hypothyroidism ◄
Low Fiber Diet ◄
Diarrhea+ constipation
Inflammatory Bowel Disease ◄
Irritable Bowel Syndrome◄ >small bowel series, colonscopy
Colorectal cancer◄ >CEA/LFT, barium enema, colonscopy
Diverticulitis◄
History:hypothyroid /colon cancer symptoms, abdominal symptoms,constitutional symptoms,Weight change, pain when defecation, colonscope
(Others: history of OP, heroin, mood for depression)
PE:HEENT(eyes, mouth for dry oral mucosa),Neck(thyroid), CV+P, Full abd, Ext(edema) # NAUSEA / VOMITING CBC/electrolytes, urine hCG, U/A, XR abdomen,
GI DM gastroparesis >sugar Gastritis ◄ bowel obstruction GERD Other inflamation
Peritoneal irritation(PID, cholecystitis, appendicitis, pyelonephritis, pancreatitis) UTI ◄ >urine culture
Pregnancy ◄
Intracranial lesion ◄ >Brain MRI
Metabolic◄ Hypercalcemia ◄ DKA
drug induced
# NAUSEA / VOMITING with headache CBC/electrolytes/ESR, MRI/CT brain, ECG, LP if no mass effect Intracranial tumor ◄ Meningitis/Encephalitis ◄ SAH/EDH/SDH ◄ Migrain, complicated ◄ stroke/TIA◄
History: Urinary infection/irritation symptoms,CNS (headache/stiffneck, vertigo, focal
numbness), abdominal symptoms,constitutional symptoms,Weight change,chest pain, vagainal discharge (others:sick contact, related meal, LMP for pregnancy,diet/fluid intake)
PE:HEENT(fundoscope, mouth for dry mucosa), CV+P,Full abd, ext
#BLOOD IN STOOLS Rectal exam, CBC/PT/PTT/CEA, CT pelvis/abdomen, barium enema/ colonscopy, Anal Proctitis ◄ Anal fissure ◄ Hemorrhoids ◄ Colon inflammation Infectious colitis◄
inflammatory bowel disease◄ Tumor
Colorectal Cancer >AST/ALT/alk-p/bilirumin (for metastasis)◄ Vascular
Angiodysplasia ◄
Ischemic Bowel Disease ◄ Other
Upper GI Bleeding Diverticulosis ◄
History;colon cancer symptoms, abdominal symptoms,constitutional symptoms,Weight change,mucous in stool, blood and BM relationship, rectal pain,
eye lesion/skin lesion/joint pain(for IBS), mucous, blood relationship with stool
(Others: bleeding duration, wafarin use, history of atherosclerotic vascular disease/ easy bleeding, diet)
PE:HEENT(eye for anemia,mouth), CV+P ,Full Abd,ext
#UPPER GI BLEEDING Rectal exam , CBC/Electrolytes, AST/ALT/bilirubin/Alk-P, stool(FOBT), endoscopy
Esophegeal
Mallory Weiss tear ◄ Esophageal Varices ◄ Esophagitis ◄ Gastric
Bleeding peptic Ulcer ◄ Gastritis ◄
Gastric Cancer ◄ >barium sawallow, CT abd
History:Jaundice symptoms, abdominal symptoms,constitutional symptoms,Weight change,nosebleed, stool color change, chronic pain, heartburn
(Others: symptoms/alcohol before bleeding, history of OP/PUD/liver disease/easy bleeding/trauma, appetite,medication like wafarin/NSAIDs, duration of bleeding, frank blood or coffee ground)
#JAUNDICE AST/ALT/bilirubin/alk-p/viral hepatitis serologies/PT/PTT , U/S abdomen,CT abdomen
Hepatitis
Infectious hepatitis ◄ Alcoholic hepatitis ◄
Drug induced hepatitis◄ >acetaminophen level
infectious mononucleosis Metabolic
Wilson's disease Hemochromatosis Obstruction:
Primary biliary cirrhosis ◄ >ERCP/MRCP
Choledocholithiasis ◄ >ERCP/MRCP
Malignancy (cholangiocarcinoma, pancreatic cancer, carcinoma of ampulla)◄ >ERCP/MRCP
Hemolytic
Hemolytic jaundice
History:Jaundice symptoms,infectiou mononucleosis symptoms, abdominal
symptoms,constitutional symptoms,Weight change,bleeding tendencies (Others: blood transfusion,hepatitis history, raw food, tarvel)
PE:HEENT(Eye),CV+P (look for spider nevi, cutaneous telangiectasis), Full Abd(Murphy sign, Liver palpation,ascites), Ext(asterixis, palmer erythema) #
DYSPHAGIA CBC/electrolytes, CXR, Barium swallow/endoscopy
Oropharyngeal dysphagia:(more on liquid)
Neuromuscular (CVA, Parkinsonism, multiple sclerosis, ALS ) Mechanical obstruction (Zenker diverticulum, thyromegaly)
Skeletal muscle disorders (myasthenia gravis, muscular dystrophies, polymyositis) Esophageal dysphagia(more on solid)
Esophageal Cancer◄ >CT chest
Esophageal Stricture ◄ Mitral Valve Stenosis ◄
Plummer Vinson Syndrome◄ >serum iron, ferritin, TIBC
Esophagitis ◄ ->HIV antibody and CD4 count (for high risk HIV)
GERD ->PH monitoring
Both(liquid and fluid)
achalasia◄ ->esophageal manometry
Systemic sclerosis ◄ ->esophageal manometry
History: abdominal symptoms,constitutional symptoms,Weight change,heart burns, painful swollowing(odynophagia), drooling, color change in finger,
choking sensation or regurgitation/aspiration,weakness of the arms or legs,SOB (Others: HIV risk factors, dysphagia on fluid/solid food, where the food stuck ) PE: HEENT(nose, mouth,eye for anemia), Neck(LN,thyroid), CV+P, Full abd,
EYES and ENT
#Blurred vision (CBC, blood glucose/HbA1C/lipid, U/A ,Doppler of carotids)
Diabetic retinopathy ◄ Hypertensive retinopathy ◄ Cataracts ◄ ->slip lamp
Glaucoma ◄ >tomoometry
Macular degeneration ◄
History:DM constitutional symptoms, eye symptoms
PE:HEENT(fundoscope), Neck(bruit), Neuro(cranial nerve,motor, sensory), CV
#SORE THROAT CBC+perepheral smear/LFT, Throat swab(culture and ASLO), Monospot test, HIV antibody/viral load/CD4
Common
Infectious Mononucleosis◄ >anti-EBV antibody
Viral or Bacterial Pharyngitis ◄ Uncommon
Acute HIV Infection ◄ Hepatitis
Mycoplasma pneumonia ◄ > mycoplasma IgM
Secondary Syphilis >VDRL/RPR
History:URI+LRI +constitutional symptoms ,mononucleosis symptoms, joint pain ,vaginal discharge(Others:ill contact)
PE:HEENT(eye for jaundice, Nose,mouth for oral thrush/tonsillar exudate,sinus), Neck(LN) CV+P, Full abd(organomegaly), Ext(rash)
Counsel:Infectious mononucleosis suggest no strenuous sport
#Lose of hearing VDRL/RPR, CT—head, Audiometry/Tympanography, BAEPs(Brain stem auditory evoked potentials)
conduction loss Cerumen impaction◄ Foreign body
Tympanic membrane perforation ◄ Cholesteatoma◄
Otitis media with effusion ◄ Otosclerosis ◄
Tumor in middle ear/ear canal Sensorineural loss
Ménière’s disease ◄ Ototoxicity ◄
Presbycusis ◄ Acoustic neuroma◄ Cochlear nerve damage:◄
History:Ear/CNS symptoms (Headache, weakness/sensational change, trauma) (Others: noise expose,social impact)
(Loud Foreign Jazz):
Exposure to loud noises? Insertion of foreign body?
Do words sound jumbled or distorted? Is hearing lost for all sounds or for anything specific? Can you locate the source of sound? Do you have any problems understanding speech? Dizziness/Vertigo:Do you feel like spinning is around you or it's inside?
PE:HEENT(nose, mouth ,sinuses,otoscopy/Rinne/Weber+whisper test ),Neck(carotid bruit) Full neuro, (CV)
#Hoarseness CBC/TSH, laryngoscopy+biopsy, CXR
Vocal nodules/ polyps Laryngitis
Leukoplakia
Lung cancer/ laryngeal cancer GERD > PH monitoring
Hypothyroidism Amyloidosis
Parkinson’s disease/stroke Trauma
History:Chest symptoms, hypothyroid symptoms,constitutional symptoms Heartburns,
dysphagia, swelling glands,postnasal dripping(Others: Activity/when get worse?environmental exposure)
PE:HEENT(Nose/mouth), Neck(Thyroid, LN), CV+P Counselling:
1.Voice rest
2.smoking cessation 3.Voice therapy in singer
RESPIRATORY TRACT
#SOBCBC, Gram stain and culture (if with sputum), PPD, CXR/CT chest, serum Mycoplasma IgM, Urine Legionella antigen, ABG (if SOB)
Treachea
Chronic Bronchitis◄ >PFT
Asthma ◄ >PFT+peak flow measurement
Aveolar/Interstitium
Pneumonia(typical and atypical) ◄ Interstitial Lung Disease >PFT
Heart:
Congestive Heart Failure◄ >U/S heart, ECG,BNP
Cardiac Valvular disease >U/S heart, ECG
Destructive
Tuberculosis ◄ >bronchoscopy, Acid fast stain
Lung Cancer ◄ >bronchoscopy
Phychologic
Anxiety and panic attacks
#COUGH (add SOB causes SOB causes)CBC, Gram stain and culture (if with sputum), PPD, CXR/CT chest, serum Mycoplasma IgM, Urine Legionella antigen, ABG (if SOB)
URI
Post nasal drip
URI associated (post infectious) GI
GERD ◄ Exposure
Occupation exposure Secondary to ACEI use◄
History:Respiratory, constitutioal symptoms,Postnatal drips, heartburns, night SOB,orthopnea leg pain/swelling,LOC (Others: TB/animal/chemical/sick people exposure, Last PPD,
family history of blood clots and heart problems, MI and immobilization) PE:HEENT(eye,nose,mouth,sinus),Neck(LN,JVP, carotid pulse/bruits)
full CV+Full P, Ext(clubbing/cyanosis, edema, calf muscle tenderness, pulses)
#Hemoptysis CBC/PT/PT, sputum Gram stain/AFB/culture/cytology, CXR/CT chest, PPD
Bronchiectasis ◄
Acute or chronic bronchitis ◄ Pneumonia
Bronchogenic carcinoma ◄ >bronchoscopy
Lung abscess Tuberculosis ◄
Connective tissue diseases ◄ (Wegener‘s disease, Goodpasture‘s, Lupus) ->ESR, BUN/Cre, c-anca
Pulmonary embolism >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer
History: Respiratory, constitutioal symptoms ,skin rash (Others:TB contact, Family history of coagulation)
PE:HEENT(eye,nose,mouth,sinus),Neck(LN,JVP, carotid pulse/bruits)
full CV+Full P, Ext(clubbing/cyanosis, edema, calf muscle tenderness, pulses) #Asthma drug refill:CBC/aspergillus serology, CXR, PFT, skin tests
Bronchial asthma COPD
bronchopulmonary aspergillosiss sinusitis
atypital GERD
History:Respiratory, constitutioal symptoms,medication problem, asthma control(regular activity /exercise/exccessive coughing/emergency), precititation,
PE:HEENT(nose,mouth,sinus),Neck(LN,JVP) full CV+Full P, Ext(clubbing/cyanosis, edema) Counsel:
1.Most common cause of recurrence of asthma symptoms is interruption of controller medications.
2.You should take it every day without missing a single dose. 3.see you again in about 3 months for a checkup.
Cardiovascular
#CHEST PAIN CBC/electrolytes, CPK-MB/troponin I, ECG, CXR, ABG(if SOB)
Heart(and aorta)
Angina >cardiac cathterization, exercise stress test
Myocardial Infarction (MI) ◄ >cardiac cathterization
Pericarditis
Aortic Dissection ◄ >TEE,aortic angiography, MRI/MRA-aorta
Pulmonary
Pulmonary embolism◄ >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer
Pulmonary Infarction – Sickle Cell Disease >V/Q scan, CT chest with contrast
Pneumothorax ◄ Pneumonia GI Esophageal Spasm Esophageal Rupture Esophagitis
GERD >Endoscopy, PH monitoring, barium swallow
Chest wall Muscle Strain Costochondritis Rib frcature
#If young adults+TSH/CBC/troponin/CK-MB/CPK, EKG,Urine VMA, CXR
Panic disorder ◄ Hyperthyroidism ◄
Pheochromocytoma ◄ >Urine VMA
Hyperventilation syndrome ◄
History:CV,LRI symptoms, noctural dyspnea, sweating, leg swelling/pain, dizzy, sense of terror, syncope , headache (Others: MI and immobilization)
PE:Neck(JVD, carotid pulse/bruit),Full CV+Full P, Full abd, Ext(edema, perepheral pusle) # Sickle cell anemia pt c/o chest pain :
History:CV symptoms,Pulmonary symptoms, pain in joint, dehydration, trauma PE:HEENT:(eye, mouth), Neck(LN), full P+full CV, Ext
Counsel:
1.avoid dehydration
2.contact doctor if there’s fever and short of breath 3.Flu shot each year
#PALPITATIONS CBC/electrolytes/glucose/TSH, ECG, Holter monitor
Heart Angina Cardiac Arrhythmias ◄ Endocrine Hypoglycemia ◄ Hyperthyroidism ◄ >FT4
Pheochromocytoma◄ >MRI abdomen, VMA
Carcinoid ->CT chest/abdomen ,5-HIAA
GAD (Generalized Anxiety Disorder) Hyperventilation episodes
Panic attacks ◄
History:CV, hyperthyroid /CNS symptoms (lightheadedness, headache, LOC,sweating) (Others: feeling/activity doing while palpitation, history of bleeding/anemia/heart heasese) PE:HEENT(exophthalmos, lid retraction, lid lag)Neck(thyroid palpation/bruit),
full CV,Ext(tremor, edema)
Neurology
#DIZZINESS CBC/electrolytes, MRI brain audiogram(if not hearing well)
CNS
TIA or stroke ◄
Brain Stem or Cerebellar Tumor Acoustic Neuroma ◄
Vertebrobasilar Insufficiency ◄ Heart
Coronary artery disease Congestive heart failure Arrhythmias ◄
Others
Orthostatic Hypotension◄ >Orthostatic vital sign, BUN/Cre
Autonomic dysfunction Hypoglycemia
#Vertigo Dix-hallpike maneuver, CBC/electrolytes, ENG(electronystagmography), MRI/MRA brain ,audiogram/BAEP(if not hearing well)
Meniere Disease ◄ >VDRL/RPR
Vestibular Neuronitis ◄ Labyrinthitis ◄
Benign Positional Vertigo ◄ Vertebrobasilar Insufficiency ◄
History:CNS,URI/LRI/Ear/Abdomen symptoms, Falls, palpitation(Others: history of neck injury/vasular disease, any warning sign )
PE:HEENT(eye for nystagmus ,mouth sinus,otoscope/Rinne+weber+whisper test sinuses if hearing loss) ,Neck(carotid bruit) Full Neuro ,(CV)
#SUDDEN HEADACHE CBC/ESR, CT head no contrast/MRI brain, LP analysis
Brain inflammation Encephalitis ◄
Meningitis◄ >LP analysis with gram stain, PCR, culture
Temporal Arteritis >temporal artery biopsy
Vascular
Acute hypertension ◄
Carotid/Vertebral artery dissection ◄ >doppler U/S carotid
Intracranial Venous Thrombosis◄
Intracranial/Subarachnoid Hemorrhage ◄ >PT/PTT,MRA brain
Sinusitis >CT sinus
Phychiatric
Caffeine or analgesic withdrawal
#Chronic headache CBC/ESR, CT head no contrast/MRI brain, LP CSF-analysis
Common
Cluster headache ◄ Migraine ◄
Tension headache◄
Temporal Arteritis >temporal artery biopsy
Neoplasm
Intracranial Neoplasm ◄
Pseudotumor Cerebri ◄ >urine hCG, LP analysis+opening pressure
Eyes+ENT mechanical Refractive errors Sinusitis >CT sinus Trigeminal Neuralgia TMJ Dysfunction Phychiatric Depression
History:CNS,URI symptoms, Aura, cough, tearing, neck pain, pain in jaw (Others:timing (time of the day, sleeping), mense relationship, OCP use)
PE:HEENT:(Palpation of temporal/sinuses/TMJ, nose, mouth),Neck(palpation to shoulder, carotid bruit), Neuro(CN, Muscle power, DTR,Brudzinski/kernig)
#LOSS OF CONSCIOUSNESS CBC/electrolytes/glucose, CT head/Doppler U/S carotid, ECG+Holter monitor,
CNS: Stroke ◄
Seizure◄ >EEG,MRI brain, prolactin
SAH/SDH/EDH >LP CSF analysis
Heart+ Vascular
Cardiac Arrhythmia◄ > U/S heart
MI >U/S heart
Aortic Stenosis◄ >U/S heart
Pulmonary Embolism◄ >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer
Vasovagal Syncope Endocrine
Drug-induced Orthostatic Hypotension◄ >orthostatic vital sign
Hypoglycemia
Substance Abuse / Overdose >urine toxicology
History:CV/CNS/ seizure symptoms, unusual sensation(palpitation, sounds, light,nausea) before falls (Others: LOC before or after the fall, history of heart disease/seizure/stroke/ PE risk factor, what happened/activity before the LOC)
PE:Full neuro, HEENT(head/mouth),Neck(Carotid pulse/bruit/thyroid),CV Counsel:
1.not drive again until we are sure what caused you to loss consciousness, #NUMBNESS & WEAKNESS
UMN:Intracranial CNS Vasculitis
Intracranial tumor◄ >MRI brain
Seizure /Todds Paralysis◄ >EEG
Stroke /TIA ◄ >MRI/CT brain ,ECG, Doppler carotid, U/S heart, PT/PTT
SDH/EDH ◄ >Brain CT
Migraine, complicated ◄ UMN:Spinal
Tumor in the Vertebral Canal >MRI spine
Neurosyphilis >RPR/VDRL
Syringomyelia >MRI spine
ALS >EMG/NCV, CT/MRI cervical spine
Horner’s Syndrome
MS ◄ >VEP(visual evoked potential), CSF analysis, MRI brain
LMN+muscular
Peripheral Neuropathy (Diabetic/Alcoholic/B12 Deficiency)◄ Polymyositis
GBS >CSF analysis, EMG/NCV
Myasthenia Gravis◄ >Tensilon test, single fiber EMG,Ach antibody, chest CT(for thymoma)
Others:
Conversion Disorder Hyperventilation Hypoglycemia Hypocalcemia
History:CNS, constitutional symptoms (Others: distribution, history of DM/HTN/vasular disease)
PE:Neuro(Muscle power, sensation, DTR), Ext(pulse),Neck(Carotid bruit) #Frequent Falls CBC/electrolytes, MRI brain,EEG,EKG
Brain Cerebellar disease ◄ Seizure Brain tumors ◄ Parkinson‘s disease◄ Others: Diabetic neuropathy ◄ Fractured hip Vertigo ◄
History:Neurological symptoms, seizure, palpitation, dizziness
(Others:injury associated with fall,los e consciousness before or after your fall? any difference in the way you walk? living condition and supporting systems)
#Seizure CBC/electrolytes/glucose/prolactin, CT head/MRI brain, EEG, LP with CSF analysis, urine toxicology
CNS
Brain tumor ◄
SAH/SDH/EDH◄ Endocrine
hypoglycemia ◄
Alcohol withdrawal/ Substance Abuse ◄
Tremor: TSH, heavy metal screen, MRI brain
CNS lesion
Parkinson’s disease ◄ Midbrain lesion
Wilson’s disease >ceruloplamin, slit lamp examination, AST/ALT, 24 hr urine copper, liver biopsy cerebellar lesion◄ Others: Drug-induced tremor Essential tremor ◄ Physiologic tremor ◄ Psychogenic tremor Hyperthyroidism ◄
PE:Full neuro, Neck:(thyroid,carotid bruit),
#CONFUSION/MEMORY LOSS CBC/B12/TSH/RPR/electrolytes/Ca/glucose/BUN/cre, CT head/MRI brain ,EEG, LP
Dementia
Alzheimer’s Disease ◄ Lewy Body Dementia Vascular Dementia ◄ Pick's dementia
Normal Pressure Hydrocephalus◄ >LP CSF analysis+opening pressure
Huntinton's disease
Progressive supranuclear palsy Depression(pseudo-dementia)◄ Intracranial lesion
Intracranial Tumor ◄
Chronic Subdural hematoma◄ Infection cause
Creutzfeldt-Jakob Dis. >brain biopsy
Neurosyphilis Metabolic cause Hypoglycemia Hypothyroidism ◄ Wernicke’s Encephalopathy B12 Deficiency◄ >serum B12 Others: Delirium
History:MS.WC ,CNS symptoms ,ADL, IADL incotinence ,gait disturbance, Things hard to remember
ADLs(DEATH)+IADLs(SHAFT)
Begin with :Is there anything in the daily living you can't do by yourself? Dressing: Do you have problem wearing clothes?
Eating: Do you have problem eating by yourself? (Can ask alone with F) Ambulation: Do you have problem getting in and out of bed?
Toileting: Do you have problem using toliet? Hygiene: Do you have problem bathing? Shopping: Do you have problem shopping?
Housekeeping: Do you have problem keeping your house clean? Accounting: Do you have problems managing money?
(Food preparation: Do you have problem preparing food?)
(Transportation:Do you have any problem driving a car or taking a bus?) PE:Full neuro(+MMSE), HEENT(pupils, fundus),Neck:(thyroid,carotid bruit) Counsel:
1. permission to speak with family members about social support and safety at home. 2. excellent social worker managing daily activities and future living plans
3.Explain the necessity to take medicine regularly
Urology
#HEMATURIA Genitourinary exam/rectal exam, BUN/cre/PSA/CBC/PT/PTT, UA/cytology, CT abdomen/pelvis, U/S renal/transrectal, IVP
HITTERS
Hemotalogy-coagulation◄ Infection◄
Trauma
Tumor(Bladder Cancer/RCC/Prostate Cancer)◄ Exercise
Renal disorders(AGN, PCKD) Stone(Nephrolithiasis )◄
History: urinary Irritative+infection symptoms +Constitutional, sore throat ,jaundice(Others:history of vigorous
exercise/trauma/stone/cancer/hepatitis/easy bleeding, quantity of unine, food like berries/colored candy/beets)
PE:HEENT(eye for anemia,mouth),CV, full abd(+CVA tenderness), Ext(inspection, palpation for inguinal LN)
#obstructive symptoms Rectal exam, CBC/BUN/Cre/PSA, UA+culture,U/S prostate
Prostate BPH ◄
Prostate Cancer◄ >CT pelvis, IVP
Bladder
Bladder Cancer ◄ Bladder Stones ◄ Renal
Renal Cell Carcinoma Nephrolithiasis ◄
History: urinary Irritative+infection, obstructive symptoms,+Constitutional back pain, trauma,hematuria
(Others:history of stone/cancer/BPH/urinary tract instrumentation) PE:full abd(suprapubic percussion for distended bladder),
neuro(lower ext Muscle power, sensation, DTR)
#burning urine Genital exam, CBC/BUN/Cre, UA/culture, (Gram stain/culture on urethral discharge if appears), (Chlamydia and gonorrhea PCR if suspected STD)
Urethritis, ◄ Cystitis, ◄ Prostatitis ◄
Acute Pyelonephritis◄ >CT abdomen, U/S renal
Vaginitis◄
History:rinary Irritative+infection symptoms +Constitutionalpain when intercose, back pain, vaginal discharge, bleeding
(Others: STD, history of stone/cancer/UTI/BPH/trauma/urinary tract instrumentation)
#Incontinence in female Pelvic exam, Bun/cre, U/S abdomen+post voiding volumn, Urodynamic study, UA+culture
Stress incontinence Urge incontinence functional incontinence Overflow incotinence Cystitis
History:rinary Irritative+infection symptoms +Constitutional,activity/strong urge before leaking,leaking during sleep weakness/numbness, LBP
(Others: affect daily living/relationship, viginal delivery) PE:Full abd +CVA, neuro(motor, DTR,Sensory)
Counsel:
1.the outlet of bladder become weak
2.also has to rule out neurological and infection problem 3.Restriction of caffine/alcohol
4.Wearing absorbent pad to avoid embrassing incident
#FLANK PAIN Rectal exam, BUN/Cre, UA/urine culture, IVP/CT abdomen/U/S renal
Inflammation
Glomerulonephritis◄ Pyelonephritis ◄ Cancer
Renal cell carcinoma ◄ Stone
Retroperitoneal lesions
#INCREASING URINATION Fasting blood sugar/electrolytes, Urinalysis , Urine and serum osmolality
Diabetes mellitus ◄
Central diabetes insipidus ◄ Nephrogenic diabetes insipidus ◄ Psychogenic polydypsia ◄
Hypercalcemia ◄
History:DM constitutional symptom, urinary obstructive /irritative/ infection symptoms(Others: head trauma, psychiatric problems ) PE:HEENT(oral mucous, fundus),Ext (MP/reflex, sensation ), CV
Rheumatology/Musculoskeletal
Rheumatology:Ask rheumatology system specific symptoms first(CITRUS HPT) CITRUS HPT:Chest pain/ cough, Insect/tick bite,
Trauma/travel, Rash,
Ulcer in mouth Stiffness in morning Hair loss, Photosensitivity
Temperture cause finger color change
#LOW BACK PAIN XR-L spine,MRI L spine ,DEXA scan , Ca/P/Alk-P
Muscular
Lumbar Muscle Strain ◄ Mechanical
Disk Herniation ◄ Cauda equina syndrome
Osteoporosis with vertebral body fracture Degenerative joint disease ◄
Lumbar Spinal Stenosis ◄ Oncology
Tumor in the vertebral canal ◄ Pathologic fracture Rheumatology Ankylosing Spondilitis RA Infection osteomyelitis/discitis/epidural abscess Intraabdominal+retroperotoneal pathology Abdominal aortic aneurysm
Others Malingering
Knee or leg fracture >X ray knee
History:constitutional symptoms , urinary/fecal incotinence, weakness/numbness, difficulty urinating (Others: Trauma, history of cancer, urinary tractinfection, DM, renal stone)
