Osce Basil.

Please note that this is only a draft version based on several sources, including: Dr.
Basel Mohasens lectures,

Toronto Notes, Therapeutic Choices and others. Edited and organized for the sake of all attendances of the
Canadian Osce Exams: NAC OSCE and MCCQE2. by: Dr. Merlyn DSouza and Dr. Zeev Gross, Spring 2011. Page 1
Content
Medicine
CVS
Ankle swelling
Calf pain
Hypertension
MI
Palpitation
Syncope

RS
Asthma
Cough, Acute
Cough, Chronic
Hemoptysis
SOB
SOB Post Surgery

Hematology
High MCV
Wrong blood transfusion

Ophthalmology
Loss of vision

Diabetes
DKA
Tiredness

GI
Abnormal LFT
Acute abdomen
Diarrhea
Dysphagia
GERD
Mesenteric Iscemia

GU
Introduction
Dark urine
Geriatric wets himself
Difficulty to pass urine

HIV
Breaking news HIV
Fever and tiredness
Headache HIV complications
HIV test request
Needle stick injury
Tiredness for 6 weeks

Neurology
Approach to
Headache, acute
Headache, environmental
Headache, primary
Headache, subacute
Headache, template
Multiple Sclerosis
Neuropathic pain
Weakness in arm

Otolaryngology
Allergic rhinitis
Lump in neck
Please note that this is only a draft version based on several sources, including: Dr. Basel Mohasens lectures,
Counselling
Abortion
Ante-natal counselling
Breast Feeding
Diabetic daughter
Domestic violance
Endometrial cancer
Epilepsy
Fall
Febrile seizure
HRT
Lump in breast
Obesity
OCP
Pregnancy
Smoking Cessation
Warfarin Counseling
Pap Smear
OCP 3
Breast feeding 5
Ante-natal 7
HIV 9
Needle stick 10
IUGR 11
Abortion 12
Sexual abuse 14
Epilepsy 15
Drug seeker 17
Smoking cessation 18
Alcohol cessation 20
Imptence 21
HRT 22
Obesity 24

Paediatrics
Introduction
Anaphylactic Shock
Cough
Cry
Diarrhea
Diabetic daughter
Febrile seizure
Fever
Marijuana counseling
Osgood Schlatter
Pale
Phone cases
Post-concussion
Vomiting
Yellow discoloration
Immunization
IUGR
Child abuse
Enuresis

FTT 1
Child abuse 2
Speech delay 3
Vomiting in newborn 4
Enuresis 5
Febrile seizures 6
Jaundice child 7
Joint pain 8
Child with ADHD 9
Child with chronic cough 10
Child with abdominal pain 11
Well-baby visit 12
Child with fever 14
Yellow baby 16
Vomiting baby 17
Baby with diarrhea 18
Pallor baby 19
Child with chronic cough 20
Child with abdominal pain 21
Child abuse 22
Enuresis 26
Hyperactive child 27
History taking format 28
Vomiting child 30
Anemia in a child 32
Diarrhea in a child 34
Enuresis 36
Breast feeding 37
Delayed speech 39
ADHD 40
FTT 41
Child abuse 43
Anorexia nervosa 44
Vaccination 46

OBGYN
Introduction
Amenorrhea
Ask for file after C/S
HRT
Infertility
Pre-eclampsia
Request for C/S
Vaginal bleeding
Vaginal discharge
First trimester bleeding 1
Third trimester bleed 2
Pre-eclampsia 3
High risk pregnancy 4
Counseling breast feed
5
Vaginal bleeding 6
Vaginal discharge 7
Amenorrhea 8
OCPs 9
Counseling HRT 10
Screen for Breast Ca 11
Pap smear 12

Ethics
Decision to forgo treat 3
Delivering bad news 4
Woman abuse 5
Telling the truth 6
Death before arrival 7
Pharmacist refusal 8
Organ retrieval 9
Confidentiality 10
Decision maker 11
Substitute Decision M 12
(Admition) notes 13

Psychiatry
Psychiatry Introduction
Anorexia Nervosa
Bipolar Disorder
Delusions contamination
Delusions persecutory
Depression
Forms
Insomnia
Mania
Marijuana in the bag
MMSE
MMSE-Delirium
MSE-Psychosis
Panic Attack
Personality disorders
Psychiatric assessment
Req. admit (Delusion)
Req. Admit (Borderline)
Request to stop Lithium
Somatization disorder
Suicide Attempt
Depression 21
Manic episode 24
Sleep hygiene 26
Delusional disorder 35
Schizophrenia 36
Panic disorder 39
MMSE 42
MSE 43
Dementia 44
Delirium 46
Suicidal attempt 48
Competency=Capacity 50
Alcohol abuse 55
Borderline personality D. 57

Physical Exam / Manage
Introduction to Physical Exam
Acute and acute on chronic
abdomen
Back
Blood transfusion
Cranial Nerves
CVS
Diabetic Foot
ER: Trauma and Non-Trauma
Hand-Laceration
Hand - CTS
Hematemesis
Hip
Knee
Neck
PVD
Respiratory system
Secondary Hypertension
Shoulder
Unconscious Patient
Volume Status
MI
GI Bleeding 3
DKA 5
Asthmatic attack 7
TCA Overdose 8
Seizure 9
Anaphylaxis 11
Acute aortic dissection 12
Subarachnoid hemorrhage 14
Violent patient 17
Tool Setting Meaning
OCD
Any S&S Onset, Course, Duration
PQRSTUV
Pain
Position, Quality, Radiation, Scale, Time/Triggers, How
it affects YOUR life? Deja Vu is it the first time?
COCA-B
Secretion Colour, Odour, Consistency, Amount, Blood
MOAPS
Psychiatric
screening
Mood, Organic, Anxiety, Psychosis,
Suicide/Homicide/Self care
HEAADDDSSSS
Teen ager
Home, Education, Alcohol, Activities (hobies), Diet,
Dating, Drugs, Sexual activity, Stress, Sleep, Suicide,
MGOS
OBGYN
questions in Hx
Menstrual, Gynecological, Obstetrics, Sexual
MI PASS ECG
R/O Depression
Mood, Interest, Psychomotor retardation, Appetite,
Sleep, Suicide, Energy, Concentration, Guilt
SAD PERSONS
Risk of suicide
Sex: male; Age: >60; Depressed; Previus attempts; Ethanol/drugs;
Rational thinking loss; Suicide in family; Organized plan; No
support; Serious illness/pain
DIG FAST
R/O Mania
Distractability, Impulsivity, Grandiosity, Flight of ideas,
Goal directed Activity, Sleep, Talkative
ABCD
HRT or OCP
C/I
Active liver disease, Blood diathesis, Cance (breast,
endometrial), DVT
ABCDE
Benefits of
OCPs
Anemia and Acne reduced; Benign breast disease decreased; Cancer
(ovarian) decreased, Cycles regulated, Cervical mucous increased (reduces
STIs), Dysmenorrhea decreased, Ectopic pregnancy/ pregnancy reduced.
SPIKE
Bad news Setting, Perception, Invitation, Knowledge, Empathy
BINDE
Child
Birth, Immunization, Nutrition, Development,
Environment
AMPLE
Trauma
Allergies, Medications, PMHx, Last
menstruation/meal/tetanus shot, Event
SEADS
Joint P/E Swelling, Erythema, Atrophy, Deformity, and Scars
CAGE
Screening for
alcoholism
Ever felt the need to Cut down on drinking?
Ever felt Annoyed at criticism of your drinking?
Ever feel Guilty about your drinking?
Ever need a drink first thing in the morning (Eye opener)
MUD PILES
Causes to high
AG Met. Ac.
Methanol; Uremia; DKA; Paraldehyde; Isopropyl; Lactate;
Ethanol; Salicylates
HARD UP
Causes of Non
AG Met. Ac.
Hyperalimintation; Acetazolamide; RTA; Diarrhea; Ureteroentric
fistula; Pancreaticodudenal fistula
ABCDEFGHI-M
Causes of AST
and ALT raise
Autoimmune hepatitis; Hepattis B; Hepatitis C; Drugs or toxins;
Ethanol; Fatty liver; Growths (i.e. tumors); Hemodynamic disorders
(CHF); Iron (hemochromatosis), copper (Wilsons disease) or alph1-
antitrypsin deficiency; Muscle injury

WARFARIN COUNSELLING
40 M came to clinic as he was informed by clinic to come as his INR result was 1. Next 10 mins
take history & provide counselling
Divide into 2 parts:
1. History ------> 5 mins
2. Counselling ------> 5mins

General scheme:
1. Event
2. Symptoms at the time of prescription
3. Compliance
4. Risk of bleeding from other sites
5. R/O relapse of DVT
6. Drugs and diet that interfere with warfarrin: Grapefruit, Antibiotics, NSAIDs, Antifungals,

Restart INR (fresh person)
X3 dose of 10mg/d change INR every day (change the warfarrin accordingly)
Check three time a week the INR if three consecutive are in the goal range once aweek
than for every two weeks check once than every month (or depend on the condition)
If INR>10 or patient is bleeding Vit. K (if active bleeding give FFP according to setting)

Greeting: Good afternoon Mr.Hendricks,Im Dr.X with you & will be your physician for today.
As I understand, youre here to discuss your blood reports.
1. Why was the blood test done?
[Pt had DVT x 5 wks ago,& was having regular checkups till last week when he decided to
stop as hed read some alarming information on the internet & did not like warfarin (or
other scenario,his friend who was on warfarin had a stroke)]
2. When was DVT Diagnosed?
3. How was it diagnosed?
4. What was done??
5. WAS HE TREATED AS AN OUTPATIENT OR WAS HE ADMITTED?/If Yes: How many days?
6. What were the symptoms at that time?
7. Was there pain & swelling?
8. Was there SOB (lung involvement)
DO NOT LOOK FOR FACTORS THAT CAUSE DVT
9. Which medicines were you treated with? -----> Blopd thinners/Warfarin?
10. Is INR done on a regular basis?
11. What was the last time it ws done?
12. What was the target?
13. What was the level?

NOW BREAK THE NEWS
Your INR is ONE; do you know the reason why?
IF Pt vague, give him options:
1...Do you take your medications on a regular basis?
1. Do you take your meds by yourself or do you need help?
2. Any chance you were skipping a dose?
3. Did you start any new medications or antibiotics?
4. Diet: Are you eating a lot of spinach?
5. Any Vit K supplements?
[If Pt expresses concern about bleeding S/e:Adress it & say it is a reasonable enough concern.
Ive to ensure that you do not have any bleeding at that time.
Did you notice any blood from your gums,nose,bruises in body,coughing up blood?
Neuro Sx:.....
Since you stopped the meds, I want to ensure that there is no Relapse of your DVT:
Do you have: Swelling/Calf pain/SOB/Heart racing/Chest tightness?
2 Qns about PMH:
H/o long term illness or surgery

FH

COUNSELLING:
What is your understanding of DVT?....clot
Why did it occur? .......
The concern about this clot is that if not treated, there is a chance of relapse, or it may recur &
this chance is: 8%
To decrease this chance to 0.8% we use warfarin
If DVT occurs more than twice take life time medication.

If not convinced: In addition to local recurrence there is damage to veins in the legs& valves& if
this happens more than once warfarin has to be taken for a longer period
In addition these clots formed in your legs may dislodge & travel all the way to your heart,&
This is serious. If large, can cause, sudden death. Can travel to lungs & can cause a condition
called PE which again is a very serious condition

Of course the main side effect is bleeding which is very rare if properly monitored. As long as
INR is in normal limits chances of bleeding are minimal i.e: 1%
Weve to restart with Heparin & warfarin & monitor INR on a daily basis

Back to Content

EPILEPSY COUNSELLING

Young 16 yr old male for driving License counsel
Always ask Qn as to why he wants a drivers license. Usually a Dr does not give such a note
unless there is an underlying condition.

General scheme:
1. Intro
2. Event before in and after the attack. When was the drug level checked?
Any other medications that might interfere with epileptic drugs (e.g. OCPs).
3. If it is only seizure go to secondary causes of seizures refer to neurology
4. Which medication, and compliance
5. HEADDSSS
6. Triggers sleep deprivation
7. MOAPS
8. Counsel: needed to be seizure free for one year. Invite him again for f/u after one year.
Risk behaviour: drivint, swimming, hicking, bath door open and dont take bath but can take
shower, no heavy machines
You have to take it for your whole life if you have any attack let me know and well discuss
it. Talk with your physician about any new medication you want to take.
Valproic acid 500mg.
OCD:
1. Age of onset
2. When was the Ds
3. What was the Ds
4. How long does each attack last?
5. How frequently do the attacks occur?
6. +/- LOC
7. Aura prior to attack
8. How does she feel after the attack?
9. What meds is she on/Is she compliant/Were the drug levels checked?
10. Any other meds (if female ask about OCs)
11. When was last attack?
12. What happens during an attack? Does she shake/All over/Partly/roll up her eyes/bite her
tongue?

Ive to ask questions to R/o any new pathology:

System review:
CNS: Head trauma/HA/Vi
CSx:
MOOD: Any chance you may hurt yourself?
PMH: h/o Dm
HEAADDS
HOME: With whom do you live/How is your relationship with parents/siblings
EDUCATION: How is school? Howre your grades? Any recent change in grades?
ACTIVITIES: what are your hobbies?
ALCOHOL: Sometimes kids your age might smoke or take alcohol & experiment with drugs, any
of your friends do it? How about you?
If YES: How much/How often?
DIET: How is your diet?
DATING: Are you dating? Are you sexually active?
STIMULANT USE:
STRESS:
SLEEP: Do you have enough sleep?
MAKE SURE that he knows what a seizure is
What do you know about epilepsy?
It is a common condition due to increased electrical activity in the brain, some people lose
consciousness, and some do not. It does not cause learning disability or damage the brain
In those who have seizure attacks:
If lasts for a few minutes there is no brain damage
If lasts for > 30 minutes, will cause brain damage

People with epilepsy should AVOID dangerous activities such as:
1. Driving
2. Mountain climbing
3. Swimming
4. Operate machinery
5. Boating
6. Chewing gum
7. Tub baths (have a shower bath & never lock bathroom door)
You can have a drivers licence only after youve been seizure free for 1 year
It is my duty as your physician to inform the Ministry of transportation

Mention TRIGGERS
If you drink alcohol, it decreases the point at which ea seizure occurs and can cause an
attack
Sleep deprivation also can cause it
So also flashing lights

If you want to take any other meds, speak to your Dr
I will check the blood levels of your medications to see if it is at the therapeutic level
If you want to get pregnant consult your Dr
There are support groups
Regular F/u
Any Concerns?

Back to Content

OCP COUNSELLING
21 F for OCPs Counsell x 10 mins

General scheme:
Intro:
Good morning xxx,Im Dr...... As I understand,youre here today because you want a
prescription for Birth Control pills.
During the next few minutes, I will ask some questions that will help me
2 Questions here:
1. Have you ever used any form of contraception before ?
2. Why do you want to use it?
2.1. If in stable relationship
2.2. If sexually active
2.3. Do you practise safe sex?
2.4. How do you feel about this relationship?
2.5. Prior to this were you in any other relationship?
2.6. Whose idea was it/ Yours or His?

MGOS
MENSES:
MENSES Use the word period
1. When was your last period?
2. Are your periods regular / not
3. How often?
4. How many days or How long does it last?
5. How many pads do you use/change?
6. Are the pads full?
7. Are they heavy?
8. Do you see clots?
9. Between periods do you have spotting?
10. From your last menstrual period was your period different from the current one?
11. At what age did you start your periods?
12. Were they regular/irregular?
13. When did it become regular?
14. Are your periods painful / painless?
15. If irregular from beginning?
16. Discharge ask if pregnant and when LMP
GYENECOLOGY
1. Any history of Gyn. Disease polyps or cysts
2. History of pelvic surgery (if yes when?)
3. Have you used any birth control?
4. When/type/any complications
5. Paps smear
OBSTETRICS:
Have you ever been pregnant?
Have you ever had an abortion or miscarriage?
SEXUAL HISTORY:
Any STIs?
Any PIDs?
Any partner with STI?

CONTRAINDICATIONS:
To find out if youre a suitable candidate,I need to ask a few more questions:
ABCD (Active liver disease, Bleeding, Cancer, DVT)
1. Any abnormal vaginal bleeding?
2. Any active liver disease: (Ac & Ch)
3. CVS:Have you ever had clots in your calves/DVT/Very High blood pressure
4. H/o Migraine headaches?
5. FH of Ca breast/Uterine or Liver

AGREE to give if No CI

EXPLAIN what are OCs
1. Combination of hormones Estrogen & Progesterone or sometimes only a progesterone
2. These come in packs of 21 or 28 pills
3. They prevent pregnancy by interfering with hormone signals in our body & prevent ovulation
4. Also make the inner lining of the womb & makes it hostile for conception
5. Thickens secretions at the mouth of the uterus & prevents conception

MISSED PILL;
To be taken at same time every day, so chances of forgetting is less & constant blood levels
1
St
pill on 1
st
Sunday of period, or 1
st
day of periods
1
st
month use back up method of Cx like a condom
In first 2 weeks:
If miss one pill: Take 2 pills next day & use condom x 1 week
If miss 2 pills: Take 2 pills same day + 2 pills day after + Condom x 7 days
If miss 3 pills: Stop,use condom & restart new pack
In 3
rd
week:
If you miss any pills restart new pack

Explain BENEFITS:
1. Help regulate cycle if periods are irregular
2. Will eliminate pain
3. Less blood loss during periods
4. Less chances of benign breast disease & ovarian Ca
But like any other medications, there are also the SIDE EFFECTS:
MILD
N/V,Wt gain (5lbs)breast heaviness,mood changes,Spotting may occur in the initial months
If these occur,you can change brand
SEVERE;
Severe Ha/SOB Chest pain -----> If these occur STOP the pill & sek urgent medical attentiomn

DRUG INTERACTIONS:
If takes any other medications,let her Dr know she s on the pill

SAFE Sex:

PAPs Smear
If Teenager: HEAADDS

Last any Concerns or qns?

Back to Content

ABORTION
1. Young woman 19 yrs asking for abortion x 10 mins counsel
2. Can be a teenager with a vague complain
a. Read body language & assure Confidentiality
b. When did sexual contact occur?
c. Who was the partner?
d. Was she raped or was it against her will?
e. Is she being regularly abused?
f. Do her parents know?
M (Signs of pregnancy: engorgement of breast, urine frequency, n&v)
O
G
S
PMH
SHx:
HEADDSSS:
Home enviorenment & parental attitude
MOOD & Interest SUI CI DAL I DEATI ON NOW?

When pt tells outright she wants an abortion:
How do you feel about having an abortion?
If she says she feels there is no other option:
Explain that there are other options, Do you want to know them?
When did she find out she was pregnant?
Here be sensitive if she found out last night, she is probably in a panic, but if she has known it
for a week, she has thought about it well, & is more decisive.

Before it can be done, I need to ask you some qns
1. How did she find out she was pregnant?
2. Was she using any contraception?
3. Has she spoken to her partner/family/friend?
4. Would she like to talk about it?
LMP: How was her LMP, was it similar to her previous LMP? Or was it shorter, lighter?
Is there Nx/V,visiting washroom more frequently?
Breast engorgement?
O
Have you been pregnant before?
Have you ever had an abortion/miscarriage?
G
Has she ever used any kind of birth control before?
Any Pelvic surgeries
Any Pap smear (depending on age)
H/O STIs

Since it is the first time Im seeing you, I need to ask about
PMH;
Any H/o HTN/Liver disease/DM?
Surgeries/Anaesthesia complications
Blood Group
Any Medications/Allergies

SOCIAL Hx:
With whom do you live?
How do you support yourself financially?
If young teen: HEAADDS

Whatever you choose to decide, I will support you. Is she decides to go in for an abortion:
I will refer you to an abortion clinic
However it is difficult to get an obstetrician who will do it after 20 weeks
She has to make a decision fast
Also here ask about her own support system (family/boyfriend)
I will also get you connected with a support group, who are women whove had abortions
before & will help you cope with it.

Now in addition to abortion there are OTHER OPTIONS:
Would you like me to tell you about them?
1. If your concern is financial, you can carry on this pregnancy & there are a lot of support
groups as well as the government who will help you.
2. You can carry on this pregnancy & give up the baby for adoption, a lot of people are looking
for a child also nowadays you can have visitation rights in certain cases.

If Pt is still going for an abortion:
For now, I will do
1. PAPs test
2. Blood tests: Sr B HCG & Blood group & Rh typing
3. USound
Once your pregnancy has been confirmed by us, I will send you to the abortion clinic
From now, until the time youve the abortion, youve to;
Quit Smoking/Alcohol/Drugs
If you happen to see any dr during this time period, youve to inform him youre pregnant

Back to Content

Smoking Cessation

According to the type of patients we will allocate the time:
Neutral: Hx (4m), Why (3m), How (3m)
Willing: Hx (4m), Why (1m), How (5m)
Unwilling: Hx (4m), Why (5m), How (1m)

General scheme:
1. Intro (Very good decision)
2. Hx
2.1. Impact: breathing, coughing, phlegm
2.2. RF: HTN, DM, Hyperlipidemia,
Questions about target organs: heart, lung
2.3. Gain from quitting: what do you think you are going to gain from quitting
2.4. Hx from previous quit what support do you need? What led to relapse?
Withdrawal symptoms? What is the longest time you quitted?
2.5. In which situations you need to smoke?
2.6. SHx: do you smoke in front of your children?
3. Counseling
What is your motivation to stop smoking (scale 1 to 10)
Different people from different reasonswhat is the reason for your smoking?
3.1. Why
3.1.1. Effects of the smoking on different of the body
3.1.2. Reduced risk for diseases time frame
3.1.3. Influence on other household
3.1.4. Economical effect
3.2. How
3.2.1. Set a quit date within 2 weeks reduce gradually within 2 weeks
3.2.2. The support youll need tell your family. Found someone who wants to quit.
3.2.3. Diary
3.2.4. Exercise, healthy diet
3.2.5. Things you can do instead of smoking
3.2.6. If taking nicoting replacement stop smoking.
3.2.7. Medication: Ziban (bupropion) 150mg (only in the morning for three days and
than increase to bid to 7-12 weekly up to 6months)
S/E Insomnia and dry mouth
C/I seizure, eating disorder, MAOI;
Varenicline (Champex)
S/E nausea
C/I Previous psychiatric conditions

Intro
Hello Mr./Ms. ..
As I understand you are here today to seek help to quit smoking. I am really happy to hear that
can you tell me what made you come to that decision?
What are your expectations from this visit?
Motivation can be assessed by asking the following two questions:
1. Given everything going on in your life right now, on a scale of 1 to 10, where 10 is the most
important thing to do right now, how important is it for you to quit smoking altogether?
2. Given everything going on in your life right now, on a scale of 1 to 10, where 10 is the most
confident you have felt about anything, how confident do you feel you will be able to quit
smoking altogether?

Ask about the smoking now how long, how much, since when
Impact of smoking of his life: breathing and coughing, weakness, relationship and sex, CSx
RF: HTn, DM, Cholesterol, FHx of CAD and Cancers,
In your opinion - what are the good things you will gain from quitiing?
Have you tried to quit before?
What stopped you from quitting before?
What support will you need in order to quit?
What are the situations in which you usually smoke?

Smoking Hx
What is the reason that made you decide to smoke?
How much you smoke, how long (More than 10pk/y -
Sleeping pills;
Withdrwal symptoms:
Heart racing, sweating, shakiness, Irritable

What is the longest time you quit
smoking? (every time you quit you have a
better chance of success.)
Because you have been smoking for long time Id like to see how this smoking has affected your
health:

Target organs: Heart, Lung, GI, PVD, Sexual,
CHx
MOAPS
FHx (also addiction, cancer, suicide, depression)
SHx
Do you smoke in front of your children?

Counselling
Why
Different people smoke from different reasons - what is the reason you smoke?
In your opinion what are the advantages of smoking?
Do you know what the active components in cigarettes are? (It is Nicotine, and when you
smoke it you have a sense of well being. To maintain the same effect you keep increasing the
number of cigarettes and by that tolerance develops. So, when you stop you get withdrawal
symptoms, and therefore it is habit forming and difficult to quit. In addition to the effect on our
brain it causes narrowing of our blood vessels all over the body.
In the heart it causes heart attacks which are leading cause of death in our society.
In the brain it causes stroke which is the third leading cause of death.
In the GI it causes peptic ulcers.
It can cause erectile dysfunction.
In addition to nicotine, cigarettes can contain few thousands of other substances some of
these affect the lungs and cause COPD which is an irreversible condition which there is no
treatment.
On top of that, smoking is associate with cancer in a lot of different organs of which lung cancer
is the leading cause of death from cancer worldwide.
In addition to medical impact it affects also family members and expose them to most of the
harmful effects mentioned previously.
It is expensive, staining and smelling, increases hazards (fire).
If you quit smoking you are taking the right step and can expect to gain the following:

After 1 year, the risk of coronary heart disease is cut in half
After 5 years, the risk of stroke falls to the same as a non-smoker
After 10 years, the risk of lung cancer is cut in half and the risk of other cancers
decreases significantly
After 15 years, the risk of coronary heart disease drops, usually to the level of a non-
smoker
How
1. Set a quit date. It should be within the next two weeks. Avoid a time when you will be under
stress.
2. Think about why you want to quit and all the good things that you expect as a result of
quitting.
3. If you have tried to quit before, you have probably learned some valuable tips of what not to
do this time. Think about what was most difficult last time and why you gave up trying.
Think about the things you need to avoid this time.
4. Decide what kind of support will be most helpful over the next six months to a year. For
example, you can join a smoking cessation group or plan to meet regularly with a health
professional (such as a pharmacist, nurse or doctor).
5. Tell your family and friends that you are quitting. Ask them to help you to stick to your plan.
If they smoke, ask them to respect your decision to quit and to not smoke in front of you.
Think of things you can do to avoid smoking while with them.
6. Find someone you know who does not smoke and ask them to help you to quit.
7. Make a diary for a few days to keep track of when and why you smoke.
8. Think of ways to avoid situations when you usually smoke.
9. Buy a brand you dont like. Buy one pack at a time. Increase the time of lighting it, and
smoke only part of it.
10. Think of things you can do instead of smoking (for example, chewing gum, sipping water,
holding a fake cigarette).
11. Most people gain weight while quitting. You can avoid this by healthy eating and increased
activity. Keep healthy snacks around for times when you get the urge to nibble.
12. Keep busy with healthy activities like walking or an exercise program. Starting a new
activity will help to break old habits connected with smoking.
13. If you are taking medication to help you to quit, be sure to follow the instructions carefully.
14. If you are taking nicotine replacement therapy, do not continue smoking, as this is very
dangerous to your health.


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OBESITY COUNSELLING

38 YOM 6 ft height,weight=260Ib 10 min.HX. and Education
Keys:
Explore motivations for wt.loss.
Provide information about the consequences of obesity (health and psychological well-
being) and nutrition.
Set realistic goals, target BMI
Offer support/reinforcement throughout the weight-losing process.
Hx
DIET & EXERCISE:
Motivation for losing wt. now?
Self image,
Health concerns?
Can you tell me more.
Good decision to come today, I am glad you came.
If patient request first surgery, tell him that sound reasonable however, surgery is not the first
line can be done based on BMI if >40
If you like I can calculate it for you; kg/m2.

I need > information about your condition:
WEIGHT:
1. What is your weight today?
2. Highest weight.
3. When started to gain wt?
4. When started to be concerned?
5. Have you tried any wt- loss programs?
6. Which one?
7. How long?
8. Did you lose wt?
9. Why did you stop?

I am going to ask you Qs to see
WHY YOURE GAINING WEIGHT:
Do you calculate your calorie intake?
How many meals do you take/day including snacks?
Tell me more about your DIET:
What do you eat?
How much fat, fruit, veg bread?
Eat while watching TV,
Before bed,
Breakfast daily,
Ever eat to relax or when stressed?
Binge eating?
Do you feel guilty about your eating?
Do you induce vomiting/purging?
ALCOHOL
How about your ACTIVITY,
Do you exercise?

IMPACT:
I am going to ask you how this Affects your life?
1. Difficulty sleeping,
2. Tiredness,
3. Heart burn,
4. Nausea, vomiting,
5. GB stones, bowel motion,
6. Back pain,
7. Jt pain.
PMH: HTN, DM,
Medications: anti-psychotic, OTC, steroids, thyroid disease, OCP.
Social Hx: With whom do you live? Any change in sexual desire?
How it affects your self esteem,mood and interest?
Do you smoke? Drink? Recreational drugs?
FHx : obesity
Education:
There are some genetic factors that influence wt. We cant modify these but we can modify our diet and
exercise. In some people, diseases are the underlying cause for obesity.
Give patient their ideal wt. for ht. >20% ideal wt is obesity.
Being overwt increases the risk of
Hypertension,CVD,CAD,GB disease,DM,fatty liver,cancers(breast,bowel),OA,sleep apnea,spinal
dysfunction.
We recommend to lose 10% of your body wt.over 6 months (gradually).guidance is BMI
There are 2 methods to lose wt: Decrease intake or Exercising more.
If you like I can refer you to a dietician.
We also recommend dividing your meals into 3 small and in between snacks ( carrot, veg.or fruit)
55% CHO, 15% protein,30% fat
Avoid saturated fat, cheese, alcohol
Give patient a target caloric intake:
to lose 1 Ib/week,should take 300-500 kcal less
1g fat-9kcal, 1g CHO-4kcal, 1g protein-4kcal
Do not recommend diet medications and fad diet, these may be harmful and are of no long-term
benefit.
If BMI>27 + RF (DM, Htn...) or BMI > 30 start pharmacotherapy:
Xenical=increase bulk of stools, leakage, decrease absorption of fat sol.Vit.
Meridia (sibutramine) = suppress appetite, cause heart racing, hypertension.
IF BMI>35 + RF or BMI > 40 recommend Baratric srgery
Exercise:begin with walking,regularly 30 min,4-5 times per week
Reach 60-80% maximum heart rate (220-age)
Self-monitoring, group support
Follow-up: advise patient to come back in a week with food intake diary etting sick

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70 yr old female with H/o fall at home .Brought in by ambulance
personell to the ER.
She is medicaly cleared;
In the next 20 minutes take history & Counsel;
Diff/Diag (Dd):
1.Poly pharmacy
2. Recent hypovolemeia
Diarrhea/Vomiting
Lack of intake
Recent bleeding
3.Orthostatic hypotension
4.Hypoglycemia
5.Elder abuse
FALL:
1. When did the fall occur?
2. Where did it occur?
3. Were you alone?
4. Could you get up by yourself or did you need help?
5. How long before you got help?
6. Did you trip or just feel your legs give way?
7. If there was a witness around ask permission to speak to witness after you finish talking
to Pt to obtain collateral history

3 parts of history relating to the EVENT:
A.Before fall
B.During the Fall
C.After the fall

Events assoc with the Fall:
A.Before:
1. Did you feel
2. Light headed/ Spinning/ Hungry/ Heart racing & Sweating --- HYPOGLYCEMIA
3. Chest pain/ Palpitations/ Shortness of breath----CVS
4. Lights flashing/ Strange smell/ Strange feeling in body--Seizure
5. Weakness/Numbness/Dificulty finding words/Visual disturbances --CNS/STROKE
6. Was the lighting good?
7. How is your vision
8. Is your footwear comfortable?


B.During the Fall:

1. Did your wife mention that you were shaking or making jerky movts?
2. Did you wet yourself?
3. Turn blue & were stiff?
4. Bite your tongue?

C.After the fall:
1. Nausea/Vomiting
2. Weaknes
3. Difficulty finding words
4. Any vision difficulties
5. Loss of sensation in the arms or legs
6. Ringing in ears

Has this ever happened before
1. When & where
2. Did you seek medical help then
3. What were you advised?

CONSTITUTIONAL SYMPTOMS:
Fever & Chills & Night sweats
Wt loss & Loss of appetite
Lumps & Bumps
Sx related to CVS:
Chest pain/SOB/Palpitations
Sx of CNS:
Weakness/Numbness/Loss of vision/LOC
Past Medical History;
1. Are you taking any medications?
2. Can you take them by yourself or does your caregiver give them to you?
3. Do you take them regularly as prescribed?
4. Can I see them please?
Please see the meds
Was there a recent change in the meds
5. Besides these do you take any additional OTC products or herbal medications?
6. Do you take alcohol? ..............
How much do you take regularly?
Did you take alcohol prior to the fall?
7. Do you have high blood pressure?
When was it last checked?
What did your doctor have to say about it?
8. Do you have high blood sugar or Diabetes?
When was it last checked?
What did your doctor have to say about it?

9. Did you ever have a stroke or heart attack?
10. Were you ever diagnosed with Cancer
11. Were you hospitalized at any time in your life?

I need to ask a few more questions concerning your lifestyle that will aid me to help you.
It is all confidential & my duty is to help you (When you suspect Elder abuse)
1. With whom do you live?
2. Are you happy living with XXXXX
3. Who prepares your meals?
4. Do you do your own shopping?
5. Do you manage your own finances?
6. Do you go out of the house & meet up with friends & have your own social life?
7. Do you get into arguments with XXXX?
8. Have you ever been hit or yelled at or threatened by XXXX?

COUNSELLING FOR POLYPHARMACY (Orthostatic Hypotension)

Based on what youve told me most likely the reason of your fall is a condition called
Orthoststic Hypotension.Have you ever heard about it?..........
When you change position from lying to sitting or standing blood pools to the legs & Bld vessels
narrow to maintain BP.
In pts with OH because of Age,Medications,DM or a combination of these condts body might
fail to react,& blood pools in the legs & thus BP drops & there is not enough bld reaching the
brain.
There is a possibility that this might happen again & from now on whenever you change your
posn from lying get up slowly,sit at edge of bed & slowly get up.
I need to get in touch with your doctor & modify the dosage of your meds or change them.
Is it alright with you?
I need to talk now to your wife & do an ECG to check your heart

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HA DOMESTIC VIOLENCE

Domestic Violence common presentations:
1. HA
2. Abd Pain
3. Ac Abd
4. Insomnia
5. Sleeping pills
6. Vaginal Bleeding

Sx
1. No good eye contact
2. Vague complaints
3. Non communicative

OCD/PQRST
CONSTITUTIONAL Sx:
R/o Migraine & Tension HA
RISK FCTS:
Smoke/Alcohol/Recreational drugs
PMH:Are you on any meds/OTC/Herbal meds?
Were you hospitalized at any time?
FH:
SOCIAL HISTORY: Important**
All information you give here is entirely confidential & will not be released unless you authorize
it
Who lives with you?
Any recent changes/Stress in your relationship
SCREEN FOR DOMESTIC VILOENCE:
Does your Partner:
1. Hit you?
2. What happens during an argument?
3. when he is angry,does he :
4. Shout/Swear & call you names or demean you?
5. Has your partner ever ridiculed you or cut you off from other relationships with
friends/family?
6. Have you ever sought help from others in health care?
ABUSE RISK FCTS:
1. Drink alcohol,drink more now than before?
2. Does he have access to firearms?
3. Does he ever get angry to the point where he gets physical & hits you?Did you ever have to
go to the ER? Was there a serious consequence?
4. Are you having more arguments now
5. Does he get more angry now,& How has all this affected your self esteem?
6. How does it make you feel?
7. Does he ever force you to have sex against your will?
8. Who controls the finances & spending?
9. Has he ever mistreated you in front of the children?- If yes: it is emotional abuseto
children & has to be reported to CAS
10. Has he ever misRxed th children?
11. Have you ever thought of putting an end to your life or his life?
Have you spoken to anybody abt this?
Do you have some support?
COUNSELLING: Empowering & Education
3 kinds of Pt:
1.She wants Help
2.She might Consider getting help
3.She does not want to get help & thinks he is right

Id like you to know that what youre experiencing is called Domestic Violence or Spousal
abuse. It is a crime against the law & not acceptable.
It is not your fault & you should not accept it & feel guilty
It can get out of hand & you can get harmed seriously
Call Police (Never Call Police from your office)
Contact Social worker, who will help you with housing, finding a job & finances & child support
If she is considering
Escape Plan
Keep a bag with important documents,change of clothes & hide it
DOCUMENT

Fup x 3 days

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Diabetic Daughter 2y, Counsel
Either she is not doing well in school
Not seeing well
Not playing well, tired
DKA

Is it regular f/u or something special you wanted to discuss?
When was the last f/u?
How was she diagnosed?
What happen then?
What were the symptoms?
Is there any pain / vomiting?
Are you feeling eating/drinking/peeing more?
Is there any weight loss or blurred vision?
From the last f/u till now have you had DKA? How about before?
Have you had low blood sugar?
Talk with the father: which medication does she take? How does she take? When was the last
time?
Do you take insulin or somebody else gave it to you? Do you take it all the time? DO you skip
dose? Does she need any help to take insulin? DO you measure blood sugar regularly? When
was the last time? Do you record them in the machine? (The glucometer should be used by only
one patient).
There is a blood work called Hemoglobin A1C it is done every three month did you do it?
Did you start new medication? How about your diet?
DO you have your log book?
What do you eat?
Have you ever seen by a dietician?
PMHx
FHx

Counseling
A lot of people have diabetes and she is not the only one. Whats your understanding of
diabetes?
Whenever we eat food contains sugar it is absorbed in our stomach and goes to the blood and
from there to different parts of our body. Sugar act in our body like a fuel, in order for our body
to use this energy it needs insulin. Patients having diabetes have not enough insulin. Sugar will
be built up in your blood. The body tries to get rid or it, by peeing extra sugar this will lead to
thirsty and tiredness.
This can be avoided by controlling the blood sugar. If you control your blood sugar youll be
able to play again. If not controlled may end in DKA, hypoglycaemia and serious
consequences.
Always be aware of hypoglycaemic symptoms: loss of conscious, sweating, heart racing, hungry.
Since you might lose conscious it is important to carry MedAlert Caed or Bracelet which will
clarify your situation.

Medical Error, Wrong blood transfused
When there is a mistake, always there is a kind of unintentional medical error.
(to the nurse) when informed about wrong blood ask: did you stop the blood? say: Well
done! If she asks not to tell the patient...ask her what her believe she may loose her job, and it is
too early to determine who is responsible. Errors take place in medical practice. We dont know
what exactly happened. We will stabilize patient and ensure hes fine and later deal with this
issue.
(to the patient) Intro: I am the doctor in charge, and it looks like it was an unintentional medical
error took place. We need to make sure you are stable. We dont know who is responsible, there
are at least 15 steps and in each step could have been an error. We will fill an incident report and
as soon as we get result we will inform you. You can sue, it is your right at the moment it is my
priority to stabilize you.
ABCD
A Open your mouth (check for anaphylaxis, no swelling in mouth, ask for any itchiness, or
difficulty breathing),
Oxygen saturation.
Normal air entry.
Normal S1, S2
Vitals again
Remove blood unit and keep cannula.
Start new IV line.
Once new line, dont give fluids if stable.
Send blood: CBC, Lytes, INR, PTT, LFT, Cr, BUN, FDP, Haptoglobulin, Direct coombs test;
Urinalysis: hemoglobulinuria
Unit to be sent to blood bank for cross matching.
Ask nurse to call the blood bank and keep original blood.

D
D1 Id like to shine a light in your eyes. Pupils are round, active, and symmetrical. Squeeze my
finger, wriggle...wriggle...
D2 (if febrile) give tylanol
Please prepare for me benedril (Diphenhydramine) 50mg. Steroids (Hydrocortisone) and
Epinephrine

Secondary survey
Hx (two parts:) condition (how is he feeling now) and the other is: Why blood was given?
Condition: Do you feel warm? Chills? Itchiness? Tinglings? Diffculty breathing? Wheezing?
Swelling in lips / fingers? Hives?
Before transfusion did you have fever?
Check for haemolytic reaction any back or flank pain?
P/E no oozing at IV line
Then press on flank and back no pain for haemolytic reaction.
Is it the first time?
Why did you receive blood?
If received blood before was there any complications?
Any long term diseases?
Counseling
Mr. X what do you know about blood transfusion?
It is a life saving measure, and a lot of measures are taken to make sure it is safe. However, like
any other medication with blood transfusion there could be side effects, and these side effects
could be serious.
The most common side effect is febrile reaction (3%), usually it is self limited and can happen
again. Next time you receive blood we will give you tylanol.
Anaphylactic reaction. It is a severe allergic reaction, and it is very serious and we cannot predict
it. However, we have good measures to deal with it, and your symptoms make it less likely that
you have had an anaphylactic reaction.
The yhird reaction reaction is more serious and called haemolytic reaction. Usually happens
when patients receive blood belonging to another blood group. The fact that this blood is same as
your blood group, and the symptoms are not consistent with haemolytic anemia make it less
likely that this is not the case here. The blood is sent to the blood bank and once results are back
we will get final confirmation, we will able to reassure you.

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Febrile Seizure
A child brought to the ER because of febrile seizure.
Next 10m counsel him.
He is stable. During the next few minutes Ill ask you few questions, and after that Ill go with you to see
him.
You should r/o meningitis. Educate, and what to do next time.
Did you see him? (Started to shake. All over his body? Bite his tongue / roling up his etes / wet himself).
After the seizure does he have any neurologic deficits.
How long did it last, or did you come on your by his own or medcial staff.
Did he stop seizing on his own or after medical interv.
Is it the 1
st
time?
Ask about fever? (if it started a week ago did you seek medical assistance? Discharge? Did they give
you any treatment? Did they give it to him or no?)
Why! Some studies show you can treat OM without antibiotics. You should look for the reason not to
give the antibiotics (negligence?). Is he having any vomiting? Skin rash? Coughing? Head to toe...
If you find nothing ask when he got his last shot? (up to 72 hours he can have fever).
R/O meningitis, pneumonia.
Any family history of febrile seizures, epilepsy
BINDE (especially immunization).

Counseling:
Your child has condition called febrile seizure (FS).
It is a condition that might happen from 6m to 60m. We dont know exactly why we believe it is a
sudden change in the temp. This might lead to the seizure. This condition might happen again.
Any time your child has fever seek medical admition. Give tylanol and sponge to decrease his temp.
Most of the children will outgrow this condition by the 6
th
year.
They dont recommend Diazepam because it might make him drowsy.

If it stopped less than 5m or more than 5m including neurological symptoms seek ER immediately.
Brochure.

This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER. I am calling that
your child swallow medication. I know you are stressed, I need to take your phone number and address,
and how far it is from the hospital.
Stay calm. Your son needs you, I am going to give you some instructions and you need to follow them. Is
your son is alert or not? Is he conscious? Can he talk to you? Can he recognize you? If he doesnt do
you know how to do CPR and start with that.
Hes crying. What is colour? Pink. Hold him and try to calm and sooth him. If he his conscious try to
hold him and check his mouth. Is he breathing? Well send the ambulance for you. When did it happen?
How long was he alone? Which medications did he take? Do you have the container? (dont go to the
next room to bring them). Do you know what condition your father have (was it vitamins, sleeping pills,
or any other?) how much the amount? Dont use any ippecak?
Is it happened before? What is the weight of the child? BINDE (was it full date, did he needed special
attention after term, does he have any special conditions). Weight for two reasons antidote and
estimate neglect.
Post encounter Q: what are the first four steps you do when he arrives? (ABC, Monitor vitals, IV line, NG,
Foley as needed, Blood works CBC, Lytes, BUN, Cr, Osmolality, Coagul, LFTs, Tox screen blood and
urine).
List three risk factors for this child.
What is the antidote for betablocker (glucagon) and for CaChannel is (Calcium gluconate).
CAS and Poisoning centre.

Second scenario while he is seizing just put him on the side, and not start any CPR. Before I proceed Id
like to take your phone number and address. Is it the same time or happened before. If it is the second
time more than 15m he needs intervention.
Is he seizing right now? Try to put him on the floor on the left side (the right bronchus is shorter than
the lt.). Observe him. What is his colour? Is he still shaking? You send the ambulance. Can you tap on his
shoulder? If he is not responding can you do CPR? Can you feel his pulse? Is he alert? Can he talk to
you? Can he move his legs? Was he shaking? Does your child have fever? Did you seek medical
attention? What prevented you from giving the medication?
Post Concussion.
2 scenarios (Osgood schlatter and Post-concussion)
Decision will based whether the child can tolerate pain or not?

#1 About to see the father of 14yom with Osgood Schlatter.
Make sure that the child best interest are preserved. What was done to diagnose the child?
OCD PQRST compare to the other knee, is the first time or not, was any trauma.
What is the child wish? (Dont go for HEADDSSS since it is the father).

Counseling
What is your understanding of OS.
Let me explain to you what is the mechanism for OS.
Avoid him from playing, especially jumping. But he can continue with ice presses and pain killers. The
rule is that he can continue up to his limit of his pain.

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54 year old female comes to clinic concerning about using
HRT.
.
When a patient has concern about any subject, address it very soon. Don't wait to the end.
Dr: As far as I understand you're here as you have concern about using HRT.
Patient: yes Dr. I feel I am confused about using HRT.
Always ask what do you mean by HRT. So the patient will tell you how much they known about HRT.
Dr: I'm glad you're here so we can discuss about it and address your concerns and hopefully by the end
of the session you can make a decision regarding using HRT. Or hopefully by doing this discussion you
will have a better understanding of HRT.
Or you can say: I agree with you as there are a lot of confusion about HRT and the reason for this
confusion is that in the past because it was used to be given routinely to all women who reach a certain
age, however 10 years ago there was study called " women health initiative" in which the authors found
that the numbers of the patients with serious side effects are very high. However those ladies used HRT
for a long time.
Serious side effects are
Cancer,
Heart attacks and Strokes.
For that reason the routine use of HRT was stopped.
Nowadays we have a better understanding and have better guidelines.
Not only that we do it on the individualized basis.
We use it only for short time, they don't exceed five years.
So using HRT within five years is safe.
So I would take some information from you and we will discuss about the risk factors and if you are a
good candidates we can make a decision to prescribe it or not.
Dr: What makes you interested in HRT?
Patient: because of hot flushes.
At this stage if the patient gives you the symptom, it is your chief complaint.
But if patient doesn't give you any symptoms, you should start with her LMP
If she starts with the symptom of hot flushes, ask the patient
1. When did hot flushes start,
2. Is it all the time,
3. On & off or continues,
4. How many attacks,
5. Day or night,
6. How do you feel that you have it.
7. Night episodes, you have any night sweating, does it wake you up.
Asked patient if the hot flushes wake her up during the night and if she needs to change her gown of
nights sweats.
1. Affect your sleep and how does it affect your concentration.
2. Change in your mood, anybody has told you that your short tempered, and if you
3. feel tired.
4. Some women with the same symptoms may notice some change in their sexual life.
a) So the doctor should ask with whom do you live?
b) Are you sexually active?
c) Any dryness or pain during the intercourse?
5. Any change in your urination?
6. Have you ever lost control?
7. Last period?
Are you periods regular or not?
If it's irregular, when did it start to become irregular?
Are your periods heavy or not?
Any clots?
*Any bleeding or spotting between periods? This is a very important point.
8. Bone pain? Any fractures? Any family history of osteoporosis? If yes, tell the patient that you will
discuss this in another meeting. Because that's another session to discuss about using steroids,
smoking, alcohol, caffeine, warfarin and diet. If she takes calcium supplements.

MGOS for GYN cases: Menstural, Gynecologic diseases, Obstetrics, Sextually transmitted disease
Dr: any history of gynecological disease like polyps, cysts, any pelvic intervention/instrumentation,
surgeries.
Dr: did you use to take any oral contraception? If yes, which one and did you have any side effects?
Also you should ask about her last smear.
Because she is 50+ you should ask about her mammogram.
At any age you ask about Pap smear, once you reach 50 to ask about mammogram and when the patient
pass 65 you should add bone density.
You can ask about her obstetrics history, like have you ever been pregnant if yes how many times you
have been pregnant?
Now use the transition...
Because this is the first time I met you, I would like to ask you about your past medical and social history.
Is there any long-term disease, hospitalization before, any surgery, diabetes, or hypertension. Any history
of allergy, and the medication she takes.
ABCD: Active liver disease, vaginal Bleeding, Cancer, DVT
For A you ask about any history of Active liver disease. Have you ever been yellowish? Any dark urine or
pay stool?
For B you should ask about any vaginal Bleeding? ... You have already asked these question before
For C you should check about Cancer. I would like to ask about constitutional symptoms here to see if
there is any endometrial cancer. Fever, chills, weight loss, appetite, lumps & bumps. A history of cancer in
yourself or family (breast cancer, endometrial cancer,and colon cancer).
For D you should ask about any history of swelling in the legs (DVT), any history of heart attacks,
pulmonary embolism or stroke.
Social history: smoking, taking alcohol, recreational drugs, how does she support financially herself, how
does this affect her life and ask about osteoporosis.
Usually in this set of scenario, you tell her on the basis of the history you are good candidates for HRT.
However as I told you it is an important information to tell you to make your decision.
As we go through different stages of life usually for ladies, we go to the stage called menopause which is
vary between person to person.
At this stage there is hormonal changes and ovaries start to produce less hormones specialty estrogen
and progesterone and that changes affect the whole body. It can explain about dryness, decreasing or
absence of periods. And that's why we try to replace those decreased hormones by HRT. They are the
same hormones but we give it through external sources either tablets or skin patches.
As I told you before there is a balance it's your decision to make. And the balance is to use it up to five
years. Using more than five years would increase the risk of stroke, heart attack or some cancers
depending on what we call it estrogen dependent that includes breast and endometrial cancer. And some
studies showed that it might increase the risk of Alzheimer's disease.
So the risk of use for less than five years is not significant and still acceptable. So if you want to use it the
shorter the better.
To get rid off the hot flushes that are other measures like exercise or herbal supplements that you can try
to improve the symptoms.

The HRTs are the same as OCP's but in this smaller doses and you can take one tablet a day. They have
a few side effects like weight gain, bloating, nausea, abdominal distention and pain but they improve by
time.
This serious side effects are headaches, swelling of the legs or chest tightness which whenever happen
you should go to emergency room. By using these HRT's your periods may stop or you may see
spottings.
If the patient had hysterectomy before you only give estrogen without progesterone, otherwise you should
give both.
Because you take it regular shootout regular ultrasound scans to check the thickness of the endometrium

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CARDIO
1.45 yr old Chest Pain x 45 mins ER History x 5 mins (MI)
Onset:
1. When did it start?
2. What were you doing at that time?
3. How did you get here today?
4. If you came in by Ambulance, did the paramedics give you a tablet to be kept under
your tongue?
Course:
Was it sudden or gradual?

Position:
Where exactly is it hurting you the most?
Quality:
Can you describe the pain? Is it crushing? Knifelike?.......
Radiation:
1. Does it move anywhere else in your body
2. Does it move to the back?
Severity:
On a scale of 1 to 10 where one is minimum & 10 is highest, where would you place this pain?

Associated symptoms:
CVS:
N/V,Sweating?
Heart racing?
SOB/Orthopnoea/PND?
Have you been under stress recently?
Cough with blood tainted sputum?
GI
Acid taste in mouth?
Heart burn?
Dysphagia
Pud?
MSK
Have you had any trauma to the chest
Are there any blisters on chest?
RS
Did you have any flu recently?
Cough with Phglem?
CONSTITUNIOL Sx
Do you have night sweats
Loss of appetite & Loss of wt?

Alleviating Fcts:
What makes you feel better?
1. Rest?
2. GTN?
3. Antacid?
4. Sitting forward?
Aggravating Factors:
1. Exercise/exertion?
2. Movements?
3. Deep inspiration?
4. Lying down?
5. Eating?

RISK FCTS:
I need to know additional information that could be related to your pain right now, and need to
ask some further questions......
1. Do you have a high Blood pressure?
When,& what did your doctor have to say about it?
Were you put on medicatn?

2. Were you diagnosed at any time with an elevated Blood Sugar or were told you had
diabetes?
Were you put on medication?

3. Have you ever had your cholesterol checked?
If yes:
Were you put on medication?

4. Do you smoke?
If Yes;
How many & Since how long?
5. Do you take alcohol
6. Have you used recreational drugs?
Cocaine?
7. .Do you find time for regular physical activity?
8. Do you eat a lot fast food?
9. In your family has anyone had a heart attack under the age of 50?

CAUSES/Consequences & Symptoms:
1. Did you ever have a stroke?
2. Did you have a weakness or numbness?

Past Medical History:
1. Do you take any medications?/OTC or herbal products?
2. Are you allergic to anything?
3. Were you hospitalized at any time?
4. Did you ever undergo any surgery?
5. Were you ever diagnosed with Cancer?
6. Do you have a bleeding disorder?
7. Did you have any head/facial trauma since last 3 mo?

I need some more information about your family
HTN/DM/MI/Stroke

Social History:
2. How do you support yourself?

MANAGEMENT:
Rapid, targeted history and physical examination, with particular attention to onset of
symptoms, contraindications to use of thrombolytic agents
Absolute contraindications:
1. Previous intracranial hemorrhage;
2. Known malignant intracranial neoplasm,
3. Known cerebral vascular lesion,
4. Ischemic stroke within 3 mo EXCEPT acute stroke within 3 h;
5. Suspected aortic dissection;
6. Active bleeding or bleeding diathesis (excluding menses);
7. Significant closed head or facial trauma within 3 mo.
Relative contraindications:
1. History of chronic severe, poorly controlled HTN,
2. Severe uncontrolled HTN (BP > 180/110 mm Hg)
c
;
3. Prior CVA greater than 3 mo or known intracerebral pathology not covered above;
4. Traumatic or prolonged (> 10 min) CPR or
5. Major surgery (< 3 wk);
6. Noncompressible venous punctures;
7. recent (24 wk) internal bleeding; pregnancy;
8. active peptic ulcer;
9. current use of anticoagulants.

and evidence of high-risk features (tachycardia, hypotension, congestive heart failure)

Management
1. ECG STAT, then every 8 hours for the first 24 hours, then daily for 3 days.
a. In addition, repeat the ECG with each recurrence of chest pain
2. Baseline troponin STAT, (creatine kinase if troponin is unavailable) and then every 8
hours until enzymatic confirmation of the diagnosis
3. CBC to rule out the presence of anemia,
4. Baseline electrolytes,
5. Creatinine,
6. Fasting lipid profile (within 24 hours of presentation)
7. Liver function tests
8. Portable chest x-ray (CXR) STAT
9. Echocardiography to assess LV function after stabilization and treatment.
Echocardiography is also used emergently when there is suspicion of acute mechanical
complications post-MI
Therapeutic Tips

The goal for thrombolytic treatment is a door-to-needle time of 30 minutes or less.
The goal for primary PCI is a door-to-dilatation time of 90 minutes or less.
Careful attention to maximum pain relief is important.
In patients with right ventricular infarcts:
o avoid nitrates and diuretics
o use fluids and inotropes to treat hypotension
Administer beta-blockers early to all patients without contraindications. Increase the dose
every 12 hours (every 24 hours for once-daily beta-blockers), if tolerated (monitor blood
pressure and heart rate), until the patient has reached adequate beta-blockade (HR 55-
65 BPM).
Start ACE inhibitors early. The choice of agent can depend on practitioner preference,
hospital formulary or financial constraints for the individual patient.
In smokers, the need to quit smoking should be reinforced early (within 24 hours) and
frequently.
Stool softeners are often used in the immediate post-MI period to prevent straining with
bowel movements.
Anxiolytics are often used on an as-needed basis in the immediate post-MI period.

Early Management of STEMI



Hx
OCD
PQRST (if it is suspected to be ACS - stop at R and start primary survey)
Primary Survey (If patient talks Airway preserved, take Oxygen saturation and start Oxygen
Stat 4L/m through nasal prongs)
Vitals
Auscultation: normal air entry and normal S1, S2
IV lines (normal NaCl 50ml/hr to keep line open, from the other side take blood for: Troponin,
CK-MB, Cr, BUN, Lytes, CBC, INR, PTT, LFT, Toxic., Alcohol, Lipids; and finger prick for Glucose)
ECG 12 leads and continue monitoring
Ask about Allergy and Viagra (if negative)
Give ASA chewable (325mg)
Non-ST elevation: give Nitro x3 (S.L) if there is no benefit give Morphine.
Contin
PQRST
AA&A
How do you feel now?
Ask Hx on CVS and GI (especially peptic ulcer)
CSx
RS
DVT

ST Elevation: do not go for DDx, Vitals (again)
RF
Nitro (2
nd
dose)
Examination:
JVP
Listen to heart
Base of lung
Compare BP in both Upper extremities to r/o coarctation of Ao
CXR
Once there is no Aortic Dissection Thrombolytics (should be clear to r/o: Peptic ulcer, recent
surgery, pericarditis, aortic dissection, brain tumor, and stroke)
Based on ECG counselling

Counseling
Based on your ECG it is most likely you are having an heart attack. If stable BP and HR are
stable, but it is a serious condition, however it is treatable. Heart attack means that greater
than one blood vessel supporting your heart is blocked by a clot that has to be reimoved. The
medications are called clot busters. Based on ECG and no sign of pericarditis or signs of aortic
dissection you are a good candidate for treatment. It is an effective medication, needs consent.
1% chance of stroke and we can start heparin.

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PALPITATIONS
A.37 M/6wks [H&PE]
B.30F/4wks[H&C]
Dd:
VITAMINS C
VASCULAR: SVT,Rapid atrial fibrillation,& V Tach
METABOLIC:Fever,Anemia,Hyperthyroidism,Acromegaly
NEOPLASTIC: Pheochromocytoma
SUBSTANCE ABUSE & PSYCHIATRIC DRUG INGESTION (sympathomimetic) Drug
Withdrawl,Anxiety
CONGENITAL:WPW Syndrome

>48 hrs not panic attack

OCD:
O: When did it start? How did it Start?
Sudden/Gradual
What were you doing at that time?
C:
Does it come in bouts or Continous?
How often does it occur?
What was the duration of the attack?
D:
How long since youve had these palpitations?
How long does each episode last? / ? > 48 hrs?
PQRSTUV
Q:
Ask Pt to tap with his fingers the heart beat.
Does it Miss abeat/Racing/Slowing of heart beat?
S:
On a scale of 1 10 How has it affected the quality of your life?
T:
Does it occur even at night?Is it the first time or has it happened before?
Emphatize: I know it can be a fairly scary feeling
AA&A
A: What makes it worse:Coffee/Recreational
drugs/Stress/Smoke(extrasystoles)Choclates/Alcohol
A:
Anything makes it better?
How was your health prior to the palpitations?

ASOC Sx:
CVS: Chest Pain/SOB/Orthopnea/PND/Dizziness/Sweating/N/VSwelling of feet/Cough
CNS: Weakness/Vision loss/Difficulty in finding words/Numbness or loss of sensation
THYROID: Do you feel hot/cold
Do you have wt loss inspite of increased appetite?/Tremors?Shakiness?Sweaty palms & moist
skin?
PHEOCHROMOCYTOMA: Repeated headaches,with increased sweating
CARCINOID:Flushing/Diarrhoea
CNS:In last few weeks did you notice any difficulty in Walking,numbness,finding words? (Look
for Sx/o Embolism)
CONSTITUTIONAL Sx: Fever/Chills/Loss of appetite/Lumps & Bumps

RISK FCTS: Smoking/Alcohol (Holiday Heart)/Recreational drugs

PMH:
Are you on any medications?
Have you seen a psychiatrist?
Any OTC/Herbal products/Cold meds/Asthma meds
Are you allergic to anything?
If Allergic to Penicillin:
1. When did you find out?
2. Where did you take it?
3. Why did you take it?
Do you have any Heart disease/HTN/DM/Stroke/Ca/MI
H/O Rheumatic fever as a child?
Did you get repeated sore throat infections as a child?
Did you receive Penicillin injections regularly as a child?

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HTN(GAO Pg:95)
History:
OCD
o O:
* When did you notice your BP was high?
* When was your last (N) BP
o Duration of hypertension,
* Usual level of blood pressure and
* Any sudden change in severity of hypertension
o History of antihypertensive drug use,
* Reason for changing therapy,
* effectiveness,
* side effects and intolerance (IMPOTENCE)
o Drugs that may cause hypertension drugs that may interact with antihypertensive drugs
(those that induce or inhibit metabolism)
o Adherence with lifestyle recommendations and drug therapy
HOME MONITORING
END ORGAN DAMAGE:
1. Angina/Mi: Chest pain/SOB
2. TIA/Stroke:LOC/Vision changes/weakness/Numbness
3. Peripheral Vascular disease/Leg pain/ED/
4. Kidney disease
SX of SECONDARY HTN, ,
1. Pheochromocytoma (hyperadrenergic symptoms)Do you have episodes of
palpitations/HA/Sweating?
2. Hyper- and hypothyroidism: Feel Hot/Cold/Tremors
3. Cushings syndrome: Bruising of skin/Wt gain
4. Renal/urinary symptoms or a past history of renal disease
RISK FCTS:
1. Cigarette and alcohol use,
2. Usual physical activity
3. Usual diet and sodium intake,
4. Current weight and recent weight change, waist circumference,
5. Diabetes
6. Dyslipidemia

PAST MED HISTORY
1. Medications Pt is on/OTC/Herbal
2. Allergies
3. Hospitalizations/Surgery

FAMILY HISTORY
Hypertension,
Cardiovascular risk factors
Premature cardiovascular disease

SOCIAL HISTORY
Nonpharmacologic Choices
Effect of Lifestyle Changes on Blood Pressure in Adults with Hypertension
Intervention Change in Blood Pressure
(systolic/diastolic) mm Hg
1. Reduction in sodium
intake
by 1800 mg (78
mmol) per day
5.8/2.5
2. Weight loss 4.5 kg 7.2/5.9
3. Reduction in alcohol
intake
by 2.7 drinks/day 4.6/2.3
4. Exercise 3 times/week 10.3/7.5
5. Dietary
recommendations
DASH diet
a
11.4/5.5
Weight loss of 4 kg or more if overweight (target body mass index: 18.5 to 24.9 kg/m
2
; waist
circumference <102 cm in men and <88 cm in women).
Healthy diethigh in fresh fruits, vegetables, soluble fibre and low-fat dairy products, low in
saturated fats and sodium, e.g., DASH diet available at Sodium intake of 1500 mg (65 mmol) per
day for those aged 1950 years, 1300 mg (56 mmol) per day for those aged 5170 years and
1200 mg (52 mmol) per day in those 71 years and older.
Regular, moderate intensity cardiorespiratory physical activity for 3060 minutes on most days.
Low risk alcohol consumption (0 to 2 drinks/day, < 9 drinks/week for women and <
14 drinks/week for men).
Smoke-free environment.
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SYNCOPE
Volume depletion and drugs
Volume depletion
Diarrhea
Diminished oral intake
Polyuria
Drugs
ACE inhibitors
o Alcohol
o Alpha- and beta-adrenergic blockers
o Antiparkinsonian drugs
o Diuretics
o Nitrates
o Phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil)
o Vasodilators
Orthostatic intolerance disorders
Reflex syncope syndromes
o Carotid sinus hypersensitivity
o Vasovagal syncope syndromes
Autonomic neuropathies
o Pure autonomic failure syndromes
o Multiple system atrophy syndromes
Arrhythmias
1. Bradycardias
o Complete (third degree) and bifasicular heart block
o Sinus node disease
2. Tachycardias
o Supraventricular arrhythmias (uncommon)
o Torsades de pointes polymorphic ventricular tachycardia
o Ventricular tachycardia

Obstruction
Aortic stenosis
Pulmonary emboli
Many other rare causes

Investigations
In patients with transient loss of consciousness perform a complete cardiovascular and neurologic
history and physical examination. Rule out seizures, then screen for life-threatening causes such as
obstruction, ventricular tachycardia and asystole or heart block
Tailor laboratory investigations to the individual patient:
o ECG (most patients)
o older patients ( >55 years) should have ambulatory ECG monitoring unless the history is
strongly persuasive for vasovagal syncope.
o echocardiogram or other noninvasive measure of left ventricular function if structural
heart disease is suspected
o coronary angiography as indicated
o refer patients with structural heart disease for electrophysiologic assessment
o unless contraindicated, carotid sinus massage should be performed in patients >50
years old to screen for carotid sinus hypersensitivity (do not perform in patients with
carotid bruits)
o tilt table testing might be useful in diagnosing vasovagal syncope in patients with
atypical symptoms
After potentially fatal causes are eliminated and reversible causes are removed, most patients
will have one of several syndromes of orthostatic intolerance:
3

o reflex syncope syndromes
vasovagal syncope
carotid sinus hypersensitivity in the elderly
o pure autonomic failure syndromes
o multiple system atrophy syndromes
The orthostatic intolerance syndromes can be distinguished based on history and a simple stand
test in the office.
To perform the stand test, first measure blood pressure
and heart rate after the patient has been supine for 5
minutes, then after 2 and 4 minutes of standing. These
responses are seen:
Normal and vasovagal syncope: modest rises in heart
rate (about 10 BPM) and blood pressure (about 10 mm
Hg).
Autonomic failure: progressive fall in blood pressure of
20 mm Hg systolic or 10 mm Hg diastolic with
development of presyncope; often no increase in heart
rate.

Therapeutic Choices
Treatment is directed at the cause of syncope. Treat any reversible causes. Refer patients with
syncope secondary to bradycardia (asystole or complete heart block) for a permanent pacemaker.
Refer patients with suspected or diagnosed ventricular tachycardia, and all patients with
structural heart disease to a cardiologist, preferably an electrophysiologist. The following
addresses treatment of syndromes of orthostatic intolerance.
Reassure the patient that this syndrome is not life threatening and that it is a physical problem,
not a psychiatric disorder. Encourage increased dietary salt intake of about 35 g daily, in the
absence of contraindications such as hypertension or heart failure.
5

,

8

Teach the patient to use physical counterpressure manoeuvres at the onset of presyncope.
9

,

10

These include squatting, crossing the legs with isometric contraction if standing, and vigorous
hand clenching with upper girdle isometric contraction. All should be tried. The evidence is
based on a good physiologic study
10
and an open label randomized clinical trial.
9

Pacemaker therapy is no longer indicated, based on the results of an adequately powered
randomized placebo-controlled trial.
11
The occasional patient with asystole documented during
vasovagal syncope might benefit, and these uncommon patients should be assessed at a tertiary
referral cl

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65/F Calf Pain x 10 weeks
How many blocks you could go? How many now?
How fast the pain disappears after resting?
Is the pain alleviated by bending forward or extending backward?
Is it awakening you at night?
Ddx:
1. Spinal Stenosis (Pain disappears about 15min after resting, alleviate by leaning forward)
2. Disc herniation (Pain disappears about 15 min after resting, alleviated by extending)
3. Intermittent Claudication (After resting pain disappears by few minutes)
4. PE
5. Cellulitis
6. Ruptured Bakers cyst
CC:
Unilateral Vs (B)
O:
Can you tell me when it all started?
Sudden Vs Gradual
What made you come in today?
C:
Is it Increasing,decreasing or same?
Has the intensity increased?
*Does it awaken you up at night?
D:
How often does each episode occur?
How long does it last?
PQRSTUV:
R:Does it move anywhere else in the body? Buttock/Toes/Feet/Thigh
T:When does it come on?
When you walk?
How many blocks can you walk when it comes? ------ >Now & at the beginning?
Reproducible pain

U
V:
Has it happened before?
If Yes When?
How Often?
AAA:
AGGRAVATING:
Stand/Sit?
When you walk uphill or downhill?
When you raise your leg?
ASSOC. SX:
CONSTITIONAL Sx: Fever/ /night sweats/Loss of appetite & los of Wt/Lumps & bumps.
Local Sx:
1. Swelling/Raised temp
2. Back Pain or Trauma to back or knee/Morning stiffness
3. Numbness/Tingling/Weakness/Burning sensation
4. Change in nails/Hair loss/Skin is it shiny/any Ulcers?
5. Are your feet cold?
CARDIAC:
Chest pain/Palpitations/SOB
*How is your sex life? Desire & Erection?........ How has this affected your life?
RS:
Cough
RISK FCTS:
I need to ask you some more qns that will help me arrive at a diagnosis of your pain:
1. Do you Smoke?
2. Drink Alcohol?
3. Have you recently travelled a long distance in an airplane?
4. Were you at any time Diagnosed as HTN,Is it Rxed & Under control? When was the last time
you saw your Dr.?
5. Were you at any time Diagnosedwith high blood sugar?Is it Rxed & Under control? When
was the last time you saw your Dr.?
6. Have you checked your cholesterol? .......
7. Did you have recent surgery?
PMH:
I need some information about your health in general:
Are you on any meds?/OTC/Herbal products?
Allergies?
Were you ever hospitalized?
FHx
SOCIAL:
Who lives with you?

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ANKLE SWELLING 30 M x 10 days
A. Gout
B. CHF
Dd:
A. UNILATERAL
1. Trauma
2. Arthritis: Gout/SepticA
3. Cellulitis
4. Varicosities

B. BILATERAL
1. CHF
2. Nephrotic
3. Liver failure
4. Myxoedema
5. Protein losing enteropathy
First Qn: Unilateral or Bilateral
OCD:
O; Sudden/Gradual
Off & On/Continous
Everyday/Certain time of day
Related to activity/Standing
PQRSTUV:
P:Above kne/Below knee
Posture
AA&A
What makes it worse: Activity/Alcohol & diet(Gout)/Standing
Alleviating fcts:Rest with elevation of feet....
ASSOC Sx:
LOCAL Sx:
In addition to the swelling did you notice any:
Pain/Stiffness/Fullness/Redness
Did you notice swelling anywhere else?
Face/Eyes particularly did you feel your eyes were puffy in the morning/Increasing waist
size/Rings are tighter?
CONSTITUTIONAL Sx: Fever/Wt loss/Night sweats/lumps & bumps
CARDIAC Sx: Chest Pain/SOB/Heart racing
GI/LIVER Disease:Yellow discoloration of skin/Pale stools/Dark urine
KIDNEY DISEASE:Change in the amount of: Urine/Color/Consistency (Frothy/Cloudy)/Odour

RISK FCTS:
I need to ask you some more details to get more insight into your condt:
Do you Smoke,Take Alcohol or Recreational drugs?
What is your diet like? Do you eat a lot of red meats? (GOUT)

PMH:
Any meds youre currently taking?(*Aspirin & Thiazides for gout)/OTC/Herbal products?
Have you ever been diagnosed with HTN/DM/MI/Stroke/Ca?
Were you ever hospitalized or undergone any surgical procedure?

FH:
Does anyone in the family have a similar condt?
DM/HTN/MI/Stroke?

SOCIAL H: Who lives with you

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24 female, acute asthma in ER, 3 dasys ago,asthmatic for the last 3yr
comes to you at clinic for F up

As I understand you were in ER 3 days ago with an attack of Ac asthma.
HOW DO YOU FEEL RIGHT NOW?

Event
Before
Event
After
OCD
Can you tell me what happened at that time?
SX:
1. Sudden/Gradual
2. Was there Wheezing?
3. Chest tightness?
4. Were you able to talk?
5. How many times did you use the puffer?
6. How did you get to the ER?
7. What did they do in the ER?
8. Were you intubated?
9. What medicines did they give you?

Asthma history

Let us talk about Asthma history:
1. When were you diagnosed?
2. How were you diagnosed?
3. Are you on regular f/Up?
4. When was the last time you were seen at F/up?
5. Have you visited the ER before?
6. Did you notice any increase in nos of attacks?
7. Do you have attacks at rest? Attacks at Night?
8. Did you dr adjust your meds at that time?
9. Which meds do you use?
10. How often do you have to use your medicines?
11. Are you using the meds more frequently?
12. Triggers
13. Do you suffer from heart burn or condt called GERD?
14. Do you user a peak flow meter?

I need to ask more qns which will help me to clarify as to why you had an attack recently?
1. Have you had recently any flu/infection? (any chest infection upto 10 wks post infection
hyperreactive airways)
2. Can you show me how you take medication? (Shake it, put it in your mouth, take deep breath
when puffing).
3. Do you make sure your medication are not expired and stored expired?
4. Did you started any new medication that might interfere (beta blocker / aspirin)with your
asthma?
5. Outdoor
cold weather, pollens, exercise, construction, dust
6. Indoor
a. Do you smoke or anyone around you,
b. Pets or people around,
c. New curtain, indoor plants, carpets, curtains, pillows.
d. Basement mould, renovations, paintings;
7. Relation to any type of food;
8. Strong odour

Important to classify mild / moderate / severe

I want to ask you

What do you do for living?
PAST H:
Any HTN/DM
Hospitalizations/Surgery
FAMILY H:
Same Condt
DM/HTN/Stroke
SOCIAL H
Do you take alcohol/recreational drugs?

ER Rx of Ac Asthma

Asthma Treatment

Very mild, intermittent asthma may be treated with fast-acting beta
2
-agonists taken as needed.
Inhaled corticosteroids (ICS) should be introduced early as the initial maintenance treatment for asthma,
even in individuals who report asthma symptoms less than 3 times a week. Leukotriene receptor
antagonists (LTRAs) are second-line monotherapy for mild asthma.
If asthma is not adequately controlled by low doses of ICS, additional therapy should be considered. A
long-acting beta
2
-agonist (LABA) should be considered first as add-on therapy only in combination with
an ICS. Increasing to a moderate dose of ICS or addition of an LTRA are third-line options. Theophylline
may be considered as a fourth-line agent in adults. Severely uncontrolled asthma may require additional
treatment with prednisone. Omalizumab may be considered in individuals 12 years of age and over with
poorly controlled atopic asthma despite high doses of ICS and appropriate add-on therapy, with or without
prednisone. Asthma symptom control and lung function tests, inhaler technique, adherence to asthma
treatment, exposure to asthma triggers in the environment and the presence of comorbidities should be
reassessed at each visit and before altering the maintenance therapy. After achieving proper asthma
control for at least a few weeks to months, the medication should be reduced to the minimum necessary
to maintain adequate asthma control.
Short-acting Inhaled Beta
2
-agonists (SABAs)

Salbutamol and terbutaline are selective beta
2
-agonists that are agents of first choice for treatment of
acute exacerbations and for prevention of exercise-induced asthma. They are best used as required
rather than on a fixed schedule. Although potent bronchodilators, they have little effect on the late
(inflammatory) phase of an exacerbation. If patients use a short-acting beta
2
-agonist more than 4 times
per week (including any doses used to prevent or treat exercise-induced symptoms), initiate therapy with
an anti-inflammatory agent.
4
Isoproterenol and epinephrine are not recommended for the treatment of
asthma because of lack of beta
2
-selectivity and potential for excessive cardiac stimulation, especially at
high doses.

Long-acting Inhaled Beta
2
-agonists (LABAs)

Salmeterol and formoterol are long-acting beta
2
-agonists for regular twice daily treatment of asthma.
Salmeterol has a slow onset of action and should not be used for immediate relief of bronchospasm.
Formoterol is rapid acting and can be utilized for rescue therapy. These drugs help to prevent exercise-
induced bronchospasm.
5
Both should be used only in patients already taking inhaled corticosteroids and
may be particularly useful for the prevention of nocturnal symptoms. Adding long-acting beta
2
-agonists to
inhaled corticosteroids may permit decreasing the latters dose.
6

This information was originally published in Canadian Respiratory Journal 2010;17(1):15-24.

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ACUTE COUGH Cough for the last 5d
Local Cause
Community acquired Pn
HIV
In young Pt can ask directly H/o HIV Status
In HIV(Pneumocytis Jevorici there is (B) chest pain & night sweats
OCD:UV
O
How did it start: Sudden/Gradual?
C:
Is it first time or have you had it before?
Is it increasing/Decreasing or same intensity now as it was in the beginning?
Does it wake you up from sleep? EMPATHY if awakens him up
NATURE:
Dry/Wet
If Wet: COCA
Color
Odour
Consistency
Amount
Blood
CHEST PAIN:
PQRST
Constitutional symptoms
RESPIRATORY Sx:
1. Shortness of breath,
2. Tightness,
3. Wheezing,
4. Ear pain
5. Sore throath
CARDIAC Sx:
SOB/
Heart racing
Chest ain
S/o Meningitis:
RISK FCTS:
1. Recent contact with sick people,
2. Vaccination for flu
3. TRAVEL H
4. Smoking
5. Alcohol
6. Drug abuse
Past Med H
Any meds/OTC/Allergies
Asthma/DM/Similar condt
Hospitalizations/Surgery
FAMILY H
SOCIAL H:
Habits
IF HIV + PT:

DO you know your HIV diagnoses?
* When?
* Where?
* Regular follow up?
* Medication? Taking/or not?
* Last CD4?
* H/O Thrush?
PAST MED H
Allergy
COUNSELLING:
PE/ CXR & Bl work
Admit today

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Cough for the last 6w
Increasing, not improving
DID you seek medical attention?, what make you come today? Is it the first time?
OCD
O
How did it start: Sudden/Gradual?
C:
Is it first time or have you had it before?
Is it increasing/Decreasing or same intensity now as it was in the beginning?
Does it wake you up from sleep? EMPATHY if awakens him up
What made you come in today/
NATURE:
Dry/Wet
If wet first & then dry
2 elements:
1. Previous episode Sx:
When productive:Fever/chills/Night sweats/ muscle pain & joint ache/COCA
2. Dry cough Sx:
From that time till now,do you have fever?chills,muscle pains?
Sx of infection?
PATTERN OF COUGH:
1. Whole day?
2. How often?
3. How may attacks?
4. How long each attack?
5. Any particular time of the day?or
6. Do you wake up in morning with cough?(NIGHT COUGH: GERD/Asthma/CHF)
(MORNING COUGH: PND/GERD)
7. When you cough do you cough to the extent that youve:
a. SOB
b. Difficulty talking
c. Wheezing
d. Chest pain
e. Sweating
f. (in children----> vomit)
RISK FCTS:
I need to ask some qns now that could lead me to the cause:
H/o repeated sinusitis
Facial pain
Ned to clear throath
Runny nose
GERD: H Burn
Acid taste in mlouth
Relation to lying down/bending forward
How many pillows do you need at night
Do you get up in night gasping for breath/
ASTHMA;
h/o Asthma
Relation between cough & outdoors or indoors
SMOKING H:
Self: How many/
How long
Those around you
Pets
What do you do for a living/
Any exposure to dust?
Any perfumes?
D/D
Other causes of Ch Cough
1. Medications:
a. HTN; ACE/Aspirin/NSAIDS
2. Swelling in legs
3. Rcent travel
4. Contact with Tb
5. H/o Lung Ca

CHEST PAIN:
PQRST
Constitutional symptoms
RESPIRATORY Sx:
1. Shortness of breath,
2. Tightness,
3. Wheezing,
4. Ear pain
5. Sore throath
CARDIAC Sx:
SOB/
Heart racing
Chest ain
S/o Meningitis:


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67Male with Hemoptysis:

Same check list as H Uria look for pulmonary Sx

Intro:
As I understand youre here because youve cough x 1 week?
Any chance you may be vomiting?
OCD
Duration: Night?
COCA + Bl
Sx of Hypovolemeia: Dizziness/Faint/Tiredness/Loc
A & A
ASx:
RS
CSx:
Hoarse voice
Risk Fcts;
Smoking
Contact with TB/Screened for TB
Travel outside Canada
Exposed to asbestos
H/O Dvt,Calf pain,redness,swelling of calves
H/O Hd: PND/Orthopnea
H/o Blood thinners
Bleeding from any parts of body
CNS:
PMH

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SOB/67 F x 6wks [5min/H] HF
Dd:
VITAMINS
VASCULAR:CHF,ACS,PE
Precipatants of CHF:
Meds:
* Stopped
* NSAIDS
Increased Na intake
INFECTIONS:Pneumonia
TRAUMATIC:Pneumothorax
METABOLIC:DKA
IDIPATHIC/IATROGENIC:COPD/Asthma/Massive atelactasis
NEOPLASTIC: Large pleural effusion
FIRST evaluate:ABC,ask pt if she is comfortable.......
OCD:
O:Sudden/Gradual
What were you doing when you had this SOB? ---Exertion/Lying down?
C:
*SOB first always ask if difficulty in breathing is for: Breathing IN or Breathing OUT
Does it occur all the time or only now
Is it related to activity or does it occur even at rest
If brought on by walking? How many blocks can you walk now as compared in the
beginning?
If at Rest?
Do you sleep well?
How many pillows do you need?
Do you wake up at night gasping for breath?
D:
How long?
If assoc Leg swelling,---- How long since leg swelling?
PQRSTUV:
S:
On a scale of 1 10?
T:
Has it ever happened to you before?If so,how often?
When was the last time you had SOB? How did you cope?
U:
How has it affected your life & how do you manage? Do you have someone to help you?
[EMPATHY]
AAA
AGGRAVATING FctS:
Exercise
POsition
Exposure to cold air?
Infection?
Allergies?
ALLEVIATING FctS;
ASSOCIATED SYMPTOMS:

CONSTITUTIONAL Sx;
Fever/Chills/Wt loss/Lumps/Bumps
RS:
Cough/Sputum
GI:
Dec appetite (Liver & GI congestion)
Increase in waist size (Ascitis)
CVS:
Wt gain/weakness/Fatigue (Decreased cardiac Output)
Chest pain/Sweating/N/V/Heart racing/dizziness/Nocturia
Leg Pain/Leg Swelling/Wt gain
THYROID:
Do you feel cold/Hot /tremors
RISK FCTS:
I need some more details about you to get a better understanding abt your condt & hence need
to ask you a few more qns
Do you smoke?
Take alcohol?
* Take your meds regularly?
* Any change in your diet recently? --- Are you eating more canned foods or have you
been taking salted nuts
* Do you measure the Na in your diet?
Did you notice youre pale?
PMH:
Were you ever diagnosed with HTN? What meds do you take? Have you taken your meds
regularly?
Were you ever diagnosed with a heart condition?
Which HD?When were you diagnosed?
How were you diagnosed?
Do you have regular follow ups?
When was your last F up?
During your last visit, did your Dr add or remove any medications? How were you doing?
Were your symptoms controlled at that time?
Particularly ask about Dixogin:
How much/How long/Dose/did you have your levels checked/any chance that you mightve
missed a dose?
Particularly ask about Water pills:
NSAIDS
DM/MI/Cholesterol/Stroke/Ca/Hospitalization/Surgery
FH:
FH of premature deaths

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SHORTNESS OF BREATH POST SURGICAL
Surgery 3 days ago: SOB x 45 mins
D/D:
1. Volume status (low & High)
2. Atelectasis
3. Pneumonia
4. Heart Failure
5. Embolism
6. Fat embolism
INTRO:
As I understand, youd surgery 3 days ago & Ive to do a PE on you
VITLAS please
I would like to R/O orthostatic hypotension
Respiratory Rate
G/E:
Orientation:
Time
Place
Person
Head: Sclera & Pallor
Mouth:
S/o dehydration
No Central cyanosis
No nasal flaring or pursed lips
No S/o Respiratory distress
HANDS:
Capillary refill
Clubbing
Cyanosis
Skin: Hot/Cold
Pulse: Rate & Volume
LEGS:
Dorsalis Pedis
Temperature
Pedal oedema
Feel for DVT
Measure diameter of (B) calves
Homanns sign
NECK:
JVP
Trachea
S/o respiratory distress & use of accessory muscles of respiration
L Nodes for pneumonia
CHEST:
Inspection:
Symmetrical
No IC retraction
No accessory muscles
No obvious pulsations
No PMI seen
FEEL
Apex beat
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LUMP In Breast/Neck
40/F h/o lump in Breast x 8 wks
INTRO:
As I understand youve a lump in your breast since 8 weeks, can you tell me more about it since
it all started?
OCD:
O:
HOW did you notice it? Routine examination or Accidentally?
C:
From that time to now, is it increasing, decreasing or remaining the same?
V:
Is it the first time, or have you noticed it before?
Any relation to periods?
Did you notice it on the upper or lower half of breast or inner or outer side?
Do you feel it reaching into the arm?
SIZE:
How do you estimate the size?
Chickpea/Olive/egg/Orange?
Hard/soft/rubbery?
Pain+/-
Skin: slides or fixed?
Changes in skin above: redness/ulcers
Lumps in other breast
Nipples: Dischareg/changes/ulcer?
CSX:
TRAUMA to breast?
METASTASIS:
Ha/Nx/Vx/Back pain/Cough/numbness in hand/Tired/pruritus?
Im going to ask you qns that may explain this:
RISK FCTS:
1. H/o Ca in breast or other breast?
2. If any biopsy was performed on the breast?
3. FH of Ca breast
4. LMP
5. Have you ever been pregnant & at what age your first pregnancy?
6. Have you breast fed?
7. Any OCs & for how long?
8. Do you smoke/alcohol?
9. H/o Ovarian or uterine Ca
10. Fatty Diet?

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LUMP IN NECK:16/F X 2 WKS
D/d:
Reactive Adenitis --------> Recent Flu
Tooth problems --------->
Lymphoma ----------> Hard
IM
HIV
INTRO:
WHERE?
HOW : OCD:
SIZE:
FEEL:
Pain +/-
SKIN changes
Any other lumps?
CSx:
Sore throat / dyspahgia?
Hx/Nx/Vx?
Skin rash?
Ear discharge?
Sinusitis/cough/Pglem?
H/o Ca or malignancies?
HEADSS
Abd pain
Vaginal discharge
Urine changes
PE:
Vitals:
Look & asses the lump
Look for any other lumps: Cervical LN/Supraclavicular/axillary
Mouth
PA:
Liver & spleen
Groin LN
Popliteal fossa
Pelvic & Vaginal exam
Rectal exam
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TIREDNESS
45M with tiredness x 6 weeks
As I understand youre having Tiredness since 6 weeks, can you tell me more about it since it all
started?
Pt says he is concerned. STOP & ask about his concern.
He says he is Air traffic controller & his vision has been blurry
Pt says, he is also never been so tired before. Clarify: What do you mean about Tiredness?
Sometimes I do not feel refreshed after sleep.
Do you feel lack of energy? Like you cannot move your arm above your head.
The Statement: NOT REFRESHED ANYMORE points to an organic cause
OCD + Relation to sleep +/- Mood
If Mood Sx + ------ MOAPS
If Organic cause ---- Red Flags
OCD
At onset you can ask if there were any flu-like Sx initially (Thyroiditis)
Do you sleep more
When do you go to bed?
Do you wake up in the middle of the night
Which time of day/Night do you feel most?
Ask Nature of work;
If shift
With whom do you sleep?
Does your partner C/o you snoring or jerky movts of limbs? (Restless Leg)
Do you feel better in morning or evening(if tired in morning-->Depression If evening-------
-->Organic cause)

1. Ask Constitutional Sx first:
Fever/Wt loss/Night sweats/Chills/Lumps & Bumps
Then quick review of Sx:
2. Cardiac: Chest Pain/SOB/Palpitations
3. Pulmonary: Cough/Wheezing/Phglem
4. GI: N/V Abnormal bowel movts/Diarrhoea/Malena/
5. Liver: Dark urine/Yellow sclera/Abd pain/Loss of aooetite/Pale stool/Itchy skin
6. GU: Change in color of urine/Amt of urine/Cloudy/Frothy urine/Dysuria/Facial swelling
7. Anemia: Bleeding gums/Easy bruising/Malena/Haematuria/Female: Meorrhagia & LMP
8. Autoimmune Disease: Joint Pains/Skin rashes/Oral Ulcers
9. Endocrine: Thyroid: Feel hot/Cold Skin Moist/Dry/Tremors/Wt loss
10. DM: Risk fcts: FH & Lifestyle
Once Pt has DM in history, GO over ALL Sx & Sy:
A. Fluctuating 6 Sx
3 High:
1. Increased eating
2. Inc Drinking
3. Inc urination
3 :
4. Tired
5. Wt loss
6. Blurry vision
B. Complications:
Micro:
1. Retinopathy: Black spots
2. Neuropathy: Tingling/ numbness
3. Nephropathy: Inc Urine
4. Impotence: Sometimes people with this condition have marital problems; Do you have
changes in desire or difficulty in having or maintaining an erection?
5. Autonomic Dysfn:
Orthostatic hypotension
Gastroparesis
Diarrhea
Voiding difficulties
HTN
Macro:
1. Coronary Artery Disease: Chest Pain/SOB/
2. CVA: Weakness/numbness/difficulty finding words/Sudden visual loss
3. Peripheral Vascular disease: Pain in calves/Cramps/Cold feet
Skin infections
Candidial infections in women

RISK FCTS:
1. Diet
2. Exercise
3. FH
4. Smoking
5. Alcohol
6. Recreational drugs

PAST MEDICAL HISTORY:
Any medications/OTC/Herbal/LMP
Surgery/Hospitalization

FAMILY HISTORY:
DM/HTN/Stroke/MI

SOCIAL H:
Habits


Here Counselling should be short Focus on Blurry vision in relation to DM & why he needs to
correct it.
As I told you DM is a lifelong disease & it is imp to have the BSL controlled.
Without proper BSL control, the increasing Blood sugar damages the blood vessels in our body,
& leads to heart attacks, Strokes, Kidney failure. Also visual loss & feet ulcers
I will have to refer you to a diabetic clinic
However I will do basic blood inv & ECG first

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35 M in hospital setting had a DKA 3 days ago x 5 mins H He is
diabetic since 25 years

Here weve to look for Rf & see that are not repeated

As I understand you were seen in the hospital by my colleagues & Rxed for a condt
called DKA 3 days ago.
Can you tell me what exactly happened to you at the time?
Xxxxx
1. Was there abdominal pain
2. Vomiting?
3. Were you drowsy?
4. Was there loss of consciousness?
5. How did you get to the ER?

6. When were you Diagnosed ad Diabetes?
7. How were you Dsed?
8. What type of Dm?
9. Which medications do you take/
10. Insulin?
10.1 How much?
10.2 When was the last time your insulin was adjusted?
10.2 What was the wt at that time/
11. Any loss or gain of wt?
12. How often do you monitor your bl Glucose?
13. When was the last HbA1c
14. Did you have DKA before?
15. When was the last time you had it/Are you under regular F/U?
16. How were you doing for the last few mths?
Ask about Sx control:
Blurry vision
Inc thirst
Inc Peeing
Wt loss

Any idea why Sx are not controlled?
DIET
What about diet?
How often do you party?
Do you modify your diet when you party?
Do you adjust insulin when you party/
If you take alcohol do you count it as a part of your calories
EXERCISE:
Any RECENT INFECTION/FEVER?

LONG TERM COMPLICATIONS:
Have you ever had an eye check/
When was the last time you saw an ophthalmologist?
Any retinal complications/
Any H/o heart attack?
How are your feet/
Any feet ulcers?
How is your urine,is it frothy/Cloudy/
Do you have tingling/numbness
Thank you for the information,we will have to do further assessment

38M requesting a note to say he is well & fit to work
Cannot see at work, works as an accountant.

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ABDOMINAL PAIN/ACUTE ABDOMEN

1. Acute abdomen x 24 hrs 45/M Er x 5min H
2. Dysphagia x 6 wks 55M
3. Inc LFT:
a. 35 M ALT>>AST
b. 55M AST > ALT
4. Diarrhoea:
a. Ch Diarrhoea x 6 wks H & PE
b. Ch Diarrhoea x 6 wks H & C
c. Ac Diarrhoea x 3 days H x 5mins

AC ABD: Acute abdomen x 24 hrs 45/M Er x 5min H
As I understand youve abdominal pain since 24 hrs.
Are you comfortable sitting down?
Please bear with me for 5 mins till I find the cause of this pain & then I can give you
something for relief
OCD:
O: Gradual/Sudden
C:
From the onset till now,is it: Inc/Dec
Off & On/Ct-ous
How was it at first?
When change in course,QUALITY & SEVERITY is significant
P
Q: Ask nature from beginning
R
S
T: Any relation with time?
Before eating/After eating
U: How was your sleep?
V:
Alleviating: Eating/Antacids/Defecation/Meds?
Aggravating Fcts: Food/Posn/Alcohol/Meds?
Assoc Sx:
Nausea
Vomiting: If +ve:
* Color
* Odour
* Consistency
* Amount
* Forceful
* Does vomiting relieve pain?
* What started first: Vomiting or pain?
(If V 1
st
--Infection/ If Pain 1
st
Surgical)
BOWEL CHANGES:
* When was the last bowel movt?
* Any abdominal distension?
* Is there any blood in stool/Dark stool?
* Are you passing any gases?
APPETITE CHANGES:
Sx Dehydration:
* Dizziness
* Dark Urine
LAST MEAL:
* Did you eat alone?
* Was there anything new?
* Did others have same Sx?
RISK FCTS:
* Any Past H/o Abdominal Surgeries
* Crohns disease?
* Groin surgery(hernia repairs)
* Gall Bladder stones?
* Pancreatic stones
* Diverticulitis?
* Smoking
* Alcohol

CONSTITUNIOL Sx:
Fever/Chills/wt loss/Lumps 7 bumps
CVS: Chest Pain/Hd/HTN
FH;
Ca Colon/Polyposis
PAST Medical h:
Meds: Aspirin/OTC/Herbals/LMP

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71F/Abd pain after meals x 4 weeks [10 min H] (ischemic)
Dd:
1. GERD
2. PUD
3. Gastric Ca
4. Ischemic Mesentry
5. Pancreatic failure
6. Ischemic colitis
Here Pt was concerned that spouse died of Ca Stomach.Reassuare her that unlike Flu Ca
Stomach is not contagious, but because they were married for so long there might be a
chance that they were exposed to a risk fct.But you will conduct a thorough History &
Inv
OCD
PQRSTUV
A&A
Assoc Sx:
Constitutional Sx:
GI Sx:
* N/V/D
* Malena
* Bowel movts
* Abdominal bloating
Cardiac Sx:
* Chest Pain/Palpitations/SOB
RISK FCTS: HTN/DM/Smoking/FH of HD/Cholesterol?HD
If +ve for HD
Ascertain type & when diagnosed,enquire abt F ups
When/what & if intervention
PMH:
Any meds/OTC/Herbal
Hospitalization & Surgery
FH
Social H:
Here since Pt had Cardiac Sx.Your cardiac history is of concern to me & Ive to do a PE &
perform some blood inv & an ECG & then ask for a Surgical Consult
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DIARRHOEA

Bloody Diarrhoea:
Awakens at night?
Any constant pain?
Think Inflammatory bowel disease

Always ask about antibiotic use: if yes:
1. Why
2. Which Ab
3. For how long
4. When
In acute Diarrhoea look for dehydration
In ch diarrhoea look for Wt loss & then dehydration

Bad Diarrhoea if:
+ve for fat droplets
Floats
Undigested food
Bulky

After intro:
OCD
Frequency
COCA + Blood
Impact
PAIN
ASx
D/d:
1. GE: if fever/N/V
2. Travel
3. New restaurant
4. Antibiotic
5. Osmotic
PMH
Fh
Sh

24 yr old diarrhoea x 3 days

Introduction:
Tell me more about is since the moment it all started?
O
C:
How often do you go to the wash room?
Estimated amount of stool passed?
Is it Tarry?
Mixed with blood?
Any undigested food?
Bulky?
Is it offensive?
Does it float in toilet bowl?
Is it difficult to flush?
A&A
Did you try any meds/did they help

ASx:
Do you feel dizzy/Thirsty?
Do you drink enough fluid?
Have you lost wt?
Do you have any additional Sx like abdominal pain?
Does bowel movt relieve your pain?
N/V
CSx:
Did you eat in a new place? (raw food----Shigella)
Did you recently take any antibiotics?
Anybody else in the family has diarrhoea?
Any FH of Bowel disease? Or condt called Crohns Disease?
FH
SH

24 yr M Diarrhoea x 6 weeks
(Crohns)

Can you tell me about it?
O
C:
All the day?/At night/
D
COCA + Bl
Bulky
+ Fat droplets
Floats & difficult to flush
Undigested food
PAIN
Relieved by diarrhoea or not
Distension/gases
U:
How has it affected your life
How do you deal with it?
V:
CSx:
Extraintestinal Sx:
Skin rashes/nail changes/Joint pains/back pain/Hx of psoriasis/Back pain/red eyes/Morning
urethral discharge/
D/D:
Thyroid :tremors/sweating
Relation of diarrhoea to food like dairy products
Travel or camping history
Sx of Liver disease
FH of Ulcerative colitis/Crohns
SH

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DIARRHOEA x 6 wks (Irritable bowel disease)
Dd:
1. IBD
2. Infection: camping/travel
3. Hyperthyroidism
4. IBS
5. Lactose intolerance
6. Coeliac Disease
7. HIV
8. Ch Liver & pancreratic failure
OCD
COCA + Blood + mucus
PAIN:if +ve which started first Pain or diarrhoea
Does bowel movement relieve the pain?
Does it awaken you at night?
Do you feel you want to go back to wash room again?
Distension/gases
U
V:
DIET: dairy products
C Sx:
In IBS R/o Organic cause:
Stress?
What type; Family/Job
How do you cope with it?
How is your mood/Interest?
FH: of Ca Colon at young age
SH

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42 M with Bld work LFT INCREASED:
ALT:300 AST:100

Cc: Bld works
Intro
Talk about blood works:
1. WHY?
2. Is it 1
st
time
3. When
4. Who
5. If done before: what were results then?

SPIKE
EXPLAIN Results
CONSEQUENCES: Sx. Ac & Ch
CAUSES OF LIVER DISEASE:
PMH
FH
SH

Intro:
As I understand youre here today to discuss some of your blood tests results
Is it 1
st
time/
Why/who/When
EXPLAIN:
Results show that there is an increase in the markers to measure the function of the liver, called
liver enzymes, this indicates that there is an injury to the liver cells
There are different causes, but before coming to the causes, I want to know if there are any
Symptoms of liver disease
Ac Sx;
1. Yellow discoloration of skin/eyes
2. Pale stools/Dark urine
3. Itchy skin
4. Loss of appetite/nausea/distaste for cigarettes
5. Flu like Sx few weeks ago
Ch Sx;
CAUSES OF LIVER DISEASE
1. Have you ever been diagnosed as liver disease before?
2. Have you ever ben screened for liver disease before?
3. Have you ever been vaccinated for Hepatitis A or Hepatitis B before?
TRANSITION
I want to ask qns now as to whether you were exposed to liver disease:
1. Do you smoke? Take alcohol/Recreational drugs? Past use IV drugs
2. Tattoos
3. Any past surgeries/hospitalizations
4. FH of liver disease
5. Long term disease in past
6. Any H/o bleeding disease
Thank you for all this info

Need to do some further assessment

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52 M/Dysphagia x 6 wks ----5 mins H
D/d:
1. Oesophageal Ca
2. Scleroderma
3. O.Stricture
4. O.
5. DES
6. web/Ring
7. HIV

FIRST CLARIFY:
If difficulty to initiate swallowing or food coming out from nose ---- Neuro Sx/Stroke/MS
Pain on swallowing ------ AIDS/CMV/Ca/Decreased immunity/Leukemia
If food gets stuck -> Can you show where it gets stuck?

ONSET:How did it start?
COURSE:
Intermittent /progressive
Intermittent for both solids & liqds ----> SPASM
Intermittent for only SOLIDS---------------> Oesophageal web/ring check by endoscopy
Progressive: Starts with fluid & Solids later ------>Achalasia & Scleroderma
Progressive: Starts with solids & later liquids ------> M/Canical obstruction: Ca
Here initially you could flush it down with water, but unable to do so now

ASSOC Sx:

N/Vx
Repeated chest infections
Chest pain/Tightness in chest
Do you bring up undigested food?
Cough
Change in voice
GI Sx:
Abd pain/Abd distension
Change in bowel pattern
Any blood in stool or vomit?
CONST Sx:
Fever/ Night sweats/Change in appetite/Chills /Lumps & bumps
If wt loss,how much Wt loss over how long?
Tiredness
*Mets: Liver: Yellow discoloration of skin/Dark urine & pale stools

RISK FCTS:
Im going to ask you a few qns to reach the diagnosis:
1. Any H/o heart burn?
2. Have you ever been diagnosed with a condt called GERD?----If Yes:
How long ago?
Did you seek medical attention?
Was an endoscopy performed (A tube with a camera put down your food pipe to view)
3. Were you ever diagnosed with a condt called: Barrets Oesophagus?
4. Do you smoke?/Drink alcohol?
5. FH of Oesophageal Ca
6. H/o swallowing acid or alkalies
7. H/o Chest radiation
8. H/o Achalasia
9. Any skin tightness
10. Change in color of digits when exposed to hot or cold enviorenments
11. CNS:
H/o stroke/weakness
H/o DM
H/o HIV

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Chest Pain 45 M x 6 wks
GERD
ONSET:
When did you first notice it?
How did it start?
Course:
1. Is it the same intensity it was at the beginning?
2. Is it increasing in intensity?
3. Is it decreasing in intensity
4. Is the frequency increasing or decreasing or same?
Duration:
Foe how long now youve the pain?
POSITION:
Can you tell me exactly where it hurts you?
Quality
Can you describe the nature of your pain? Burning,Tightnes....
Radiation:
Does it move anywhere else in your body?
To the (L) arm,Jaw,Neck,Back?
Severity:
On a scale of 1 10 ......
How has this pain affected your life?
Time
Does it occur at a particular time?
Does it awaken you at night?
Aggravating fcts:
1. Exercise/Stress
2. Food: (peppermint,fatty food,Citrus fruit)
3. Tobacco
4. Alcohol
5. Hot or cold food
Relieving fcts:
1. Antacid
2. Elevation of head end of bed
Assoc Fcts:
Do you have
1. Heart burn
2. Acid reflux
3. Difficulty swallowing
4. Dark stools?

5. Cough
6. Hoarse voice
7. Sore throath
8. Wheezing
9. Dental problems (dental erosions)

10. Palpitations
11. SOB/PND/Orthopnea

12. Constitutional Symptoms:
13. Loss of appetite & Wt loss
14. Fever & Chills
15. Lumps & bumps
16. Lupus
To gain more insight into your condition, I need to ask you some details about your life:
Do you smoke
Drink Alcohol
*** ? Recreational drugs?
Do you eat a lot of fatty foods?
How soon afer dinner do you go to bed?

PAST Med H
1. Are you on any medication/
2. Do you take Aspirin or any pain relievers or any OTC products?
3. Is there any herbal medication youre on?
4. Are you allergic to anything?
5. Have you ever been diagnosed to have a High BP or high BSL?
6. Have you ever had a heart attack or stroke?
7. Were you ever hospitalized?
8. Did you ever undergo any surgical procedure?

FAMILY History
Social History

MGment:

Dietary modifications (avoid chocolate, caffeine, acidic citrus juices, large fatty meals)
Weight loss if obese (BMI > 25 to 30 kg/m
2
)
No snacks within 3 hours before bedtime
No lying down after meals
Reduce alcohol intake
Elevate legs under the head of the bed on 10 to 15 cm blocks
Stop smoking
Avoid tight clothing

Pharmacologic Choices

When possible, eliminate drugs that impair esophageal motility and lower esophageal sphincter tone
(e.g., calcium channel blockers, theophylline, tricyclic antidepressants, beta-blockers, anticholinergic
agents).

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6
th
Feb
GU
If CC Urinary Sx:
I. Obstruction
II. Irritation
III. Urinary changes
OSTRUCTION 4 qns:
1. Difficulty initiating urine ----->Do U need to strain?
2. Did you notice change in stream?
3. Dribbling?
4. After passing urine, do you still need to pass more?
IRRITATION:
1. How many time do you need to go to Wash room: Now,Before At Night?
2. Does it affect your sleep?
3. Do you feel you need to rush to WC
4. Are you able to make it in time?
6. Burning sensation
7. Flank pain
8. Fever
URINE CHANGES:
COCA + Bld
Consistency,remember:
1. Frothy urine
2. Cloudy urine
3. Not clear urine
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67 M ER reten48 hrs/Colleague passed F Catheter & got 1.2 L urine
As I understand, youre here today because youd difficulty in passing urine since 24 hrs.& one of my colleagues
has passed a Foley catheter & drained 1.2L urine.
Im glad to know youre better
If Pt c/o pain: Bear with me few minutes as soon as I finish with asking you a few Qns I will deal with it.
Can you tell me about it since it all began?
OCD -------- U V
How many times did you try to void?
Were you able to pass any amt?
Is it the first time/Can be first time to this extent
Recently have you noticed any changes in your urine?you.g: Do U need to rush?
When did it first start?
From that time till now, is it Increasing/Decreasing?
Sx of Obstruction:
1. Difficulty initiating urine ----->Do U need to strain?
2. Did U notice change in stream?
3. Dribbling?
4. After passing urine,do U still need to pass more?
EMPATHY
Sx of irritation:
1. How many times do U need to go to Wash room: Now, Before At Night?
Does it affect your sleep?
2. Do U feel U need to rush to WC
Are you able to make it in time?
Have you ever lost control?
4. Flank pain
5. Fever
Urine changes:
COCA + Bld
Ask if H/o passing stones in urine
C Sx:
ASx:
Trauma to back:Back pain
Sx of GU: asked in earlier Qns
Mets to Liver: Sx of Liver Disease
Mets to lung: Cough/Haemoptysis
Mets to CNS:

RISK FCTS:
1. Have you ever been screened or diagnosed as prostrate disease?
2. Have you ever done the blood test for PSA
3. FH of Ca Prostrate: Who & at what age?
4. Do you smoke
5. Take alcohol
6. How is your diet?

D/D:
1. Are you on any medications?
2. Do you take psychiatric medications
3. Meds for Glaucoma?
4. H/O Stroke
5. H/o Urethritis
6. Sx of renal failure: Puffy face, swollen ankles

PMH:
Since this is the first time Im seeing you, I need to ask you some qns regarding your
Past Medical History:
Do you have DM/HTN
Hospitalized or had any surgeries?
SOCIAL H:
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67 M brought in by daughter,as she is concerened that he is not himself

Greeting: As I understand ..........
Whenever a pt is brought in by someone always ask:DO U AGREE?
If Yes:...Im glad youre here as we can find a working solution
If NO: I would appreciate that youre here just to make you daughter happy, I promise you I will be as
fast as I can.

Tell me more about the concern:
She is worried that Im not going out as I used to before.
Do you stay at home?
Im not going away to far places or out with my friends
When did this happen?
Do you share her concern?
My daughter overreacts
Im Glad youre here
What prevents you from going out?
GIVE CONFIDENTIALITY
I wet myself
When
How many times?
How did you react at that time?

The go to Urine History: Obstructn/Iritation/Urine

If Pt does not divulge, Go to Geriatric History:
1. What Medications?do you take & ask to see list or bag of meds
Do you take sleeping pills (specifically ask for that as it affects memory &
gait)OTC/Herbal products
2. Screen for Mood & Memory
3. Vision & Hearing/Balance & Falls
4. Urine: Retention in males & Incontinence in females
5. Sleep: How many hours
5.1 When do you go to bed?
5.2 Do you get up frequently?

Follow event..........
If still refuses to talk,do review of Sx
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67 M Dark urine x 1 week (H x 5 min)

D/D:
1. Bleeding/SE of warfarin
2. PSGN
3. Stone
4. Nephrotic syndrome
5. Renal or bladder Ca
6. Trauma
7. Bergers disease
8. Infection

If CC is Dark Urine, make sure it is haematuria & not Jaundice
What do you actually mean? Dark like Tea/Cola or Red?
OCD
O:Sudden/gradual
C: from that time till now,is it:
Off & on or continous/Same
D:
Has it ever happened before?
P
Does it occur at the:
1. Beginning of stream?(Urethra)
2. End of the stream? (bladder)
3. Whole of the stream? (Kidney)
V:
Urine changes:COCA + Bld
Consistency,remember:
1. Frothy urine
2. Cloudy urine
3. Not clear urine
Obstrn
1. Difficulty initiating urine ----->Do you need to strain?
2. Did you notice change in stream?
3. Dribbling?
4. After passing urine, do you still need to pass more?
Irritation:
1. How many time do you need to go to Wash room: Now,Before At Night?
2. Does it affect your sleep?
3. Do you feel you need to rush to WC
4. Are you able to make it in time?
7. Flank pain
8. Fever

C Sx:
ASx:
1. Back trauma
2. H/O recent Sore throat or skin infection
If yes to sore throat: When was that/Was there swelling of feet/Puffy face?
3. H/o bleeding tendencies or blood thinners
If Yes to blood thinners: Which one/Why/How long/How much do you take/When was last
F/U/what was your last INR/What is the target/Any new medications/Any antibiotics?
4. Did you notice bleeding from any other sites?
Gums/Nose/Malena/CNS:Numbness,weakness,difficulty finding words ......
5. H/o stones

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Neuropathic Pain

Neurologic Disorders: Neuropathic Pain

Table 1: Types of Neuropathic Pain
Peripheral Neuropathic Pain Central Neuropathic Pain
Nerve root pain Central post-stroke pain
Carpal tunnel syndrome Spinal cord injury pain
Trigeminal neuralgia Brain injury
Postherpetic neuralgia Multiple sclerosis
Incisional neuralgia Syringomyelia
Nerve trauma (causalgia)

Phantom limb pain

Investigations

History with attention to:
o temporal profile and characteristics of the pain
o functional status, mood, quality of life, insomnia, sexual function, previous and current
treatments, especially concurrent medications
o present or past chemical dependency, especially if opioids are considered
Physical examination:
o determine areas of sensory loss (hypoesthesia) and skin sensitivity characteristic of
neuropathic pain determine other neurologic findings that might indicate a progressive
lesion requiring imaging and surgery
o determine concurrent conditions that contribute to the pain problem, e.g., concomitant
muscular pain and psychological factors
Other investigations:
o imaging with CT or MR scanning if a space-occupying lesion is suspected
o electromyography
o diagnostic sympathetic blockade if complex regional pain syndrome is suspected
o although there is no established therapeutic range, monitoring serum levels of tricyclic
antidepressants (TCAs) and antiepileptic drugs may help to assess adherence and guide
dosage
Guideline for Use of Opioids in Chronic Nonmalignant Pain
Consider after other reasonable therapies have failed.
Perform a complete pain and psychosocial history, physical examination and
appropriate diagnostic tests. A history of substance abuse, tension-type headaches,
frequent migraine headache, muscular pain (myofascial pain, fibromyalgia) or pain
that appears to be largely determined by psychologic factors is a relative
contraindication to the use of opioid therapy.
A single physician/prescriber/pharmacy is optimal. The prescriber may choose to set
up a contract with the patient. The agreement should specify the drug regimen,
possible side effects, the functional restoration program and that violations may
result in termination of opioid therapy.
The opioid analgesic of choice should be administered around the clock and may
include a provision of rescue doses for breakthrough pain. Controlled-release
preparations include morphine, oxycodone, hydromorphone, tramadol and
transdermal fentanyl. Avoid meperidine primarily because of accumulation of its
excitotoxic metabolite normeperidine. Codeine is a poor analgesic for moderate to
severe pain because it has to be metabolized to morphine. Drug administration
should include a titration phase to minimize side effects. If a graded analgesic
response to incremental doses is not observed, the patient may not be opioid-
responsive, and opioid treatment should probably be terminated.
The patient should be seen monthly or more often for the first few months and every
23 months thereafter. At each visit
1. assess pain relief (010 scale),
2. mood,
3. side effects,
4. quality of life,
5. adherence to functional goals and
6. presence of drug-related behaviour.
Optimally, affix a copy of the prescription and drug therapy flow sheet to the medical
record.
The goal of opioid therapy is to make the pain tolerable. For some patients with
chronic noncancer pain (e.g., postherpetic neuralgia), the administration of an opioid
analgesic can mean the difference between bearable and unbearable pain.
Therapeutic Tips

Two to three months constitutes a reasonable trial of medication for neuropathic pain.
While patients frequently say they have used amitriptyline or carbamazepine or other agents,
these drugs have often been used in too high or too low a dose and for too short a period of
time. It is useful to re-institute these drugs to evaluate their effectiveness when used
appropriately: start low, go slow, increase dose until relief of symptoms or side effects occur and
treat side effects when possible.
Be sure the patient understands the goals of therapy: reduction in pain from moderate or severe
to mild, at the price of some side effects that may be tolerable or treatable.
Use a pain assessment tool, such as a scale of 010 where 0 is no pain and 10 the worst pain
imaginable, to evaluate pain with and without activity, and before and after medication.
As a matter of course, prescribe an artificial saliva mouth spray with TCAs and a stool softener
with TCAs or opioids.
Use controlled-release formulations of carbamazepine and opioids
It may be possible to reduce or gradually withdraw medication after initial control of pain and a
period of relief of 13 months (pain such as postherpetic neuralgia may resolve spontaneously
and trigeminal neuralgia may go into remission). Gradual reduction is important to avoid
withdrawal symptoms.
Always consider combining pharmacotherapy with appropriate psychological and physical
measures.
Try different drugs within a class (e.g., a TCA or a gabapentinoid such as gabapentin or
pregabalin), drugs of different classes and combination therapy (polypharmacy) for a possible
additive or synergistic effect; do not combine TCAs with SNRIs.
If opioids are used, guidelines are important and should be worked through with the patient.
A trial and error approach of scientifically unproven treatments is reasonable if standard
therapy fails.
Repeated visits can provide important psychological support and hope for desperate patients as
trial and error approaches are utilized.
If chronic neuropathic pain is being managed in general practice, semi-annual or annual visits to
a pain specialist (where available) help provide support to the family practitioner for
contentious approaches such as opioids, and offer the chance of a novel therapy for the patient
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HEADACHE:
Dd:
1. Tension H
2. Cluster H
3. Migraine
4. Temporal A
5. Cervical Spondylitis
6. Meningitis
7. SOL
8. SAH
9. Depression
10. Spousal abuse

Red Flags for Serious Headache
1. Age of onset Middle-aged to elderly patient
2. Type of onset Severe and abrupt
3. Temporal sequence Progressive severity or increased
frequency
4. Pattern Significant change in headache
pattern
5. Neurologic signs Stiff neck, focal signs, reduced
consciousness
6. Systemic signs Fever, appears sick, abnormal
examination
Caution: If headache does not fit typical pattern, a serious diagnosis can be
missed.
*****
Chronic Daily Headache & Medication
overuse Headache

Chronic headache occurs daily or almost daily for 15 days per month, for 6 months or longer. The most
common causes of these headaches are transformed migraine and chronic tension-type headache. In the
former there is history of migraine attacks and over several years the migraine attacks become more
frequent. Soon the migraine characteristics give way to chronic daily headache with a daily or near-daily
background headache that often resembles a typical tension-type headache. People with chronic
tension-type headache may have no history of distinct migraine.
Patients with these disorders frequently use excessive amounts of abortive agents, including
ergots, acetaminophen, ASA and opioid analgesics. They can have rebound headaches as a result
of medication-overuse, while some may have symptoms of depression or other psychological
comorbidities. Rebound headaches can also occur with the overuse of triptans. Most will
improve in days or a few weeks with the discontinuation of these medications, especially mixed
analgesics.
Generally, simple analgesics should be used less than 15 days per month in primary headache disorders
such as migraine or tension-type headache or they will lead to the development of medication-overuse
headache and chronic daily headache. Further, if chronic daily headache develops, other useful abortive
and prophylactic medications usually have less efficacy.
Management includes recognition of these disorders, tapering and stopping the offending
agent(s), and starting a prophylactic medication such as amitriptyline or another agent listed in.
During withdrawal, particularly in patients with transformed migraine, use abortive agents such
as DHE or a triptan for treatment of the migraine headaches that emerge. Short-term admission
to hospital may be required to use the Raskin protocol (using DHE) and give support. If
psychological comorbidities such as depression are present, they must be managed and treated.
Consider referral to a multidisciplinary pain management clinic for cases failing to respond to
therapy.
Therapeutic Tips

Give abortive treatment, without exceeding recommended dosages, as soon as possible.
Use simple analgesics less than 15 days per month, and ergots, triptans, opioids or analgesic
combinations less than 10 days per month.
A calendar or diary of headaches is useful in follow-up assessment.
Keep a record of medications (usefulness, dosage and side effects).
If migraine that does not respond adequately to symptomatic therapy occurs more than 34 times
per month, try prophylactic medications for several months and then discontinue if possible, to
assess ongoing need.
2

Different medications may need to be tried, including different members of the same class, such as
triptans.
Follow-up is most important in managing chronic headache.
Reassurance and explanation are most important to the patient in the long term.
Always offer hope to patients with chronic headache even if no cure is available; most primary
headaches can be controlled.

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ACUTE HA x 10 days: 67M in ER
HISTORY:
OCD PQRSTUV
Onset: Sudden Vs Gradual
Course:
All the time
Is it increasing or decreasing or is it the same?
VARIATION: Did you notice any variation?
Is it the same throughout the day
Does it awaken you at night? (EMPATHIZE++++)
Duration:
How long the whole disorder
How long each attack
How frequent: off & on
Posn:
Unilareral/Bilateral
Where is it exactly?
Does the part where it hurts is tender (Temporal Arteritis) & do you feel like a cord-like
structure there?
Quality:
Throbbing
Burning
Tightness/Pressure
Ice pick like
Radiation?
front,side,back of head,or in the eyes,ears or throats?
Severity:
On a scale of 1 10
Can you say It is the worst HA of your life?
Timing
Triggers:(not when single episode)
U:
Qns for empathy**
How has it affected U in your daily life?
How r U coping with it?
How do U feel abt it?
What r your expectations from todays visit?

V= deja Vu
Aggravating factors:
Eating (Jaw claudication)
Bending forwards/Coughing/Lifting/Lying down (Inc ICP)
Lights/Certain foods etc (Migraine)
Eyestrain (vision correction)
Alcohol (cluster H)
Alleviating fcts:
Did you try any meds & were they helpful?
Assoc.Symptoms:
In addition to your headache did you notice any other symptoms:
(Try & do constitutional sx first as you may forget them)
Fever/Neck pain/Photophobia/Skin rash/Ear infection
NEURO Screening:
1. Vision changes:
What type of problem?
2. Hearing abnormalities
4. Weakness/Numbness
6. Difficulty in balance or repeated falls
7. Changes n bowel/Urine Loss of bladder control
8. LOC
9. H/o Seizure

MOOD Changes
MEMORY problem
Changes in CONCENTRATION
Has anyone told you that youve ben acting strangely?

MSK Screening
Is there pain in your joints
For how long?
Can you raise your arms above your head?

H/O INJURY:
To head
Did you have a fall & hurt your head?

EXTRACRANIAL:
EYE:
Did you notice any redness or need eyeglasses?
Sinusitis:
Facial pain/flu
Throath pain
Dental pain

RISK FCTS:
Do you smoke
Take EtOh
Take recreational drugs?

PMH:
Have you taken pain killers,if +ve: How much & for how long (rebound HA)
Did you take any OTC or herbal meds?
Have you ever been diagnosed with HTN/DM/Stroke/MI/Ca?
Were you ever hospitalized or underwent Surgery?
FAMILY H:
HTN/DM/Stroke/MI
SOCIAL H:
Who lives with you?
DIAGNOSIS: Temporal Arteritis

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24 M/HA 6 wks Office 10 mins H & C

Primary Headache Secondary Headache
Type % Type %
Migraine 16 Systemic infection 63
Tension-type 69 Head injury 4
Cluster 0.1 Vascular disorders 1
Idiopathic stabbing 2 Subarachnoid hemorrhage <1
Exertional 1 Brain tumor 0.1
Cluster headache is a rare form of primary headache
The pain is deep, usually retroorbital, often excruciating in intensity, nonfluctuating, and
explosive in quality.
A core feature of cluster headache is periodicity.
At least one of the daily attacks of pain recurs at about the same hour each day for the duration
of a cluster bout.
The typical cluster headache patient has daily bouts of one to two attacks of relatively short-
duration unilateral pain for 810 weeks a year; this is usually followed by a pain-free interval
that averages 1 year.
Cluster headache is characterized as chronic when there is no period of sustained remission.
Patients are generally perfectly well between episodes.
Onset is nocturnal in about 50% of patients, and men are affected three times more often than
women. Patients with cluster headache tend to move about during attacks, pacing, rocking, or
rubbing their head for relief; some may even become aggressive during attacks. This is in sharp
contrast to patients with migraine, who prefer to remain motionless during attacks.
Cluster headache is associated with ipsilateral symptoms of cranial parasympathetic autonomic
activation: conjunctival injection or lacrimation, rhinorrhea or nasal congestion, or cranial
sympathetic dysfunction such as ptosis.
OCD
ONSET:
If pt says this time was worst: Ask Prev episode,if present:
1. How long ago?
2. Did you seek medical attention then?
3. What was the diagnosis?
4. What Rx was given?
5. Is this current HA different from from the previous one?
NOW GO to THE CURRENT HA.
Finish with the current HA & can go back to previous HA
ONSET:Gradual/Intermittent
COURSE:
Inc/Dec/Same
DURATION:
How Often?
How long does each episode last?
Everyday,few hrs,wkends longer& awaken at night?
POSN
QUALITY:
R S T U V
AlLEVIATING FCTS:
Sleep/Pacing/Dark room/Lying down
AGGRAVATING FCTS:
Flashing lights
Lack of sleep
Certain food
Alcohol (Cluster )
CONSTITUTIONAL Sx
Fever/chills/N Sweats/Loss of appetite & loss of wt/Lumps or bumps anywhere
TRAUMA:
RISK FCTS:
Are you under stress?
How do you handle stress?
Do you Smoke?......
Do you take Alcohol:
How much How long Why??
Have you used recreational drugs?
How is your MOOD?
Any chance that you may be depressed?
*MI PASS ECG
Mood:
I nterest
Psychomotor retardation
Appetite
Sleep
Suicidal ideation
Energy
Concentration
Guilt
If M& I are +ve Look for depression

PMH:
Are you taking any meds?/OTC/Herbal products?
Were you ever Diagnosed with HTN/DM/Ca
Were you ever hospitalized or had surgery?
FH:
SOCIAL HISTORY:
Who lives with you?

Acute Attack Treatment
Cluster headache attacks peak rapidly, and thus a treatment with quick onset is required. Many
patients with acute cluster headache respond very well to oxygen inhalation. This should be
given as 100% oxygen at 1012 L/min for 1520 min.
Sumatriptan 6 mg subcutaneously is rapid in onset and will usually shorten an attack to 1015
min;. Sumatriptan (20 mg) and zolmitriptan (5 mg) nasal sprays are both effective in acute
cluster headache, offering a useful option for patients who may not wish to self-inject daily. Oral
sumatriptan is not effective for prevention or for acute treatment of cluster headache.
Preventive Treatments
The choice of a preventive treatment in cluster headache depends in part on the length of the
bout. Patients with long bouts or those with chronic cluster headache require medicines that are
safe when taken for long periods. For patients with relatively short bouts, limited courses of oral
glucocorticoids or methysergide (not available in the United States) can be very useful.
A 10-day course of prednisone, beginning at 60 mg daily for 7 days and followed by a rapid
taper, may interrupt the pain bout for many patients.
When ergotamine (12 mg) is used, it is most effective when given 12 h before an expected
attack.
Patients who use ergotamine daily must be educated regarding the early symptoms of ergotism,
which may include vomiting, numbness, tingling, pain, and cyanosis of the limbs; a weekly limit
of 14 mg should be adhered to.
Lithium (600900 mg qd) appears to be particularly useful for the chronic form of the disorder.
Table 15-9 Preventive Management of Cluster Headache

Short-Term Prevention Long-Term Prevention
Episodic Cluster Headache Episodic Cluster Headache & Prolonged
Chronic Cluster Headache
Prednisone 1 mg/kg up to 60 mg qd,
tapering over 21 days
Verapamil 160960 mg/d
Methysergide 312 mg/d Lithium 400800 mg/d
Verapamil 160960 mg/d Methysergide 312 mg/d
Greater occipital nerve injection Topiramate
a
100400 mg/d

Gabapentin
a
12003600 mg/d

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35F HAx 6 wks H & C
Can you tell me abt it since you first noticed it?
Im glad you came in today,do you have the HA now?Any particular reason as to why you came
in today?
OCD
Empathize+++
PQRSTUV
CONSTITUTIONAL Sx
Local Sx:
RISK FCTS:
Smoking/alcohol/recreational drugs
PMH:
Are you on any medications
Are you on the Contraceptive Pill?
Was it changed recently?
Did you notice any relation to the HA & the Pill?
Any OTC/Herbal meds?
HTN?DM?MI?STROKE?CA?
Any hospitalizations or Surgery?
FH:
Similar HA in any one of your family members?
FH of HTN/DM/Stroke/MI
SOCIAL H:
Stress in your life?
Who lives with you? Look out for Domestic Violence....
COUNSELLING:
Migraine can be related to the pill
Disct the OC or change the particular pill & switch to another form of pill or contraception like
IUCD or barrier method
o avoid triggers, especially in migraine, e.g., too much or too little sleep, irregular
meals, lack of regular exercise, extremes of stress or relaxation, known dietary
triggers
o apply ice; sleep or rest in a dark, noise-free room
DIAGNOSIS:MIGRAINE
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45 M HAx 4 wks
OCD
PQRSTUV
This scenario Pt has typically gets HA at work,better at wkends & when he is drivng home.
Alert to possibility to exposure to something at work.
On H/o :
What sort of Job, he was a forklift operator.
Ask which sort of Environment he works whether it is:
1. Open or closed
2. Operated by electricity or gas
3. Presence or absence of ventilation
4. Presence of Carbon monoxide alarm,whether it has ben checked
5. If anybody else in the work place has a similar HA

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40F/Looks older Weakness (R) arm x 6 hrs History x 5 mins & review of Sx

D/d: Vitamin D
Vascular:Stroke/ICH/TIA
INFECTION: Abscess/Meningitis/Encephalitis
Traumatic: Head Injury
Autoimmune:Vasculitis
Metabolic: electrolyte abnormalities/Hyperthyroidism/Uremia
Idiopathic:Syncope/MS
Neoplastic: Mets or Pirmary Brain T
Drugs: EtOH/Cocaine/Phencyclidene/Amphetamine

OCD:
O: Sudden/Gradual
What were you doing at that time it occured
C: Is it getting worse?
D:

PQRST UV
Quality of defeciet: Sensory/Movt/Power
1. How weak is it?
2. Can you move at all?
3. Partially weak?
U:How has it affected your life? (ADLs)
Gross motor:(Reaching shelves/Opening doors)
Fine Motor:Buttoning shirt/using keys/writing
V: Have you had such episodes previously?
OTHER LIMB: what abt (R) Leg/(L) Arm & (L) Leg

Assoc Sx:
Local Sx:
Parasthesias/Pain
Calf Pain/Swelling
Recent travel/Immobilization
CNS:
HA/Dizziness/LOC/Visual disturbances (amaroux Fugax)/Slurred speech
CVS:
Palpitations/Chest pain
CONST Sx:
Fever/Chills/wt loss/Lumps & Bumps
Trauma: or injury
Bladder: any urinary problems (R/O MSclerosis)
RISK FCTS:
Smoke/Alcohol
Was your blood ever checked for cholesterol & Sugar? .......
When/if on any Rx .........
OC
DM/HTN/Stroke/Ca/MI
Do you have a form of regular exercise?

PMH:
Are you on any Meds/OTC/Herbal products (particularly Asa/Warfarin/Blood thinners)
Do you have any allergies
Were you ever hospitalized or had any Surgeries?
Do you have any Peptic Ulcers

FH:
Does anybody else in Family have such a condition
HTN/DM/Stroke?MI
SOCIAL H:
Who lives with you?


Alteplase in Acute Ischemic Stroke: Treatment Criteria
Treatment criteria
1. Ischemic stroke in a patient 18 years
2. Stroke onset > 1 h and 4.5 h before alteplase administration
3. Stroke deficit that is disabling or measurable on the NIH Stroke Scale
4. No intracranial hemorrhage on CT or MRI scan
Exclusion criteria
1. Time of stroke onset unknown or > 4.5 h
2. Any hemorrhage on brain CT or MRI scan
3. Symptoms suggestive of subarachnoid hemorrhage
4. CT or MRI signs of acute hemispheric infarction involving more than 1/3 of the MCA
5. History of intracranial hemorrhage
6. Stroke or serious head or spinal trauma within the preceding 3 mo
7. Seizure at stroke onset
8. Systolic blood pressure 185 mm Hg or diastolic blood pressure 110 mm Hg or aggressive
treatment (intravenous medication) necessary to reduce blood pressure to these limits
9. Recent major surgery
10. Arterial puncture at a noncompressible site within the previous 7 days
11. Elevated activated partial thromboplastin time
12. International normalized ratio > 1.7
13. Platelet count < 100 10
9
/L
14. Blood glucose concentration < 2.7 or > 22 mmol/L
15. Any other condition that could increase the risk of hemorrhage after alteplase administration

Alteplase in Acute Ischemic Stroke: Monitoring
5

Blood Pressure and Neurological Signs
Baseline, then Q15min 2 h after starting alteplase
Then Q30min 6 h
Then Q1H until 24 h after starting alteplase
Call MD if the systolic BP is > 180 mm Hg or if the diastolic BP is > 110 mm Hg on 2 or more occasions
taken 510 min apart
Stop the infusion, obtain emergency CT scan and notify MD if there is neurologic deterioration, severe
headache, or new onset of nausea or vomiting
Blood Glucose
Call MD if glucose > 12 mmol/L
Lines and Tubes
Delay placement of nasogastric tubes, indwelling catheters or intra-arterial pressure catheters
Medications
No ASA, ticlopidine, clopidogrel, heparin or warfarin for 24 h
Acetaminophen 650 mg po or pr Q4H if body temperature is 38C or for analgesia
O
2
via nasal prongs or face mask to keep O
2
saturation > 90%
After the alteplase infusion is completed, continue iv normal saline (with or without KCl)
Investigations
CT brain scan after 24 h
Carotid endarterectomy (CEA)
2

Patients with carotid territory transient ischemic attack or nondisabling stroke and ipsilateral 70
95% internal carotid artery stenosis should be offered carotid endarterectomy within 2 weeks of
the incident transient ischemic attack or stroke unless contraindicated.
CEA is also appropriate for selected patients with moderate (5069%) symptomatic stenosis.
These patients should be evaluated by a physician with expertise in stroke management. Carotid
stenting may be considered for patients who are not CEA candidates for technical, anatomical or
medical reasons.

Antiplatelet therapy

If intracranial hemorrhage is excluded by CT scan, but alteplase is not indicated, give ASA 160 mg
immediately. This is followed by ASA 80325 mg daily.
When alteplase is used, wait until intracranial hemorrhage is excluded by CT scan 24 hours later
and give ASA 160 mg once. This is followed by ASA 80325 mg daily.
Administer ASA as a suppository or via nasogastric tube to dysphagic patients. Use enteric-coated
formulation for patients who can swallow. No evidence supports the use of ASA doses greater
than 325 mg/day for secondary stroke prevention. The GI side effects of ASA are dose related.
For patients who were taking ASA prior to their stroke, consider other antiplatelet agents, such as
clopidogrel 75 mg daily or a combination of ASA and sustained-release dipyridamole 25/200 mg
twice daily, although these regimens have not been tested in acute stroke.
The combination of ASA and clopidogrel is not recommended for long-term secondary stroke
prevention.
Anticoagulant therapy

Immediate systemic anticoagulation with unfractionated heparin, low molecular weight heparin,
heparinoids or specific thrombin inhibitors is not recommended in the setting of acute ischemic
stroke, not even for patients in atrial fibrillation (AF), because there is no evidence of short- or
long-term benefit. Specifically, reduction in early recurrent ischemic stroke is completely offset by
an increase in major intracranial and extracranial bleeding.
18

ASA is as effective as warfarin for secondary stroke prevention in patients in normal sinus rhythm,
and does not require laboratory monitoring.
For patients in AF, use warfarin at a dose to maintain the INR in the range 2.0 to 3.0, provided
there are no contraindications to anticoagulation. For patients who cannot take warfarin, use
enteric-coated ASA 80325 mg daily.
The best time to initiate anticoagulant therapy is unclear. For patients with minor strokes, start
warfarin as soon as intracranial hemorrhage has been excluded by CT scan. For patients with
major strokes, delay warfarin until a CT scan done about a week or two after the stroke has
excluded hemorrhagic transformation of the infarct.
Blood pressure lowering treatment

Randomized controlled trials have not defined the optimal time to initiate blood pressure lowering
therapy after stroke.
19
Oral blood pressure lowering treatment should be initiated (or modified)
prior to discharge from hospital in patients whose blood pressure is 140/90.

IV. Restore Function of the Individual

Outcomes are optimized by care on a stroke unit provided by a coordinated interdisciplinary team
(Start rehabilitation as soon as the patient is medically stable.
Family and community supports are important for social reintegration.

Therapeutic Tips

The effectiveness of thrombolytic therapy with alteplase is exquisitely time dependent; delays of
any sort should not be tolerated. A minority of patients present to hospital within the first 90
minutes of stroke onset, leaving limited time to act. Immediate contact with the patient, rapid
triage, and (most importantly) staying with the patient continuously during the clinical
assessment, CT scan, blood tests and consent procedures are vital in ensuring that the
appropriate steps are being taken as rapidly as possible prior to alteplase administration. For
example, it is not necessary to wait for hospital porters to take the patient to the CT scanner.
Determining the time of stroke onset is critical in deciding to use alteplase, but checking the clock
is not a natural reaction in the setting of an acute stroke. Encourage patients and families to think
of time anchors (e.g., what was on the radio or TV at the time, or at what point in the patient's
daily routine did the symptoms first occur).
Patients with acute stroke are often unable to communicate. When possible, the next-of-kin
should travel with the patient to hospital (or between hospitals if the patient is transferred) to
provide collateral history and consent for treatment before the time window for intervention
closes.
If the patient is referred to a tertiary care hospital, have the stat blood work (CBC, INR) drawn at
the community hospital and the results faxed to the referral centre as soon as possible.
Point-of-care INR testing , if available, can provide results quickly.
Signs of infarction on a CT scan done within 4.5 hours of stroke onset are usually subtle. If the CT
scan of a patient being considered for treatment with alteplase shows a very definite infarct in a
location that explains the presenting clinical symptoms and signs, recheck the time of onset.

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A 30 YOF with right arm weakness for 10 hours, Hx for 5m
Intro
Where is your weakness?
Can you still work with your hand or no?
Do you have burning or tingling sensation on your hand or shoulder? How about numbness?
Any problem on your right foot? Lt. arm or leg?
Is it the first time? (If the patient says that she had it before than: When was it? How long did
it last? Which medication did she take?)
Did you fall or lost your consciousness?
Any change in your vision? Loss of vision? Double vision? Blurry vision?
Any change in your hearing? Buzzing sound? Diffucult in finding words? Any change in balance?
Any change in urination and bowel movement?
When you bent your neck do you fill electrical shock along your spine?
Do you difficult to swallow?
Have you ever had dizziness, headlightedness, loss of consciousness, jerky movement, seizure?
How is your mood / concentration / memory?
Any change in your personality?
When you touch your face do you feel any electrical shock?
Uhthoffs sign: when they get hot water or hot weather trigger for their symptoms (especially
optic neuritis).
Review systems from head to toe: chest pain, heart racing, sob, cough and phlegm, abdominal
pain, nausea and vomiting, joint pain, skin rash, diabetes, thyroid disease, anemia
CSx
RF for MS, PMHx, FMHx

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PAEDS

1. Pediatrics (30)
2. Psychiatry (30)
3. Physical exam (30)
4. Management (12)
5. OBGYN (
6. Communication Skills (10)
7. Counseling (10)
8. Medicine (CVS 15, Neu 15, Med 20)

Pediatrics
Consider abuse
There are no children in the room, only parents.
Maternity leave either husband or wifes.

A child 9m chronic diarrhea (CF, Celiac, HIV; Lactose deficien cy)

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5y.o fever take history.
Skin rash ask questions about it (distribution, relation to vfever)
HSP

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Son, 3y.o is coughing for 4wk and they want to renew his antibiotics
This shows there was a condition
Ask What Ab,for which condt,When?.
Dont waste your time R/O: Hyperactive airways or is it infection that has not cleared,or could be
asthma.

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A mother just delivers a baby who is IUGR
all questions should about pregnancy and delivery.
1. Reassure her,
2. Note appearance of the child
3. Note Paediatricians visit,
4. History of pregnancy/Obstetric History
5. Family history.
In case mum was smoking,taking alcohol & drugs & asks if her fault if child has IUGR
Dont reproach her it is NOT her mistake.
It is a multi-factorial condition.Can be due to various causes,some genetic,pregnancy,related to baby
Because safe levels of smoking,drugs & alcohol not known,
We always recommend not to smoke or drink for futurepregnancies.

Parents are concerned that their child is not growing enough: [AGEx2+8]
What his weight in birth.

14m 8Kg (birth weight 3.5Kg). He is underweight.

CC
OCD
COCA-B
AA
ASx
PMHx
SHx
0-6m: BINDE
Birth Pregnancy:
Was it a planned pregnancy?
1. Did you have any regular follow-up?
2. Did you have any US? Was it normal or not?
3. During your pregnancy did you have any fever or skin rash?
4. Any contact with sick person or cats?
5. Any medication/smoking/drugs/alcohol?
6. Screened for HIV/Syphilis/GBS/Hepatitis B? Blood group?
Birth Delivery:
1. Was it in term or not?
2. What is the route? (Cs/NVD)
3. How long it took? (18hr is normal for primi, 12hr for multi),
4. Early gush of water?
5. Any need for augmentation?
6. What was the APGAR score?
7. Did the baby cry immediately?
8. Did your baby need any special attention?
9. Any bulging or bruising in his body?
10. When were you sent home?(C/S 3d, V/D 1d).
11. After delivery did you have any fever/vaginal discharge/any medication?
12. Were you told that your baby had any congenital deformity?

Immunization if he says that the child is not immunized you have to inquire for the reason.
If he is not vaccinated because the parent is busy look for child abuse RED FLAG.Ask wt &
milestones
If it is due to religion believe you dont have to ask more. Otherwise ask about nutrition.

Nutrition
WEIGHT:
1. What his weight today,
2. Weight at birth,
3. Highest weight,
Growth chart.
X (birth), 5m-2x, 1y-3x, 2y-4x. Weight: Agex2+8
H (birth, about 50cm), 1y-1y, 2y-1.75H (half of his adult height), 4y-3.5H
HC (at birth): 35cm
What do you FEED your baby
If formula:
When did you start the formula
If B Fed at all
Did you consider B feeding?
what type of formula do you use?
How do you prepare it?
Was there any changes in the feeding?
Did you add any solid food or supplements (any fortified serials or iron) do you feed him with
any bread, solid food
when started the diarrhea (before the solid food or after?)

Development
At the end 1y they use words, 2y two words at one sentence, 3y 3words in one sentence;
4y speak normally.
Gross motor: role 4m, seat- 6m, crowling 9m, standing 1y, climbing upstairs 18y,
riding bicycle 3y

Environment
with whom do you live at home?
Any other children?
Relation between your child and other households?
Who spends most of the time with the child?
Financially how do you support yourself?
Do you live in your own house?
Do you have basement in your house?
Anybody drinks or uses drugs?
Building basement (mold) and
Old houses (lead poisoning).
6-12m: School Performance: comparing the grades between now and previous.
>12-14 yrs: HEAADDSSS
Home: with whom do you live?
Education: Which grade?
How are your marks?
What do you want to be?
Recent drop in grades?
Activities: Any hobbies? (in case of epilepsy ask for the risky activities)
Alcohol: do you smoke, drink, (a lot of people of your age might experiment with drugs? How
about you?), Smoking
Diet: do you have any special diet?
Drugs: have you ever tried recreational drugs?
Smoke
Sexual: are you in relationship?
Suicide: how is your mood?

Questions for dehydration: Does baby have tears when crying?
How many times you pee?
How many times you change his diapers?

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5 Day old infant with yellow discoloration since he was 2 days old
A mother who is after 5days from deliver (if she uses jaundice what do you mean be that?).
Is it early in the second day is it pathological.
Late in the second day it has no value.
Make sure that the baby is stable Red flags:
1. High pitched crying,
2. Poor feeding & Poor sucking
3. Floppy baby,
4. If above three are present, it is a problem, decide to reassure her or tell her youve to do a
physical exam& admit
If you have to take history and counsel ------>Reassuarence
Only history-------->Pathological
m/p it is not physiology

What is the name of your child?
(He is yellow)
Good you are here; I hope you can reassure you at the end.
OCD
Tell me more about it since the moment it started
O:
Is it early in the second day is it pathological.
Late in the second day it has no value
C:
D:
Where did you notice it?
Is it spreading?
Did it reaches the legs?
Is it getting darker?
In addition to it did you notice any dark urine?
Pale stool (in bliary atresia pale stool from the beginning?)
ASx:
INFECTION:
In addition to that did you notice any
fever, cough, discharge from ear,discharge diarrhea, vomiting, foul smell urine,
is he crying, is he floppy, is he sucking well, (RED FLAGS)
Rash,
Dehydration:
how many diapers did he change, any tears
Transition: I am going to ask you some questions to see if any conditions cause this issue back to
your pregnancy
FHx: of liver disease and blood disease. If she are concerned why you are concerned (will he be
mental retarded).

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Mike Tyson, Child crying for the last 10d, 6w years old.
A child whos with infantile colic.
How do you feel when your child is crying.
Crying child could be colic,screen for abuse,see how parents handle it
The crying might cause abuse

Weight, dehydration,
Start to observe the body language of the father.
OCD
O;
At that time was there any illness,like fever,runny nose
C;
Off & On/all the time
Every single day,every day,how many days/week
also is he crying during the night? how does it affect you and your wife?)
Aggravating FCts:
Any chance he is hungry?
Any chance he is wet & neds a diaper change?
Diaper rash?
Any chance he is too hot or cold?
Alleviating Sx:
Do you soothe him/hug him/carry him & walk/take hime for a ride/listen to music?
Do you burp him/rock him/Skhe him?
If Yes: How many times?
When was the last time?
What happens to him when you shake him?
Does he stop crying?
Does he pass out?
(Children at this age cannot express their discomfort& only means of communication is by
cryingI am going to ask some questions to see if there is any reason for this crying?
ASx;
INFECTION:
Fever, sweating, tender points in his body
Running nose, coughing, vomiting, discharge from his ear, yellow discoloration, fowel smell
urine,
GI
does he have distension of abdomen
Gases
Does he draw up his legs & cry
Any relation to feeds

BINDE (Partial)
N 1
st

P
Planned pregnancy,
Reg F/u
Was it term P
Any illness
Smoke/Drugs, Term, Complicated, Needed special attention, separation,
any congenital abnormality
Environment: financial how do you support yourself, any financial stress, with whom do you live,
repeated visits to ER, anyone in home have psychiatric problems/drugs/alcohol, relationship
with your partner
PMHx diseases, hospitalizations

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Rita Gordon, mother of 5w who vomit for the last 10d
Pyeloric stenosis
GERD
Infection
Alleric to milk
overfeeding
Not Pyloric stenosis
If the colour of vomit is yellow or greenish discolouration
Not projectile + Wt loss

GERD
No wt loss at 6 weeks
Wt loss at 18 mo due to anaemia,due to bleeding due to oesophageal bleeding

Confidential give it early according to the cues.
Depressed: after my son become vomit or preceding the vomit. Not reliable history.

CC
OC fD
O:
C;
Off & on/All the time
How many/day
Increasing/Decreasing or same?
COCAB
Forceful
Feed: Formula/Breast?
COCA
How much F do you give? & How much does he vomi t out?
AA:
Any particular posn improves it? ( GERd upright better)
IMPACT:
WT & Dehydration
Do you feel he is still hungry after you feed him?
How many diapers do you change,Now & at the beginning?
ASx: wt & s/o dehydration
Gerd no weight loss
Pyeloric stenosis yellowish colour (ask specifically about the colour, relation to feeding up to
half hour can be related to PS, what about position, do you burp him?)
ASx:
Infection any signs of infection
BINDE:
N 1
st

If formula fed?
Did you change the Formula?
Have you considered breastfeeding? Is there any reason not to breast feeding?
Overfeeding overweight
Allergy less likely if she uses it from birth
Abdominal distended
B
PWas it planned pregnancy
Were there regular F/u?
How do yu feel about being a mum?
MOOD & INTERSET
Any chance of being depressed?
Any chance you feel like harming the baby or yourself?
Do you have any support at home?
I see you are preoccupied / overwhelmed
Child abuse/neglect
If there is a growth chart it it is from the beginning.
4 min on the child, last 1 min to concentrate to the mother.

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Sandra Bullock, 19 y.o, 8m child, pale.
Intro
Name of the child
CC: Anemia
?
OCD
IMPACT
Causes: Red Flags (bleeding & BINDE)
Past MH
FH
ENv: Old house
Pale what do you mean? Who told you that
OCD

If told by another person/ If you think about it,any chance he was pale before that or just
now?,& you were unaware
I like to see how it has affected your son:
IMPACT: Is he as active as before?
Crawl? Playful as before? LOC? Heavy breathing? Stop to breath when you feed him?
T:
Im going to ask you some questions that could be the cause of this?
Asx:
Infection:
Sweat, Fever, Loose of weight, Painful points?
Does your child have bleeding? Bruises? Coughing blood? Tarry stool?
BINDE:
N 1
st

What do you feed him? (B/F)
Any solids /supplements
P:
Was it a term Preganacy?
IMMUNIZATION:
ENV:
Any financial concerns?
Old/new home
Do youve a supportive family?
PMH:
FH:
Any bleeding disorder?
Repeated lver disease
Any gall bladder disease or splenectomy
Certain blood disease are more common in particular parts of the world & for that reason I need
to know your & partners ethnic background.
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ANEMIA: 29/F MCV Inc (Counsel)
D/d:[TN10/H21]
A. MEGALABLOBALSTIC:
a) B12 defeciency:
I. Diet (vegan)
II. Gastric:
a) Mucosal atrophy
b) Pernicious An
c) Post G-ectomy
III. Intestinal Absorption
a) Malabsorption (Crohns,celiac sprue,pancreatic disease)
b) Stagnant bowel (blind loop,stricture)
c) Fish tapeworm
d) Resection of ileum
b) Folate deficiency
I. Diet
II. Intestinal malabsorption
III. Drugs/Chemicals:
a) Alcohol
b) Anticonvulsants
c) Methorexate
d) Birth control pills
IV. Inc demands:
V. Pregnancy/Hemolysis/Hemodialysis/Psoriasis
c) Drugs (Methroxate,azathioprine)
B.Non Megalobalstic:
I. Liver disease
II. Alcohol
III. Hypothyroid
IV. Myelodysplastic syndromes
Start By saying: Ive the results of your test with me & before I proceed I need to get some
information abt you that will help me understand:
If Pt asks if Serious: STOP & ask WHAT is her concern.
There can be many reasons for this result,though most are simple,however some can be
serious,
2QNS:
1. What is the reason for doing the test
2. Is it the first time?
Then explain the results

Search for the cause of iron deficiency, including very careful consideration of occult
gastrointestinal bleeding
Menorrhagia must be convincing before it is accepted as the sole cause of iron deficiency. This
may be an opportunity for early recognition of a gastrointestinal malignancydont miss it!
A reticulocyte response should be evident within one week of beginning iron therapy, with
subsequent improvement in the Hgb of about 10 g/L every 710 days.
If the Hgb fails to respond as anticipated, consider that there may be:
o ongoing blood loss
o use of other medications that impair iron absorption
o a different or concurrent cause of anemia and/or an impaired erythropoietic response
o compliance issues
Gastrointestinal side effects are the most common reasons for non-compliance:
o use a graduated approach to dosing. Begin with a single tablet taken after a meal. On a
weekly basis, as tolerance permits, add another tablet until the patient is taking one
dose with each meal. Thereafter, gradually shift the timing of the doses to the beginning
of meals
o small oral doses may be adequate in patients that are susceptible to gastrointestinal
upset.
In the elderly, daily doses of elemental iron as low as 15 to 50 mg are effective in the
treatment of iron deficiency anemia
9

In pregnant women, 20 mg/day of elemental iron, started at 20 weeks' gestation, is
sufficient to prevent iron deficiency
11

o iron contained in enteric-coated tablets is poorly absorbed. These products should be
avoided
Some physicians replenish iron stores while others prefer to stop therapy when the Hgb
normalizes, so that further blood loss will not be masked by robust iron stores. As a
compromise:
o completely replenish iron stores when the cause of iron deficiency has been identified
and corrected
o do not replenish iron stores when investigation has failed to


Therapeutic Tips

Search for the cause of iron deficiency, including very careful consideration of occult
gastrointestinal bleeding
Menorrhagia must be convincing before it is accepted as the sole cause of iron deficiency. This
may be an opportunity for early recognition of a gastrointestinal malignancydont miss it!
A reticulocyte response should be evident within one week of beginning iron therapy, with
subsequent improvement in the Hgb of about 10 g/L every 710 days.
If the Hgb fails to respond as anticipated, consider that there may be:
o ongoing blood loss
o use of other medications that impair iron absorption
o a different or concurrent cause of anemia and/or an impaired erythropoietic response
o compliance issues
Gastrointestinal side effects are the most common reasons for non-compliance:
o use a graduated approach to dosing. Begin with a single tablet taken after a meal. On a
weekly basis, as tolerance permits, add another tablet until the patient is taking one
dose with each meal. Thereafter, gradually shift the timing of the doses to the beginning
of meals
o small oral doses may be adequate in patients that are susceptible to gastrointestinal
upset.
In the elderly, daily doses of elemental iron as low as 15 to 50 mg are effective in the
treatment of iron deficiency anemia
9

In pregnant women, 20 mg/day of elemental iron, started at 20 weeks' gestation, is
sufficient to prevent iron deficiency
11

o iron contained in enteric-coated tablets is poorly absorbed. These products should be
avoided
Some physicians replenish iron stores while others prefer to stop therapy when the Hgb
normalizes, so that further blood loss will not be masked by robust iron stores. As a
compromise:
o completely replenish iron stores when the cause of iron deficiency has been identified
and corrected
o do not replenish iron stores when investigation has failed to

32 M Fever & Tiredness x 6 wks ---- 10 mins focused History

3 Scenarios:
H/O Splenectomy
IV drug user
Unprotected Intercourse

After introduction,Analyse Fever
Constitunat Sx
Then go to causes from Head to toe
End with Liver
Risk Fcts
Travel
Drugs
PAST MH
FH
Social H (Which is linked to Risk Fcts)

Can you tell me more about your fever from the moment it started?
O;
Sudden/Gradual
When it first started did you have any other illness?
Did you seek medical attention then?
C;
1. Is it on & Off/All the time/everyday
2. Does it inc/Dec or is it the same?
3. Any variation during the day, like more in morning? Any particular patern? 3
rd
or 4
th
day
or alt days
4. Did you measure it?
5. How often do you measure it?
6. Which was the highest temp?
7. Does it increase at night?
8. Did you take any meds?/were they helpful?
9. Is it the first time or have you ever had it before?
10. Anything increases or decreases it?

CONSTITIONAL Sx:
Fever/chills/N Sweats/wt loss/Lumps/bumps

TRANSITION:
Ive to ask a couple of more qns to help me come to a diagnosis. If youve concerns at any time
please tell me & I will answer them
CNS:
HA/N/Vx/Photophobia/neck pain/Neck stiffness
Ear pain/Discharge from ear/runny nose/Facial pain/Sinusitis/Sore th/Difficulty swallowing
Dental pain/Tooth ache
CVS:
H racing/Chest pain/SOB
RS:
Cough/Phglem/wheezing/H-maemesis
Contact with TB/Have you ben screened for TB?
GI
Abd Pain/Diarrhoea/Malena
GU
Flank pain/burning urine/bld in urine/Inc freq in passing urine
MSK
Jt pain/Swelling/Skin rash/Ulcers in mouth/red eyes
Have you ever been Dsed as a condt called Autoimmune Disease? Or has anyone else in your
family been diagnosed?
LIVER DISEASE:
Have you ben screened for liver disease?
Have you been vaccinated against Hepatitis A & B?
Sx of Ac Liver Disease: Yellow discoloration of skin & nails/Pale stools/Dark urine/Itchy
skin
Sx of Ch L Disease: Inc abd girth/bruises /leg swelling/vomiting bld/memory changes

TRANSITION:
Ive to ask you some questions to see if you were exposed to liver disease without being aware
of ,some of these qns may be personal, but it is imp that I ask them.All that you tell me is
confidential & the information will not be released without your permission, unless Im
requested by law
TRAVEL & CAMPING H
Travel outside Canada
H/o eating raw fish,raw shell fish.Have you visited a new restrauant?
H/O Surgery/Hospitalizations
Donated/recvd bld
Tattooing/Piercings
Smoke/Drink Alcohol/Recreational drugs?
Any injectable drugs?

SOCIAL H:
Whom do you live with?
How long have you been with your partner?
If for a specified time with a partner,ask if had any other sexual partners,though this qn is
personal,Ive to ask it as it is imp:
When was the last time youd sex with another partner/ Did you use a condom then?
If YES:
Ask Discharge/Lumps in groin/Genital ulcers
How is wife:Does she have: Fever/Sx/Discharge?
RISK FCTS:
How do you support your self financially?
Have you ben exposed to body fluids/TB
H/Ca
Any contacts with fever?

HIV
SEXUAL HISTORY:
Before marriage or before current relationship;
1. Did you have sexual partners?
2. At what age were you sexually active?
3. From that time till now, how many partners did you have?
4. Did you practise Safe Sex (Use of condoms?)
5. What is your sexual preference? M? F? Or Both?
6. What type of sexual activities do you prefer? Anal/vaginal/oral
7. Were you ever screened or diagnosed for STIs?
8. Did you have any sexual relationship besides your regular partner

Laboratory investigations:
o HIV antibody test (repeat to rule out lab error)
o plasma HI V RNA level (viral load) with the CD4 lymphocyte count
is the best prognostic marker for progression to AI DS and survival.
o viral drug resistance mutations become harder to detect over time. Therefore
conduct a resistance test at entry into treatment program even if use of
antiretroviral treatment is not currently contemplated
2

o CD4 lymphocyte count and percentage is useful in determining where a patient
lies in the continuum of HIV disease and the need for specific intervention (Table
1). Knowledge of the CD4 count can also help to narrow the differential diagnosis
in a symptomatic HIV-infected patient. In adults, a CD4 count of 430 to 1360
cells/L (0.43 to 1.36 Giga/Litre or G/L) is considered normal in most
laboratories
o screen all patients for the presence of the HLA-B*5701 allele before starting or
restarting abacavir.
2

,

3
A positive result indicates a very high risk for severe
allergy to abacavir and should be filed in the patient's chart
o perform a tropism assay to determine the chemokine receptor status (CCR5,
CXCR4 or dual-mixed tropic) if considering use of the CCR5 inhibitor
maraviroc. A plasma viral load of at least 1000 copies/mL is required to perform
this test
o CBC, differential and platelet count
o liver (AST, ALT, GGT, LDH, CPK, alkaline phosphatase, bilirubin, INR,
albumin) and renal (BUN, creatinine, electrolytes, urinalysis) profiles
o metabolic profiles (fasting glucose and lipidstotal cholesterol, LDL, HDL,
triglycerides)
o hepatitis B, hepatitis C, syphilis, cytomegalovirus (CMV) and toxoplasmosis
serologies
o cultures and smears for sexually transmitted diseases as indicated
o tuberculosis skin tests, sputum cultures and smears for mycobacteria as indicated
o chest x-ray

Management of Patients with HIV Infection
CD4 Count
(cells/L)
Action
At all levels General counselling (safer sex, nutrition, need for follow-up,
importance of adherence, etc.)
History and physical examination every 3 6 mo
Plasma viral load and CD4 count at least every 3 4 mo
Herpes suppression if frequent recurrences (more than 46
episodes per year)
Syphilis serology
Pneumococcal vaccine; hepatitis A and B vaccines if appropriate;
update diphtheria, tetanus and inactivated polio vaccines as
needed; consider annual influenza vaccinations
TB skin test and isoniazid prophylaxis if indicated (consider
CD4 Count
(cells/L)
Action
repeating skin test yearly)

< 500 Plasma viral load and CD4 count every 3 4 mo
Clinical evaluations and laboratory investigations at least
bimonthly if symptomatic, diagnosed with AIDS, or on
antiretroviral therapy

< 200 Start prophylaxis for Pneumocystis jirovecii pneumonia (PCP)

< 100 Start toxoplasmosis prophylaxis if seropositive and not on
trimethoprim/sulfamethoxazole for PCP prophylaxis

< 75 Consider MAC prophylaxis

< 50 Screen by an ophthalmologist for early CMV retinitis (repeat at
3 6 mo intervals) or consider CMV prophylaxis

Advise patients with HIV infection and immunosuppression that their risk of
infections can be reduced by following good hygienic practices.
1. Ensure thorough hand washing after contact with potentially
contaminated substances (diapers, soil, uncooked meat and produce) or
handling pets
2. Avoid raw or uncooked meat and eggs, e.g., Caesar salad
3. Drink from treated water sources only
4. Avoid handling sick animals or pet (especially cat) litter
5. Avoid cat scratches and do not allow cats to lick wounds
6. Avoid contact with reptiles

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45M with tiredness x 6 weeks
As I understand youre having Tiredness since 6 weeks, can you tell me more about it since it all
started?
Pt says he is concerned. STOP & ask about his concern.
Pt says, he is also never been so tired before. Clarify: What do you mean about Tiredness?
Sometimes I do not feel refreshed after sleep.
Do you feel lack of energy? Like you cannot move your arm above your head.

The Statement: NOT REFRESHED ANYMORE points to an organic cause
OCD + Relation to sleep +/- Mood
If Mood Sx + ------ MOAPS
If Organic cause ---- Red Flags
OCD
At onset you can ask if there were any flu-like Sx initially (Thyroiditis)
Do you sleep more
Do you wake up in the middle of the night
Which time of day/Night do you feel most?
Ask Nature of work;
If shift
With whom do you sleep?
Does your partner C/o you snoring or jerky movts of limbs? (Restless Leg)
Do you feel better in morning or evening(if tired in morning-->Depression If evening-------
-->Organic cause)
Depression 1
st
Low mood then tired
In organic 1
st
Tired the Low mood

11. Ask Constitutional Sx first:
Fever/Wt loss/Night sweats/Chills/Lumps & Bumps
Then quick review of Sx:
12. Cardiac: Chest Pain/SOB/Palpitations
13. Pulmonary: Cough/Wheezing/Phglem
14. GI: N/V Abnormal bowel movts/Diarrhoea/Malena/
15. Liver: Dark urine/Yellow sclera/Abd pain/Loss of aooetite/Pale stool/Itchy skin
16. GU: Change in color of urine/Amt of urine/Cloudy/Frothy urine/Dysuria/Facial swelling
17. Anemia: Bleeding gums/Easy bruising/Malena/Haematuria/Female: Meorrhagia & LMP
18. Autoimmune Disease: Joint Pains/Skin rashes/Oral Ulcers
19. Endocrine: Thyroid: Feel hot/Cold Skin Moist/Dry/Tremors/Wt loss
If Pt has thyroid Sx,ak if on Thyroxine
When Dsed
If thyroxine levels are monitored?
20. DM: Risk fcts: FH & Lifestyle
Once Pt has DM in history, GO over ALL Sx & Sy:

RISK FCTS:
7. Diet
8. Exercise
9. FH
10. Smoking
11. Alcohol
12. Recreational drugs

Any medications/OTC/Herbal/LMP
Surgery/Hospitalization

FAMILY HISTORY:
DM/HTN/Stroke/MI

SOCIAL H:
Habits

Hypothyroidism (underactive thyroid) is a condition in which your thyroid gland doesn't produce
enough of certain important hormones.
Hypothyroidism upsets the normal balance of chemical reactions in your body. It seldom causes
symptoms in the early stages, but, over time, untreated hypothyroidism can cause a number of health
problems, such as obesity, joint pain, infertility and heart disease.
The good news is that accurate thyroid function tests are available to diagnose hypothyroidism, and
treatment of hypothyroidism with synthetic thyroid hormone is usually simple, safe and effective once
the proper dosage is established.
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NEEDLE STICK INJURY
Michael Jackson, Nurse in hospital, Needle stick 20min ago; History and counsel, 10min
Variations: Janitor who was pricked in junk yard (here touch TT prophylaxis)
0.3% - HIV; 3% HCV; 30% HBV

The treatment will be the same no matter what is the situation of the other patient...
Did anybody talk to him? Did he accept to get his HIV status? By law we are not allowed to take his
blood without his consent
QUESTIONS RELATED TO EVENT:
1. Size of needle
2. Blunt/hollow
3. Any blood on it
4. How deep was the injury?
5. What was gauge of needle?
6. Where was the location of the prick?
7. Any bleeding after that?
8. Whether he was wearing gloves?
9. What measures did he take? (Wash hands?)
10. Is it the first time?
If Pt insists on doing HIV testing of the contaminated pt:
I know it is of great concern about the pts HIV status, however from the ethical point of view we cannot
do the HIV test without the pts consent. I can go after our interview & personally request him
If Still he insists or ask for CD4 count:
How do you think this will help us? It is a reasonable way of thinking.
There are different conditions reflecting CD4 count & ethically not the right step We do it to obtain Pts
information & not for the best interest of the pt
However whatever the CD4 count it makes no sense in our management.
Weve to follow protocol:
RISKS
Give him the risks of being infected with N Stick injury:
HIV------->0.3%
Hepa C----->3%
Hepa B-------> 30%
. In order to know what is the best line for you I need to ask you more questions.
Do you know what the chances for getting infected are? (Out of 1000 people only 3 will be affected).
ASSESMENT:
Being a health care provider
1. Have you been vaccinated before for Hepa A & B
1.1 How many doses?
1.2 When was the last dose?
2. Liver Disease:
Have you ever been yellowish? Itchiness? Dark urine? Pale stool? Btuises in body?
C Sx:
Repeated infections?
Chronic diarrhea?

Have you been screen for HIV or HCV?
I am going to ask you some questions if you were exposed before for any of the viruses mentioned
above
1. Any travel outside Canada?
2. Any surgery
3. Any blood transfusions/
4. Tattoos/Piercings
SH
With whom do you do live.
For how long have you been together

COUNSELLING:

Whenever we face such a situation,were faced with three possible infections that could be transmitted:
HIV------->0.3%
Hepa C----->3%
Hepa B-------> 30%

Good news HBV high risk but good plan; we are going to measure the titer of antibody in your blood.
If Okay,you need not worry,if low you may need an Immunoglobulin or revaccination

What do you know about HIV.
If infected,some bcome carriers,not all develoe into AIDS,we will screen you today:
For screening you we need to sample today to have base line. Most of the patients dont react until 6wk,
few until 6m we have to take it in these times.
If at the end of 6 mo tests come back negative, youre cleared
If not youre infected
Other options: we will also refer you to occupation clinic Who will start you on prophylaxis treatment.
It consists of three medications usually.
They will explain to you which medication and describe the SE. It will decrease the chances by ...%
HCV This is of concern as We dont have prophylaxis yet
there is more than 50% to be carrier, more than 50% of them become chronic, 50% of them will get
cancer.
However certain medications might help like Interferon & Anti retrivirals

How do you feel about it? Sometimes patients are overwhelmed and might harm yourself or others
From now till the results of your blood tests:
Practise Safe sex
Do not donate blood
Joint a support group.
I wii file an incident report.
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35y.o, male, counselling about HIV test
Wants to do HIV test as his partner has tested =ve

As I understand youe here as you want a blood test.Can you tell me which blood test
you specifically need?
Can you tell me what made you come in today?
**PT: I feel Im at risk screen me for disease
We cannot order all bl works, weve to look for a specific disease e.g: for TB we do a
CXR/DM BSL/HIV Bl tests
** My Partner has tested for HIV +
EMPATHY:
Im sorry, when was that? How is she doing now?
How long have you two been together?
How has it affected you?
How do you feel?
This can be a difficult for you, & youve done the right thing,& definitely we can arrange
for a blood test
20 years ago we had no options, now even if you are positive we will have treatments and
prophylaxis.
In order to get the diagnosis we need to do more questions.
1. Have you ever been screened for HIVor HCV
If Yes: When & where?
2. Any Sx OF HIV
CSx, Mouth, Ulcers,difficulty swallowing
RS;Cough
,Diarrhea, Discharge,Ulcers,Skin rash/yellowish, Dark urine/Pale stool
I am going to ask you some questions if you were EXPOSED BEFORE for any of the viruses
mentioned above
1. Any travel outside Canada?
2. Any surgery
3. Any blood transfusions/
Tattoos/Piercings?
SEXUAL HISTORY
Relationships now and before / Sexual predilection / Sexual practice
When were you sexually active?
How many partners have you had?
Did you practise safe sex?
PMH
Any long term disease/hospitalization/allergies/medications

COUNSELLING
What do you know about HIV?
Nowadays we have better control over the disease. Once they start get the infection they called
AIDS patients.
HIV is a virus which affects our immunologic system. It is different if you are the carrier as
oppose to have symptoms when you are an AIDS patient.
HIV is a virus. HIV attacks the immune system itself - the very thing that would normally get rid
of a virus
It takes around ten years on average for someone with HIV to develop AIDS
Is that reasonable?
Am I clear? Do you have any questions?
In order to know whether you are infected or no we need to do a blood work. We need your
consent for that. They will give you the results within two weeks. If the results are positive they
will call you back. If it negative they will not call you.
Options to send the sample:
Nominal with your name
Non-nominal put a bar-code (the public health and the doctor will know the identity)
Anonymous put a barcode on the sample and only you know the results
(needs a lot of counselling.
How do you feel about it? Sometimes patients are overwhelmed and might harm yourself or
others
From now till the results of your blood tests:
Practise Safe sex
Do not donate blood
Joint a support group.
I like you to know that in 2011 there are a lot of options open, with Rx it is controllable & people
can live with it for a long time.
If you test positive youve a have legal obligation to inform your partner.

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Freddy Mercury, 37y.o, Male, HIV results came back and are
positive
Divide time: 2min telling the results, 3min assessing symptoms, 2min explain about the virus,
3min the plan
HIV treatment in Ontario is covered.
Nice to meet you. Or Hello
Because this is the first time I see you I am going to ask you some questions, to get a better
understanding of your results:
Why/Who/Is the first time/When you did it?
** Somebody I knew died from it last week
Who is the person that you got it from him? (nature of the relationship)
People dont get it from normal daily contact. Was there any direct contact?
SPIKE
Setting
Perception what do you know about HIV?
What did you think was going on with you when you felt the lump?
What have you been told about all this so far?
Are you worried that this might be something serious?
Invitation how much details you want me to discuss? DO you want someone else to be
present?
Are you the kind of person who prefers to know all the details about what is going on?
How much information would you like me to give you about your diagnosis and treatment?
Would you like me to give you details of what is going on or would you prefer that I just tell you
about treatments I am proposing?
Knowledge
Unfortunately, Ive got some bad news to tell you, Mr. Andrews.
Mrs. Smith, Im so sorry to have to tell you.
Empathy What are your expectations from this visit?
If he is not very anxious you might take some time until giving him the results. Otherwise you
give them immediately.

I wish Id better news for you. Unfortunately the results came back and I am very sorry to tell
you that the result is positive.
Silence.
Wait x 10 sec if he cries
How do you feel right now?
Do you need more time/
Do you need water?
Do you want me to proceed?
**If mistake?
Whenever we do a screening test we confirm it if it positive. So the result is very accurate.
The initial test is ELISA & then we do a confirmatory test called Western Blot
Part of F/u atre other tests like the CD4 count & Viral load

SOCIAL Hx:
We will ask you several questions concerning your sexual partners.
Drug use
Asx:
CSx:
AIDS Sx:
PMH: any long term disease? HTN/DM?
Any hospitalizations/Surgeries?

If does not want to inform his wife
From experience it is not necessarily that your partner will leave you. From that reason we need
to inform your wife. Part of the public health job is to tell her. The same measures we are taking
for you we should do for her. It is better that she will know it from you rather than from the
Public Health otherwise shell loose the trust in you.

Do you have any symptoms relating to HIV?
PMHx and drugs.

COUNSELLING
If asked what he knows about HIV dong repeat. Otherwise you explain here.
From HIV+ to AIDS.
Significance of CD4 and Viral load:
Viral load,amt of HIV virus existing in your body, lower the viral load,& higher the CD4 count,
better condition
We should think about HIV these days like a chronic disease as DM or HTn,it can be controlled
but not cured.
Part of your treatment is to refer you to HIV clinic they will treat you based on these
parameters. The newer medications are effective and control your disease however they have
side effects.
Hows your mood, how you feel about that, there are a lot of support groups. Ill give you hot
lines number.
From now on you have to practice safe sex & do not donate blood

In case of the resident who was asked to backup his supervisor orthopaed
1. I am competent to emphasize
2. Short term we dont have time so we need to see her urgently
3. Long term solve the situations that it wouldnt occur again

Dr. Smith, Chief of staff of the hospital, ask another doctor to talk with the doctors me because they
smell alcohol from the doctor.
You smelled like alcohol.
People have different ways to relieve their stress how do you relieve your stress?

Team worker interpersonal relation
It is better to provide prescription than getting pregnancy
I may share your point of view that doesnt say it gives me the right to impose my beliefs.
My concern is if we face the same situation in the future...what will we do?
Why wont we contact the College?
Dont give any names. In case of report it should be reported to the college.
We are here to help you. Moving to new place can be stressful. The reason of this meeting we have
received two complaints they claimed they have smelled alcohol from you. Is that happened?
If you dont mind me asking few more questions: do you drink more, or you did it on lunch time? Before
working here where else did you work? Did you ever have a complain about drinking?
I would recommend that you will contact the program for doctors who drink. They will suspend your
license. After stop drinking you will resume your work. At the end you will have your career back.

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24M: HA 6 wks ER 10 mins H & Counsel

OCD PQRSTUV

INC ICP:
SOL: Brain Tumors
Mets
Infection
Toxoplasmosis

HA + Inc ICP
Constitutional Symptoms: fever: Always ask what came first: fever or headache
* If primary tumor;
FH of Malignancy
H/o Cancer,Leukemia,Melanoma
H/o HIV:
Ask if HIV status known,
Have you ever been checked?
Im concerned because of the risk factors involved

IF HIV status known ask:
When was the last time you saw your Dr
What was the last CD4 count
Are U on any Anti AIDS meds?
TB Skin test results
Syphillis tst results
Date & results of PAPs smear

* Ocurence f opportunistic infections,malignancies,
* STIs: Hepatitis B & C,Syphillis,Gonorrhoea,Chlamydia,Molluscum contagious
* Other bacterial infections,fungal infections,Malignancies
* Travel History,illness while away & use of preventative vaccines
* Medication History:
* Antiretroviral History (including response,CD4,Viral load)
adherence,toxicity,any resistance testing & results
If HIV or AIDS & not on meds:
Asses condt by asking:
Constitutional symptoms:
Fever
Repeated chest infections
Cough thrush
Odonophagia
TB
In Female: Cx al Ca

OCD
ONSET:
COURSE:
When Pt says HA now Ct ous
Ask:
When did it become constant?
In beginning how often did you have it?
What time of the day?
Is it more in the morning? Or is it worse in the evening?
Does it wake you up?
DURATION:
PQRST UV
S: How was it in the beginning as compared to Now
U Qns for empathy**
How has it affected U in your daily life?
How r U coping with it?
How do U feel abt it?
What r your expectations from todays visit?

Aggravating fcts:
Coughing/leaning forwards/lying down
Alleviating fcts:

ASOC Sx:
CONstitonal Sx:
Fever/nightsweats/chills (if before headache indicates patho) Ask when Wt loss started
LOCal Sx:
NEURO Screening:
1. Vision changes:
What type of problem?
2. Hearing abnormalities
4. Weakness/Numbness
6. Difficulty in balance or repeated falls
7. Changes n bowel/Urine Loss of bladder control
8. LOC
9. H/o Seizure

MOOD Changes
MEMORY problem
Changes in CONCENTRATION
Has anyone told you that youve been acting strangely?
H/O INJURY:
To head
Did you have a fall & hurt your head?

EXTRACRANIAL:
EYE:
Did you notice any redness or need eyeglasses?
Sinusitis:
Facial pain/flu
Throath pain
Dental pain
PMH:

RISK FCTS:
Do you smoke
Take EtOh
Take recreational drugs? Route
Tattoo

COUNSELLING:
Do you have any qns for me?
Based on what youve told me,the symptoms are concerning & I need to admit you
today, as youd stopped your meds, you may be exposed to an infection
Your HA may be caused by this infection.
I will refer you to an Infectious Disease Specialist
Also do some blood investigations & Imaging of your head.

DIAGNOSIS: CNS Toxoplasmosis in HIV +ve Male

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22F sudden loss of vision x 2 wks seen by 2 drs one opthal
(Somatization GAO -207)
As I understand youre here because youd loss of vision in (R) eye x 10 days, I understand
youve been seen by 2 Drs
What did the drs tell you?
What diagnosis did they give you?
Any investigations were done?
Howre you doing today/Tell me how it all began...... OCD

ONSET: Sudden/gradual
What were you doing at that time? Anything particular happened at that time?
Is the loss all the time or off & On?
Ask a little about local Sx: Pain Photophobia/Injury
U
V
SOCIAL H:
Speak about confidentially here
Who lives with you?
What is your relationship?
Any difficulties in your relationship? Emphasize confidentiality
Was there a stressful situation before you lost your vision?
Let us go back to that day........
Make sure no suicidal/Homicidal ideation
COUNSELLING:
This seems like a stressful situation for you & sometimes when we face such situations our
brain finds it difficult to deal with it & this stress can be manifested by loss of function.
In this case you saw something that made you lose your sight.It is not uncommon & called
CONVERSION DISORDER
I will refer you to a therapist to help you understand the stressor in your life & learn how to
handle it.

LOSS OF VISION: 32 M/F

Pt presented with vision loss x 2 weeks

OCD
Onset after car accident
Here enquire about the nature of accident Ask whether she or other driver was hurt & how is
her driving now, does she still drive?
Gradual
C:
Is it increasing now?/Same/Varies at certain times of day
U &V
CONSTITUNAT SX:
Assoc Sx:
*HA: Here +ve,OCD: PQRST:
When does it occur? Morning or evening
Vomiting +/Quality---- projectile
Weakness/Numbness/Difficulty finding words
ENDOCRINE:
Thyroid Disease: feel hot/cold/Warm & moist skin/tremors
Pituitary:Sometimes Pts in similar situations can notice breast engorgement & secretions from
breast (For Males) & changes in sexual life ,desire & habits
In Females ask directly about amenorrhoea galactorrhea
SX of Acromegaly: Inc size of shoes/Tight ring
FH of Kidney stone/Pancreatic Ca/Diarrhea/Foul smelly stools

Past H
Fh
Social H

VISION LOSS
1. 40 M difficulty in vision 2 wks 10 mins H & C
2. 22F sudden loss of vision x 2 wks seen by 2 drs one opthal (Somatization GAO -207)
3. 40M diificulty in vision x 4 wks seen by optometrist counsel All D/vision:
Screening Qn: What do you mean?
Pt will answer: Im not seeing well
Now ask close ended qns:
1. One/(B) eyes
2. Blurry V
3. Double vision:
a. Relieved by covering one eye?
b. Horizontal/Vertical/Oblique
c. Worse in one direction of gaze?
d. Fluctating or constant? (Gets worse at end of day)
4. Loss of vision
5. Curtain falling
6. Dark spots/flashes
7. Difficulty seeing on sides/when you drive do you have difficulty changing lanes?
8. Do you bump into objects when walking?
9. Do you see halo around objects?

OCD:
O;Suden/gradual
Painless/Painful
PAIN: Assoc with:
Blinking
Eye movts
HA/N/V
Brow/Temporal pain
Photophobia
Gritty sensation
How has it affected your life
Asso Sx:
Fatigue wt loss,joint SxNight sweats,ever
Polyuria/poly dipsia
Tingling /Numbness
Past Occular H: Use of eyeglasses/Contacts: Duration
H/O Occular surgery,Laser Rx,Infection,trauma,FB
Presence of Ch eye disease: Glaucoma/DM
PMH: Htn/DMMS/HIV
Asthma
Allergies
Meds:Occular meds Current+Past

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Somatization Disorder
22 YOF Somatization disorder
4-2-1-1
If seen by a surgeon suspect somatisation.
What did the surgeon tell you.
OCD
PQRST
During the day or night.
CSx
Jaundice, white stool and dark urine
Foul smell, bulking, droplets
Change in bowel movement
First time to have this pain or had it before (V)
MRI why do you think it is important?
Somatic pain disorder / Somatization
Pains: headache, joints, back, pain with intercourse
Sexual:
You are here because you are concern. The pain you have, and multiple doctors all these are
consistent with somatisation.
Once every 2-3weeks

See Zu09: 207-8

Introduction to OBGYN
OCD
COCA +/- Blood
A
ASx: which organism
MSGO
PMHx
OBGYN MAP
CC
Menses
Gynecology history
Obstetriscs h
Sexual h

VAGINAL DISCHARGE.
OCD
COCA
A
AsSx which organism
MSGO
PMHx

AMENORRHEA
OCD
MAGOS

VAGINAL BLEEDING
OCD
COCA +/- Dc
A
M
ASx
G
O
SHx
PHx
FHx

INFERTILITY
I+O
Tr
Partner
C
M
G
S
Intro
How many months trying to conceive?
If less than 35 y wait for 1yr
If around 40 wait for 6m
If greater than 40 immediately
O if children from previous relationship
Transition: In order for a couple to achieve pregnancy both partner involves should be relatively healthy
and capable of having children. For that reason I need to ask questions about your and your partners
health. Some of these questions can be personal, but important to ask, but I can assure that everything
king is strictly confidential. The male factor is responsible for 40%.
COITAL H.
How often do you have intercourse?
Do you monitor tmp?
MGOS
All causes of secondary amenorrhea:
Endometriosis
Past medical history
Family History
Social history

MENSES
Use the word period
2. Are your periods regular / not
3. How often?
4. How many days?
5. How many pads do you use/change?
6. Are the pads full?
7. How long does it last?
8. Are they heavy?
9. Do you see clots?
10. Between periods do you have spotting?
11. From your last menstrual period was your period different from the current one?
12. At what age did you start your periods?
13. Were they regular/irregular?
14. When did it become regular?
15. Are your periods painful / painless?
16. If irregular, from beginning?
17. Discharge ask if pregnant and when LMP

GYENECOLOGY
1. Any history of Gyn. Disease polyps or cysts
2. History of pelvic surgery (if yes when?)
3. Have you used any birth control?
When/type/any complications?
4. If less than 50 have you ever done PAP (if yes when and what were the results?)
5. If 50 and older in addition ask for mammogram
6. If more than 65 ask for bone density

OBSTETRICS
Have you ever been pregnant
How many times, how about abortion and termination/ Abortion termination medically;
How many live children, what was the route, any complication?
Were there any complications with the children?
During pregnancy: any HTM/GDM/Vaginal bleeding
How do you feel about (miscarriage?)
If NULLIPAROUS:FH of HTN/DM?cong anomalies/repeatd C S/Twins

SEXUAL Hx:
2. How long have you been together? (a relationship below 6 month is not stable)
3. If you live alone are you in relationship?
4. Are you sexually active?
5. Do you practice safe sex using condoms?
6. When did you start to be sexually active?
7. How many partners you had last years?
8. What is your sexual preference?
9. What type of sexual activity do you practice?
10. Have you ever been diagnosed with PID
11. Any Vaginal discharge?
12. How about your partner? Does he have any symptoms
have you ever been screned for HIV?
PREGNANT IN T3:
Reg F/U:
No-----> Social Hx
Yes:------->When
If recent ask 2-3 qns about PET:
1. What was your BP
2. Was there swelling?
MUMs STABILITY:
1. Abd pains
2. Abd cramps
3. Vaginal bleeding or discharge
4. Any gush of water
BABY:
1. Is baby kicking like before?
2. 10 movts/12 hrs

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19 year old with Vaginal discharge for the last 10 days
History 5 minutes
VAGINAL DISCHARGE.
OCD
COCA
A
AsSx which organism
MSGO
PMHx: Recent use of Ab + DM

Intro: How can I help you today?
O:
Sudden(Allergey)/Gradual
How did it start?
C:
1. Is it all the time or on and off?
2. Is it increasing, decreasing or the same?
COCA + BL
1. Can you estimate the amount for me?Do you use pads? How many?
2. How about the colour? Is it greenish, whitish or yellowish?
3. How about the consistency? Is it thick or watery?
4. Is the smell offensive?
5. Is this your first time?
A & A:Does it increase after IC?
I would like to ask you a few personal questions, hope you dont mind?

Sexual Hx: as part of A & A
2. Any relation to your periods or with intercourse?
3. Do you have any pain with intercourse?
4. Any itching, redness, blisters or ulcers?
U:
V:
LOCAL Sx:
Pain with IC
Itching/redness/blisters/warts/ulcers
GU: Any burning in urination in urination?
GI: Any change in bowel movements?
PID : Any abdominal pain? If yes, then OCD, PQRST.
:MSK: Any ulcers in mouth, difficulty swallowing, joint pain, skin rash or red eyes?

Constitutional Sx:

Menstrual Hx:

1. When was your last menstrual period?
2. Are your periods regular?
3. Was the last period the same as before?
Gynecological Hx:
1. Do you use any form of contraception?
2. Have you had a pap smear? When and what was the result?
Obsteterics Hx:
1. Have you ever been pregnant?
2. Have you ever had an abortion or miscarriage?

Sexual Hx:
As I understand youre in a relationship
How long?
Do you practise safe sex?
Does the partner have any urinary symptoms,discharge?
Before this?
What age were you sexually active?
How many partners in last one year?
PMH:Since it is 1
st
time Im seeing you,I need to ask some qns about PMH:
SHx:

RX:

Infectious Diseases: Sexually Transmitted Infections

Table 1: Differential Diagnosis of Vaginal Discharge
1

,

2

Candidiasis Trichomoniasis Bacterial Vaginosis
Signs/symptoms:
Pruritus + +
Odour + + (fishy)
Discharge white, clumpy &
curdy
off-white or yellow,
frothy
grey or milky, thin, copious
Inflammation + +
Simple tests:
pH < 4.5 > 4.5 > 4.5
"Whiff" test
a
+/- +
Microscopic findings:
Specific budding yeast,
psuedohyphae
motile
trichomonads
clue cells,
b
predominant Gram-
negative curved bacilli and
coccobacilli
PMNs ++ +++
Lactobacilli +
a.
Malodour often intensified after addition of 10% potassium hydroxide (KOH).
b.
Clue cells are vaginal epithelial cells covered with numerous coccobacilli.

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36 weeks pregnant with vaginal bleeding for 2 hrs
History 5 min

Differentials:
1. When did the bleeding start?
2. How long has it been?
3. Were the pads fully soaked? Any clots?
4. What were you doing at the time?
5. Any H/o trauma?
6. Did you have any abdominal pain?
If yes:
Did the pain start first or the bleeding?
Are you having any pain now?
OCD, PQRST
7. Any gush of water?
8. Are you under regular F/U?
9. When was the last F/U ? If missed, why?
10. Symptoms of pre-eclampsia:
a. Weight gain?
b. Headache?
c. High blood pressure?
d. Flashing lights or disturbance in vision?
e. Swelling?
11. Stability of Mother: .........................?
Have you had an U/S?
When was the last one?
# of babies?
Position of placenta?
Amount of fluid?
12. Stability of fetus:
Is your baby kicking like before?
Obsteterics Hx:
1. Have you ever been pregnant?
2. Have you ever had an abortion or miscarriage?
3. Any complications during previous pregnancy?

39 year old with vaginal bleeding for 50 days
History 5 min
OCD + COCA +/- Discharge
AA
ASx:
M
G
O
S
Risk Fcts: GPOS
D/d:
PMH
Fh
SH
INTRO:
1. What made you come here today?
2. Did you seek medical attention before?
OCD:
O:
How did it start?
What were you doing at the time?
Did it start gradually or suddenly?
C:
Is it on and off or all the time?
Is it increasing, decreasing or the same?
COCA
Can you estimate the amount for me?
Foul smell?
A&A:
Is there any relation to periods or with intercourse?
Menstrual Hx:

1. When was your last menstrual period?
2. Are your periods regular?
3. Was the last period the same as before?
4. Can you differentiate this bleeding from periods?

Im going to ask a few qns to see how it has affected your life:
IMPACT:
Are you having any dizziness? Hrt racing? LOC?

CSx:
Local & Mets
1. Local symptoms:
Any itchiness, redness, discharge, pain during intercourse?
Itching/rednes/blisters/warts
1. Any abdominal pain?

When was your last Paps smear?
What was result?
O
Sexual Hx:
D/D;
Hypothyroidism
Bl thinners
Bleding disorders
PMH
FH of Ca

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AMENORRHOEA 22 yr old Female:

PEP:
1. what is your Ds?
2. What is your inv?
3. What is your Rx?

Always R/o pregnancy
Intro: As I understand youre here today because you did not have your periods since last 6
mo.. Can you tell me more about it?
CC------->
When was your LMP?
Any spotting in between?
Let us talk about your periods from the beginning..
1. When did you have your 1
st
period?
2. Was it regular from the start? Or was it irregular?
3. When did it become irregular?
4. When your periods were regular,How often did they come?
5. How long did each cycle last?
6. When irregular,How often did they come? How many days did they last?
7. When periods were regular, were you using any contraception?
If Yes:
How long?
When did you stop?(if Inj Depo provera I yr post injection amenorrhoea OC can be upto 6 mo
Amenorrhoea)
Are you sexually active? Any chance that you may be pregnant?
Ask Sx of pregnancy:
Breast tenderness
N/Vx
Increased visits to washroom
OB Hx: Any time you were pregnant?
Any abortions or miscarriages?
RISK FCTS:
Im going to ask you questions to help reach what could be the cause
HYPOTHALAMIC:
1. Are you under stress?
2. Are you losing wt?
3. How do you perceive yourself when you look into the mirror?
4. Do you exercise excessively?
PITUITARY:
1. Any change in vision/Any difficulty in seeing on sides or changing lanes when driving?
2. Discharge from nipples & breast engorgement?
THYROID:
1. Do you feel hot when others around feel cold or do you feel cold when others around feel
cold?
2. Do you have constipation/Diarrhoea?
OVARIAN:
PCO:
1. Any acne
2. Increased facial hair?
3. Are you concerned about your weight?
4. Are you trying to lose weight?
5. Is there h/o DM? (ask for Sx of DM)
6. Any FH of PCOs or infertility?
Premature Ov Failure:
1. Hx of Chemotherapy/Radiation to pelvis
2. Hot flushes
3. Night sweats
Ovarian tumors:
1. Increased muscle bulk
2. Change in voice
C Sx:
Gyn Hx:
Sexual Hx;
Any H/o STis
PMH:
Since it is 1
st
time I see you,do you have any H/o HTN,DM
Have you ever seen a psychiatrist before or used antipsychotic medications/

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31 year old woman with 36 weeks pregnancy:BP155/110
Urine Protein +++

Intro: As I understand..,youre here today for a F/u visit,& nurse measured your BP & did a urine
test.Ive your results here & will discuss them with you, But I need to ask you some qns to gain a better
insight into your condition
1. Were you ever diagnosed with increased blood pressure prior to this pregnancy?
2. When was your last F/U visit?
3. What was your Bp the last time?
4. What about your blood tests?
5. Were you anemic?

Based on your BP & urine, these results are consistent with pregnancy induced HTN,& I need to ask
you qns,to see if youve Sx pertaining to that.
It could be a serious condition
1. Do youve H/O: HA ---------> OCD
2. How is your Vision ------------->Do you see flashes of light/Blurring
3. CNS --------> Weakness/numbness
4. Nx/V/Chest pain/SOB
5. ABD PAIN?
6. Bruises on body?
7. Yellow discoloration OF SKIN/ITCHINESS/Pale stool/Dark Urine
8. Swelling feet/Tight shoes/Rings tight
9. Difficulty opening eyes in morning/Inc wt gain
10. Vaginal bleeding/Discharge?
When was the last US:
1. How many babies
2. Is the baby kicking
When is the due date?
PMH
FH of PET

COUNSELLING: Do you like me to explain it to you?
It is a very serious condition
What do you know about it?

Preeclampsia is a condition of pregnancy marked by high blood pressure and excess protein in your
urine after 20 weeks of pregnancy. Preeclampsia often causes only modest increases in blood
pressure. Left untreated, however, preeclampsia can lead to serious even fatal complications for
both you and your baby.
Preeclampsia develops only during pregnancy. Risk factors include:
1. History of preeclampsia. A personal or family history of preeclampsia increases your risk of
developing the condition.
2. First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy
or your first pregnancy with a new partner.
3. Age. The risk of preeclampsia is higher for pregnant women younger than 20 and older than
40.
4. Obesity. The risk of preeclampsia is higher if you're obese.
5. Multiple pregnancy. Preeclampsia is more common in women who are carrying twins,
triplets or other multiples.
6. Prolonged interval between pregnancies. This seems to increase the risk of preeclampsia.
7. Gestational diabetes. Women who develop gestational diabetes have a higher risk of
developing preeclampsia as the pregnancy progresses.
8. History of certain conditions. Having certain conditions before you become pregnant
such as chronic high blood pressure, migraine headaches, diabetes, kidney disease,
rheumatoid arthritis or lupus increases the risk of preeclampsia.
Most women with preeclampsia deliver healthy babies. The more severe your preeclampsia and the
earlier it occurs in your pregnancy, however, the greater the risks for you and your baby.
Preeclampsia may require induced labor and delivery by Caesarian section. Complications of
preeclampsia may include:
Lack of blood flow to the placenta. Preeclampsia affects the arteries carrying blood to the
placenta. If the placenta doesn't get enough blood, your baby may receive less oxygen and fewer
nutrients. This can lead to slow growth, low birth weight, preterm birth and breathing difficulties for
your baby.
1. Placental abruption. Preeclampsia increases your risk of placental abruption, in which the
placenta separates from the inner wall of your uterus before delivery. Severe abruption can
cause heavy bleeding, which can be life-threatening for both you and your baby.
2. HELLP syndrome. HELLP which stands for hemolysis (the destruction of red blood cells),
elevated liver enzymes and low platelet count syndrome can rapidly become life-threatening
for both you and your baby. Symptoms of HELLP syndrome include nausea and vomiting,
headache, and upper right abdominal pain. HELLP syndrome is particularly dangerous because
it can occur before signs or symptoms of preeclampsia appear.
3. Eclampsia. When preeclampsia isn't controlled, eclampsia which is essentially preeclampsia
plus seizures can develop. Symptoms of eclampsia include upper right abdominal pain,
severe headache, vision problems and change in mental status, such as decreased alertness.
Eclampsia can permanently damage your vital organs, including your brain, liver and kidneys.
Left untreated, eclampsia can cause coma, brain damage and death for both you and your
baby.
4. Cardiovascular disease. Having preeclampsia may increase your risk of future
cardiovascular disease.

Admit you ..

Stabilize you
MgSo4
IV Labetolol
May consider Steroids for babe

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REQ FOR CS
34 wks pregnant primi requesting for CS

Intro: As I understand youre 34 weeks pregnant & arte requesting a Cs.
Before I proceed any further,I need to ask qns to reach the best plan.
WHY?
Pt: I believe it is painfull
What makes you believe it is painful?
Have youd a prior experience?
Pt: My sister had a NVD
Never imply that sister did not receive best care
There are 2 options:
There are a lot of options to control pain nowadays & different people have a different pain
threshold

Are you on regular F/u?
Is it a planned pregnancy?
When was the last time you saw a doctor?

if not on reg F/u as she is alone BF left etc always Empathize,Ask how she is coping with him
leaving & how she is handling the stress
I can see that this is a very difficult period & I want you to know that there are a lot of help &
resources available in the community. I will make sure youre connected to a social worker who
will help you support you & your child & will help you to start your life

If on reg F/U
When was the last time youd your BP measured?
Sx of PE: Any HA/Nx/V
Blurry vision/Abd pain......
MUMS STABILITY:
Abd pain
Contractions
Vaginal bleeding
Vaginal discharge
BABY:
Is baby kicking like before
DUE DATE
OBG Hx:
How many times
How about abortions/Mc
If +
At how many weeks?
What reason
When
Any complications
How did you feel about that?
PMH:
Risk fcts
NEXT come to PAIN CONTROL:

As I understand you want a CS,however if pain is a major concern, there are several options:
You can attend antenatal classes that will teach you to breathe, meditate
During your delivery a person will accompany you to give you support & emotionally support you
If that does not work, there is another very popular method of delivery: EPIDURAL Anaesthesia ...
explain....
An epidural block is a common type of anesthesia for labor and delivery. During labor, a needle is
placed in the epidural space, which is just outside the spinal canal. A small, hollow tube called a
catheter is inserted through this needle. Once the catheter is in place, the needle is removed and
medication is injected through the catheter to numb your lower abdomen and birth canal. It may take
10 to 20 minutes to feel pain relief from an epidural block. As labor continues, the medication can be
adjusted to help keep you comfortable.
Painless & effective
SE: rarely it may causeHa/Dizziness/infection & may prolong labour

If still does not accept:
What is your understanding about CS?
It is a major surgery which is effective & lifesaving.
However if there is no real indication,NVD is preferred as it is natural
With CS there is a scar
Longer recovery
More bleeding
Higher risk of infection

Why dont you think about it
Give brochures
Refer to Obstetrician for 2
nd
opinion
F/U in 2 weeks

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32F with 34 weeks pregnancy in hosp clinic,3yrs ago had
an urgent CS due to cord prolapsed,needs her
file,counsel her

See if request is logical
Ask type of Cs
Why not happy with last Cs
May be bad experience pain/bleeding/Complications
Maybe dead baby
Was it 1
st
Cs or 2
nd

Was it CLASSICAL Cs? Then always Cs
Risk of rupture of Classical Cs ------12% of which 10% will die
LSCS risk of rupture is 1%

INTRO: As I understand youre here cuz you want your file & based on your report youd a
hospital delivery because of cord prolapsed & it was an urgent Cs.
Why?
PT: Delivery by midwife who wants to look at it
We will give you the file, but until then I want to discuss
Pt: in a hurry
Because youve had a previous Cs & you want a midwife. In order to make a proper decision
youve some imp info to know
What happened the last time?
When did you know?
How many week s were you?
How did you feel?
What was done?
Did they explain it to you?
Was there any bleeding/Infection
How was the recovery period/
How is the baby/ Is it a boy/Girl
How old?
Is the baby healthy?
If baby was fine & no complications:
Looks like it was a right decision & the outcome was good
What is your understanding about cord prolapsed?
Cord is squeezed between head of baby & pelvic bones.It is a life threatening condition & needs
urgent intervention

Have you ever been pregnant other times?
How are you doing in this pregnancy?
What was your last F/u
Bp?
US
Baby kicking
PMH
Due Date

Waht is your understanding of Cs?
There are different methods:
Classical Section Vertical incision
Lowere Segment C Section ----->transverse incision

Most common is the transverse sectionThe cut is parallel to the fibres & thus it is a strong scar

If you go into labour there is a lot of pressure & tension on the scar & with continuous pressure
there can be rupture of scar this is concerning

There will be a lot of bleeding we might not be able to help you & the mechanism of delivery will
stop
Chances of rupture in cl S is 12% of which 105 will die
However if you want to continue the decision is yours Your life & the babys are endangered

With a transverse Cs We can give you chance of normal delivery in hospital,as in case we need to
do an urgent Cs we can

If Not ConVinced:
Why dont you go back to your midwife & talk to her & mention
She is trained & qualified We share the same guidelines

We can arrange 2
nd
opinion
F/U

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54 year old female comes to clinic concerning about using
HRT.
.
When a patient has concern about any subject, address it very soon. Don't wait to the end.
Dr: As far as I understand you're here as you have concern about using HRT.
Patient: yes Dr. I feel I am confused about using HRT.
Always ask what do you mean by HRT. So the patient will tell you how much they known
about HRT.
Dr: I'm glad you're here so we can discuss about it and address your concerns and hopefully by
the end of the session you can make a decision regarding using HRT. Or hopefully by doing this
discussion you will have a better understanding of HRT.
Or you can say: I agree with you as there are a lot of confusion about HRT and the reason for
this confusion is that in the past because it was used to be given routinely to all women who
reach a certain age, however 10 years ago there was study called " women health initiative" in
which the authors found that the numbers of the patients with serious side effects are very high.
However those ladies used HRT for a long time.
Serious side effects are
Cancer,
Heart attacks and
Strokes. For that reason the routine use of HRT was stopped.
Nowadays we have a better understanding and have better guidelines. Not only that we do it on
the individualized basis.
We use it only for short time, they don't exceed five years. So using HRT within five years is
safe.
So I would take some information from you and we will discuss about the risk factors and if you
are a good candidates we can make a decision to prescribe it or not.
Dr: What makes you interested in HRT?
Patient: because of hot flushes.
At this stage if the patient give you the symptom, it is your chief complaint.
But if patient doesn't give you any symptoms, you should start with her LMP
If she starts with the symptom of hot flushes, ask the patient
1. When did hot flushes start,
2. Is it all the time,
3. On & off or continues,
4. How many attacks,
5. Day or night,
6. How do you feel that you have it.
7. Night episodes, you have any night sweating, does it wake you up.
Asked patient if the hot flushes wake her up during the night, and if she needs to change her
gown of nights sweats.
1. Affect your sleep and how does it affect your concentration.
2. Change in your mood, anybody has told you that your short tempered, and if you
3. feel tired.
4. Some women with the same symptoms may notice some change in their sexual life.
d) So the doctor should ask with whom do you live?
e) Are you sexually active?
f) Any dryness or pain during the intercourse?
8. Any change in your urination?
Have you ever lost control?
9. Last period?
Are you periods regular or not?
If it's irregular, when did it start to become irregular?
Are your periods heavy or not?
Any clots?
*Any bleeding or spotting between periods? This is a very important point.
10. Bone pain? Any fractures? Any family history of osteoporosis? If yes, tell the patient that you
will discuss this in another meeting. Because that's another session to discuss about using
steroids, smoking, alcohol, caffeine, warfarin and diet. If she takes calcium supplements.
MGOS for GYN cases: Menstural, Gynecologic diseases, Obstetrics, Sextually transmitted
disease
Dr: any history of gynecological disease like polyps, cysts, any pelvic
intervention/instrumentation, surgeries.
Dr: did you use to take any oral contraception? If yes, which one and did you have any side
effects? Also you should ask about her last smear.
Because she is 50+ you should ask about her mammogram.
At any age you ask about Pap smear, once you reach 50 to ask about mammogram and when
the patient pass 65 you should add bone density.
You can ask about her obstetrics history, like have you ever been pregnant if yes how many
times you have been pregnant?
Now use the transition...
Because this is the first time I met you, I would like to ask you about your past medical and
social history. Is there any long-term disease, hospitalization before, any surgery, diabetes, or
hypertension. Any history of allergy, and the medication she takes.
ABCD: Active liver disease, vaginal Bleeding, Cancer, DVT
For A you ask about any history of Active liver disease. Have you ever been yellowish? Any
dark urine or pay stool?
For B you should ask about any vaginal Bleeding? ... You have already asked these question
before
For C you should check about Cancer. I would like to ask about constitutional symptoms here to
see if there is any endometrial cancer. Fever, chills, weight loss, appetite, lumps & bumps. A
history of cancer in yourself or family (breast cancer, endometrial cancer,and colon cancer).
For D you should ask about any history of swelling in the legs (DVT), any history of heart
attacks, pulmonary embolism or stroke.
Social history: smoking, taking alcohol, recreational drugs, how does she support financially
herself, how does this affect her life and ask about osteoporosis.

Usually in this set of scenario, you tell her on the basis of the history you are good candidates
for HRT.
However as I told you it is an important information to tell you to make your decision.
As we go through different stages of life usually for ladies, we go to the stage called menopause
which is vary between person to person.
At this stage there is hormonal changes and ovaries start to produce less hormones specialty
estrogen and progesterone and that changes affect the whole body. It can explain about
dryness, decreasing or absence of periods. And that's why we try to replace those decreased
hormones by HRT. They are the same hormones but we give it through external sources either
tablets or skin patches.
As I told you before there is a balance it's your decision to make. And the balance is to use it up
to five years. Using more than five years would increase the risk of stroke, heart attack or some
cancers depending on what we call it estrogen dependent that includes breast and endometrial
cancer. And some studies showed that it might increase the risk of Alzheimer's disease.
So the risk of use for less than five years is not significant and still acceptable. So if you want to
use it the shorter the better.
To get rid off the hot flushes there are other measures like exercise or herbal supplements that
you can try to improve the symptoms.

The HRTs are the same as OCP's but in smaller doses and you can take one tablet a day. They
have a few side effects like weight gain, bloating, nausea, abdominal distention and pain but
they improve by time.
The serious side effects are headaches, swelling of the legs or chest tightness which whenever
happen you should go to emergency room. By using these HRT's your periods may stop or you
may see spottings.
If the patient had hysterectomy before you only give estrogen without progesterone, otherwise
you should give both.
Because you take it regular shootout regular ultrasound scans to check the thickness of the
endometrium and sometimes we should take a sample

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INFERTILITY

(Sometimes it is not easy/Sometimes it takes time/Im glad youre here)
Intro:
As I understand youre here because youve been to get pregnant for the last 14
mo, during the next few minutes tell me more about this difficulty.
Did you seek medical attention before?
(<35 1yr/35 -40 6m0/>40 ASAP)
PID & other med condts: ASAP
How long have you been in this Relationship?
How long have you tried?
Have you ever been pregnant before?
Have you ever had Mc or Abortion?
Spouse: has he had children from a previous relationship?
Let us talk about your Partner:
(If less time Fast otherwise get details)
Fast: Was he ever investigated?
Did he have Semen analysis?
What was his sperm count?
Detailed:
How is his health
Does he have (Htn?DM/On meds)
Any back trauma,back pain?
Any Surgeries
Any H/o mumps in childhood?
H/O Ca, Rxt Cxt,STIs?
Any Psy meds,Stress,travel a lot?
Exposed to heat at work or recreational way?
COITAL Hx
Some qns about intimacy:
How often do you have IC with husband?
How do you monitor your temp?
How do you measure your urine test?
Is your husband capable of having an erection & ejaculation?
Do you use any lubrication?
MENSTURAL
When was your LMP?
GYN:
SEXUAL:
Any STIs

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16 YOF information about Pap Smear,
counselling, health maintaining issues (comes with HEADDSSS).
Whenever there is counselling take history.
.
Pap smear
What do you like to know about Pap smear?
Usually we offer it for people who are sexually active, for that reason Id like to know if you are in a
relationship?
Are you sexually active?
When did you start?
Any other relationships or partners prior?
Do you use protection?
What oprotection do you use?
Any STD (blisters, ulcers, warts) in the last 6 mo?
MGOS:
M:LMP
How often do you get your menses?
Are they regular?
Are your periods painful?
Are they heavy?
G any gynaecologic disease? Any pelvic exam?
O: Any H/o pregnancies/Abortions?
Past medical Hx?
HEADDSS .... Counsel about Seat belts
Mood & Risks of suicide?

Counselling: Why? & How?
I am glad you came here today to talk about Pap smear. As a matter of fact PS is one of the most
successful screening tests to pick up one type of dangerous cancer called Ca Cx which is caused by
a virus called Human Papilloma virus & a condom does not protect you from this.
It is important to pick it up early, since by time it starts to give symptoms it is too late. Let me explain it
to you.
The area connecting the vagina to womb is called Cervix, & from the outside it looks like this:(Draw the
circle with a dot) from this part weve to get a sample it gets infected with HPV virus which is similar to
wart virus, but in the cervix, it leads to cancer. It should be done a week after your menses. It has to be
done in a certain way, there will be a nurse with me,& you will be on your back, the exam bed has
pedals to support your feet. We will use a speculum which come in different sizes & are plastic &
disposable & we use a water based lubricant.
If spatula rotate it to 360 & put on a slide, fix it & send to lab.
If brush, rotate it 5 times put in fluid & send to lab. Results will be back in 2 weeks. If all is well, we will
not contact you.
PS has to be done every year .Once results are normal for 3 yrs & youre with same partner you casn
do it every 2 years till 69 years old, when you can stop
,If you change your partner, youve to do it yearly again. Other hazards drinking and driving.
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YOUNG WOMAN: ANTENATAL COUNSELLINg
History
Ask how Pt feels about being pregnant
When did you do the test? How did you find out?
Congratulate if she is happy. It is a very exciting time of your life.
Ask questions about the pregnancy
LMP:
LLMP was it similar to prev menses or less bleeding?
Calculate EDD; - 3mo + 7 days
Sx:,
N/V/Breast engorgement/Inc visits to washroom
Rh status
If nausea severe, ask about dizziness
O: GTPAL
Any complications in previous pregnancies: HTN/DM/Twins/Congenital anomalies
G: (surgeries, infections, PAPs)
S: Any STIs
PMH:
Vaccinations, diabetes, hypertension, heartdisease, genetic diseases, kidney diseases, immunological
diseases
Past history of surgery-especially childhood
Family Hx:
Genetic disease, prematurity, early onset deafness
SHx:Medications, Smoking, Alcohol, Recreational drugs
OTC if on Aspirin ask to stop & change to Tylenol
Social Hx:
partner, support, provisions for child
How does your partner feel about this pregnancy?
Do you feel safe in this relationship?
Do you have pets?
If has cat,not to change litter.

COUNSELLING:
I will confirm pregnancy by blood work
Physical
Vitals, weight, full exam including PAP smear (if not done in last 6 mo)and cultures
I nvestigations
CBC, Lytes, INR/PTT, Urea, Creatinine, Blood Type, VDRL, Rubella antibody,
Serum folate, Hepatitis, +/- HIV, Urine dip and microscopy, ECG if indicated,
+/- sickle cell and thalessemia screens.
Nuchal Translucency at 12 weeks
Maternal serum screen at 16 weeks
Anatomy ultrasound at 18-20 weeks
Glucose challenge test at 24 weeks
+/- Rhogam at 28 weeks
Diet, smoking, alcohol, exercise, medications, morning sickness
Average weight gain is 25-35 lbs with 5-10ibs up to 20 weeks and then 1lb/week thereafter
Risks of Downs 1/200 at 35
Consult MD prior to meds
For morning sickness eat bland foods, small portions, Diclectin is an option
Hemorrhoids, back pain, heartburn and increased vaginal discharge are common
Visits are every 4 weeks until 28 weeks then every 2 weeks
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19/2/2011
Introduction
What to write on the note before entering the room:
Name
Age
CC
What required
DDx

First buzz turn and read the stem (2m)
Second buzz knock the door and enter.
The examiner might tell you that at the end he will ask you 1 or 2 questions.
In the next buzz it will be the time for the questions. If he doesnt ask complete the task.
After another minute there will be a longer bip sound.

Short station (history, physical exam, s/e of psychiatric medications):
1.5 m buzz enter
Short buzz after 4.5 m (do
Thank you for the information, Ill do the physical exam and Ill take it from there.

CC
As I understand you have ...for ... can you tell me more from the moment you started to notice it.
I am glad you took the time to come here

In case of physical exam:
Intro: name, position, why you are here, time that I am going to spend with you and for which purpose.
Good morning, my name is...I am the attending physician here. I understand you are here because....In
the following 5 minutes I will perform physical exam, hopefully towards the end we will reach a
workable plan. If you feel any discomfort please inform me. Do you have any questions?

Imaging, blood work
Hello, good afternoon Mr. ... as I understand you are here to get your blood work results, since this is
the first time I see you before I am discussing the results with you I have some questions to discuss with
you.
Than: Why, 1
st
time, who and when.
In case of breaking bad news: SPIKE
Setting
Perception (What is your understanding about the test, and why you are doing that
Invitation (How much details do you like to discuss with you? DO you like anyone to be with you?)
Knowledge (What do you know about the condition?)
Expectations (What are your expectations from todays visit? What is your expectation from the result?)
Gives the result.

Questions for telephone session:
Whats your number?
Where do you live?

...did I say it right?
Connecting with a colleague:

Psychiatry

Psychosis
1. 55 yo, believe that have strange feeling in hands. Do mental exam.
Either organic, late onset of schizophrenia, not complying with medication.
2. 35 yo, believes that the RCMP chasing him.
Persecutory delusions. Reassurance about his safety. DDx substance abuse.
3. 24 yo, brought by his roommate because havent been himself in the last 10days.
Can be acute psychosis, substance abuse, HIV, mania
4. 30 yo, wants to arrange DNA test for his children.
5. 17 yom, worried about contamination wants to be admitted to get rid from it. 10min
councsel.
6. 22yo, diagnosed with schizophrenia 6wk ago, concerned about his condition.
Think about suicide!
7. 17 yo male, pain in his neck.
s/e of drugs.
8. 35 yo, brought by the police because he wanted to slaughter his children (thinks he his
Abraham).
Ask him Who is Abraham?
Ask early about: How is your mood today? To differentiate from mania.

Mood (Presenting symtoms)
MI PASS ECG
1. Low mood for the last 6w.
2. Patient with difficulty to sleep:
2.1. 22 yof
2.2. 35 yof
2.3. 75 yof asking for sleeping pills
3. Suicide case.
4. Presentation with tiredness 34 yo.
5. 40 yom hasnt been himself for the last 3w his wife concerned.
6. 70 yo has back pain for 3w (x2 cases).
7. Dysthemia case. A young lady with low mood for years

DIG FAST
1. Impulsive behaviour might be presented with intoxication to the ER. Sexual activity with no
protection. Issues with the law (fighting in the bar, waking up the neighbours).
2. Grandiosity some delusional ideas.
3. Patient who wants to discontinue the medication.

Anxiety
1. Panic attack heart racing, sob, dizziness, tingling, numbness (hyperventilation hypocapnea)
STUDENTS FEAR 3Cs
2. Patient already diagnosed recently with PA or Panic disorder or generalized anxiety discuss the
treatment.
Delirium and Dementia Cognition disorders
1. 57 yom difficulty with her memory. History and mental status exam (mini mental). 5min.
2. 67 yof difficulty with her memory. Score for mini-mental 20.
3. 67 yom came with his wife, concerned about his memory for the last 3m. Next 15min talk with
him.
4. 70 yom, s/p hip replacement 3d ago. Didnt sleep last night (reversed sleep cycle) delirium.
Fragmented sleep cycle dementia.
5. His dad is not being himself. You talk with the son. You cannot do mini-mental to the son.
6. Talk to the son about his mom that is in senior home. He is concerned she was given 15u
instead of 5u of Insulin. It looks like there is some kind of medical error.

Eating disorder, borderline, schizotypal, conversion
1. 16yof, the parents concern that she loses weight.
Part of the DDx is figure out that she has amenorrhea.
2. 22 yof wants to be admitted. She wants to kill herself.
If is the first time you need to admit her.
If it is several times its not necessary to admit her.
You have to finish the assessment.
If she lives the room before finish the interview you will write form #1.
Usually people with psychiatry problem have: social worker and case manager.
Have you ever seen by psychiatry.
3. Schizotypal disorder
4. Sudden loss of function. Seen by two doctors, one of them specialist in that field it means it is
conversion.
4.1. Loss of vision in her rt eye. Seen by ophthalm.
4.2. 22 abdominal pain for 3w, seen by a surgeon a week ago. Counsel.
4.3. Headache for the last 6 mo, she wants to renew her thylanol 3 (x2)
5. Alcholism
5.1. AST>ALT, GGT elevated
5.2. His wife concerned he is not himself for the last 3m
6. Suicide (SAD PERSONS score more than 4 you have to admit).
6.1. Overdose of aspirin. Medically clear.

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Psychiatry Assesment
In PSY Ds look for:
I. TIME
II. CRITERIA
If CC is psychiatric, make an early decision in MOAPS format, where:
M=Mood
Depression --MI PASS ECG
Mood How is your mood? Do you feel down? Do you cry a lot?
Have you felt that before?
You look down for me is there any chance you are depressed?
Is your mood always down or does it alternate?
Have you been very happy at times? if YES: enquire about Mania
INTEREST: Have you lost interest in activities in doing activities that were enjoyable to
you?
Anything makes you happy?
If he doesnt it any more Why? (Doesnt have time, no energy, or doesnt enjoy it)
PSYCHOMOTOR RETARDATION/AGITATION:
DO you feel things are getting slower? Do you need more time to do things you did
before?
APPETITE
Did you lose weight deliberately?
SUICIDAL Ideation
Any plan?
Did you live a note?
Did you start to give your belongings to others?
SLEEP
When you go to sleep? When wake up? Do you feel fresh?
ENERGY
Do you feel tired?
CONCENTRATION
When you read an article can you finish it to the end?
Do you find to focus to concentrate in one subject?
GUILTY
Do you feel guilty?
Do you feel there is no hope in life?
After getting two depression episodes. If they are at least two month apart Major depressive
For teen age istead of mood and interest is replaced by irritability and droped in school
performance.
In elder person you might have need somatic disorders.
Bipolar I (Mania) - DIG FAST (elevated mood + at least three out of the seven for a
week) sometimes it is irritated mood than you need 4 out of seven for a week. Usually they
dont last a week so if they end up in hospital look for the criteria even for less than a week.
DISTRACTATIBILITY:
DO you find difficult to focus on one subject?
Are you working on more than one project at the same time?
How many projects do you work in? Are you able to finish it or not?
IMPULSIVITY
Are you spending more time than before?
Are you borrowing money from other people? For what reason?
Are you drinking more than before? Do you use cocaine? Which happen first?
elevation of mood or using cocaine?
With whom do you live? Are you sexually active? How many partners do you have? Do
you practice safe sex?
Do you have any problems with the law? Speeding tickets? Any fights?
GRANDIOSITY:
Do you believe youre a special person?
Do you believe you deserve to be treated in a special manner?
Do you feel youve a special power?
Do you feel youve a special mission?--- if Yes Always ask what is the mission? &
probe deeper & inquire about Delusions*
FLIGHT OF IDEAS:
Do you feel thoughts racing in your head?
Do people say youre jumping from topic to topic
GOAL DIRECTED ACTIVITY:
How much time you spend in your activity?
SLEEP
TALKATIVE
Anybody mentioned that you are talking faster or more than others?
Ask:If first episode or has it occurred before?
Also look for OPPOSITE mood
Relapse rate for the first time: 60% next time it is 80% third time 95%.
Intro
Why?
Concern
Assess mood today
How you were diagnose with bipolar I? When? Why? Were there any
serious consequences? Regular follow up? When you saw last your
doctor? What was the level of Lithium that time? How do you feel about
Lithium? Did you notice any s/e?
Have you ever forget to take the drug? (It will be easier in the
counselling).
I know that you have been this question before but I am going to ask
you again do you hear any voices. Do you worry a lot...
Counselling
Compare mania to depression. What is your understanding of mania. It
is a condition...

O=ORGANIC (I MAD):
ENDOGENOUS (ILLNESS);
Depression: Hypothyroid/Lupus/Ca Pancreas/Post MI/CVA
EXOGENOUS: (Substances: MAD)
M: Medications: Dosages/duration/SE/Toxicity
A: Alcohol: How much/day?
D: Drugs:
1. What drugs have you tried?
2. When
3. How much
4. Any Hx of O/D,W/d,SE,hospitalizations?
5. Which drugs NOW?

A=ANXIETY SCREEN:
Do you worry a lot?
Interview Questions to Establish Specific Anxiety Diagnosis
Questions Further Inquiry
1. Do you have sudden episodes of intense
anxiety? Establish nature of attack *
2. Do you have difficulty going to places to
which you used to be able to go?
Inquire about crowded places, line-ups,
movies, highways, distance from home.
3. Do you have difficulty talking to people
in authority or speaking in public?
Establish situations (one-on-one or groups).
4. Are you afraid of blood, small animals or
heights?
Establish precise feared situation.
5. Do you repeat actions that you feel are
excessive?
Ask about washing, counting, checking and
hoarding.
6. Do you have thoughts that keep going in
your mind that you can't stop?
Do these thought cause stress for you?
How do you relieve this stress?
Ask nature of thoughts (illness, harm, sex)
Relieved by washing hands/praying.
7. Have you experienced any emotionally
stressful events?
Establish the nature (accident, sexual,
torture) and timing of the trauma.
When & What happened?
8. Do you worry a lot of the time? Ask about worries related to health, family,
job and finances.

P=PSYCHOSIS
HALLUCINATIONS:
VISUAL HALLUCINATIONS:
1. Do you sense things that are not actually there?
2. Do you see things that others do not see?
3. What do you see?
4. Can you describe what you see?
5. Does it have a message for you?
6. Does the message ask you to harm yourself?
7. How do you feel about it?
8. Is this the first time?
AUDITORY HALLUCINATIONS:
1. Do you hear voices other people cannot hear?
OR :
a) If youre alone & nobody with you, do you hear voices?
b) Do you hear voices inside your head?
2. How many voices?
3. Are the voices familiar?
4. Do you recognize the voices?
5. Do they talk to you?
6. Do they talk about you?
7. What are they asking you to do?
8. Do they ask you to harm yourself?
9. Do they ask you to harm anybody else?
If YES:
10. What is preventing you from doing this?........Screens for INSIGHT
11. How do you feel about these voices? (Some people feel comforted when
they hear these voices, others feel threatened).
DELUSIONS:
1. Do you feel anyone wants to hurt you or harm you?
If YES: WHO & WHY?
2. Anybody tries to control you?
3. Anybody wants to put thoughts into your head? (Thought Insertion)
Anybody wants to steal thoughts from your head? (Thought withdrawl)
4. Others can read your thoughts? (Thought broadcasting)
5. When youre watching TV or reading the News, do you feel theyre talking
about you? (Ideas of reference)
6. Do you feel any part of your body is rotting?
7. Do you feel everybody is falling in love with you?

S=SELF CARE
HOMICIDE:
SUICIDE
SOCIAL HISTORY:
o With whom do you live?
o How do you care for yourself?

PAST PSY HISTORY:
1. Any similar Sx/Ds in past?
2. Any Other psy Sx/ Ds in past? If YES:
3. Analyse Sx/extent of incapacity/Rx recvd/names of hosp/Compliance
R/OAny medical illness:DM/HTN/Thyoriod/Surgery/Head trauma/HIV/AIDS/Syphillis
SAD Smoking, Alcohol. Drugs (especially long use of cocaine)
Screen for anxiety are you fear a lot? any fears, especially from open places?
Screen for psychosis anybody wants to harm you? Sometimes people having similar
experience they might hear voices or see things other people dont see. How about you?
FHx:
Anyone in family with similar Sx/Ds
Anyone in family with other pSy Sx/Ds
Drinking / hospitalized from psychiatry reason?
Relationships
SADD FHx:
Suicide
Alcohol
Depression/Divorce/Drug
PERSONAL Hx:
1. Prea-dulthood
2. Adulthood:
Social activity: Support system, Friendships (depth/duration/Quality) isolated, asocial
With whom do you live? If he lives alone do you have any friends you talk with?
Current Living Situation:
Where/with whom/Relationships at home/financial support/Assistance
OCCUPATIONAL HX:
How do you support yourself?
What are your ambitions/goals/relationships/Conflicts at work?/STRESSES/ Job changes
MARITAL & RELATIONSHIP Hx; Age/Duration/areas of (dis) agreements,outcomes
MILITARY Hx Gen Adjustement,combat,Injury
Educational Hx: Highest grade/Area of interest
Religion:Strict/Permissive attitude towards suicide

PSYSOCIAL Hx:
Sx/attitudes/orientation/practises/STDs (HIV)
1. Are you currently in a relationship?
3. Are you active with males, females or both?
4. How long have you been in the current relationship?
5. Are you practising safe sex?
6. Are you using condoms all the times or just sometimes?
7. Is there a risk for you to be at a risk for STDs like HIV/HBV/Syphilis?
8. How about your partner?
9. How about your previous partners? Or the previous partners of your partner?
10. Have you or your partner tested for HIV,HBV or Syphilis?/When/Outcome
11. Are you currently seeing anyone else?
12. What other relationship have you had in the past?/ Anytime with more than one person at a
time
13. Have you ever paid/received money for Sex?

Allergies

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MSE/MMSE

APPEARANCE:
1. Well dressed
2. Well groomed
3. Dress matches weather
4. Given age matches chronological age
BEHAVIOUR:
1. Agitated
2. Psychomotor retardation
3. Eye Contact
4. Co operative
5. Non hostile
6. No abnormal movts/Jerking/lip smacking
C/SPEECH:
1. Volume
2. Tone
3. Fluency
4. Articulate
MOOD& AFFECT:
Mood;Subjective Sx in pts own words
Affect (qarms)
1. Quality: Euthymic/depressed/elevated/Anxious
2. Appropiateness to thought content
3. Range:Full/Restricted/Flat/Blunted
4. Mood Congruence
5. Stability: Fixedt/Labile
PERCEPTION:
Hallucination
Illusion
THOUGHT PROCESS:
Coherence/Incoherent
Logical/Illogical
Circumstantiality/Tangentiality
THOUGHT CONTENT:
Suicidal/Homicidal Ideation
1. Low-- fleeting thoughts,no formulated plan,no Intent
2. Intermediate--More frequent ideation,well formulated plan,No active intent
3. High --Persistent ideation & profound hopelessness/Anger,well formulated plan,active
intent,believes suicide,homicide is only helpful option available
Obsession:
1. Recurrent or persistent thoughts,impulses or images that cannot be stopped which is
intrusive or inappropriate
2. Cannot be stopped by reason & Causes marked anxiety & distress
Preoccuption:
Overvalued Ideas:
Ideas of reference:
Delusions:
Magical thinking:
First Rank Sx of Shz:Thought insertion/T withdrawal/T broadcasting
COGNITION: MMSE
Level of consciousness
Orientation in time/place/person
Memory: immediate,remote,recent
Attention & Conc
Global evaluation of intellect: Intellectual Fns:
INSIGHT:
JUDGEMENT:

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DELERIUM
MMSE
1
st
reassuare the pt,calm him down talk & do MMSE

O-O-O-O-O = 5 = Time: Year/Season/Month/Day/Date

O-O-O-O-O = 5 = Place:Country/Province/City/Street/No
O-O-O = Immediate recall:Black/Honesty/Tulip (if he makes mistakes,correct him but give
_ve
O-O-O-O-O = Concentration: Can you spell WORLD backwords?

O-O-O = Delayed recall

O-O-O = Comprehension: 3 step command

O-O = Naming 2 objects (pencil & paper)

O = Reading ; write a sentence: Close your eyes & ask him to follow the command

O= Writing

O = Repeating; No ifs ands or buts

O= Copying

Why Delerium:
Fever
Ha/photophobia?
Did you eat last night?
Abdominal pain /Flank pain?
Calf pain?
Medications
Alcohol (Last time & now)
CSx:
Ask examiner for I/O chart
& medication chart

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FORMS to Be filled: [TN10-PS52]
If during an interview a pt decides to leave & not finished......
If pt wants to kill someone or himself....ADMIT
If Pt refuses to be admitted & insists on leaving:
INVOLUNTARY ADMISSION----------FORM 1
And another doctor must come & asses him.
Cannot hold in hospital for > 72 hrs

If a wife /partner brings & dr assesses & there may be a chance that the Pt may commit
suicide/homicide, pt can be sent home, on condition that if Pt detoriates she should call back &
immediately & bring
Can file FORM1
If pt refuses voluntary admission with first dr,but second D. Can assess & can discharge if he
feels fit for discharge,or admit on VOLUNTARY basis

Admission always better on voluntary basis

If second dr admits on involuntary basis it is FORM 3 & valid for 2 wks
During these 2 wks,pt improves,& so can be discharged, or gets voluntary admission
When admission voluntary --- FORM 4
Form 4 is renewed
Released on --FORM 5
Thus FORMS 3 & $ are for Rx

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PANIC Attack
ONSET:
1. When did it start
2. How did it start?
3. What were you doing at that time?
COURSE:
1. Is the Intensity same now as it was when it all started?
2. How about the frequency?
3. What made you come in today?
DURATION:
How long does each attack last?
PQRSTUV
1. Where exactly does it hurt you?
2. Can you describe the pain?
3. Does it move to anywhere else n your body?
4. On a scale of 1 to 10,wher 1 is mild & 10 is max,where would you rate this pain?
5. Has this affected your life in any way?
6. Is there a particular time it comes on?
7. Did you ever have this before?
AAA
Alleviating Fcts:
What makes it better?
What Aggravates it?
1. Exercise
2. Stress
3. Certain situations or places?
4. Coffee?
5. Medications?
6. When passing urine or having a bowel movt or cough?
ARE YOU AFRAID THAT AN ATTACK IS COMING?
Assoc Sx: first R/o cardiac then GI & then shift to Psy
N/V/Diarrhoea
Heart racing/ Sweating/ Dizzy
Decreased wt & Increased appetite/ Tremors
Headache
Tingling & Numbness
Nervous & Out of control
Do you feel youre going to die?
During these attacks do you feel things are unreal?
During these attacks do you feel you can see yourself?
Do you feel youre going crazy?
Do you feel worried about being in places or situations where escape might not be
possible
e.g: Crowded places
Closed spaces
If YES:
* What place or situation?
* What happens in such a situation?
* How has it impacted your life?
* How have you dealt with this issue?
Here ask for anxiety disorder: Are you a person who worries a lot?
Interview Questions to Establish Specific Anxiety Diagnosis
Questions Further Inquiry
1. Do you have sudden episodes of intense
anxiety?
Establish nature of attack
2. Do you have difficulty going to places to
which you used to be able to go?
Inquire about crowded places, line-ups,
movies, highways, distance from home.
3. Do you have difficulty talking to people in
authority or speaking in public?
Establish situations (one-on-one or
groups).
4. Are you afraid of blood, small animals or
heights?
Establish precise feared situation.
5. Do you repeat actions that you feel are
excessive?
Ask about washing, counting, checking and
hoarding.
6. Do you have thoughts that keep going in
your mind that you can't stop?
Ask nature of thoughts (illness, harm, sex).
7. Have you experienced any emotionally
stressful events?
Establish the nature (accident, sexual,
torture) and timing of the trauma.
8. Do you worry a lot of the time? Ask about worries related to health, family,
job and finances.
a.
MOAPPS
MOOD
RISK FCTS:
To gain more insight into your condition, I need to ask some questions about your personal life :
Do you:
Smoke
Take alcohol
Recreational drugs (in case of cocaine ask if sniffs or injects it. If injects continue by
r/o HIV symptoms)
Are you on any medications?
Did you take anything for a cold or flu
Are you taking OTC products/herbal remedies?
When was your last period?
Are you going through a stressful situation in your life?
How are you coping with it?
FAMILY H:
Does anyone in your family have a similar condt?
SOCIAL H:
COUNSELLING:
From what youve told me, your chest pain seems related to a condition called Panic Attack
It is a fairly common condt
It's not known what causes panic attacks or panic disorder. Things that may play a role include:
Genetics
Stress
Certain changes in the way parts of your brain function
Some research suggests that your body's natural fight-or-flight response to danger is involved in panic
attacks. For example, if a grizzly bear came after you, your body would react instinctively. Your heart
rate and breathing would speed up as your body prepared itself for a life-threatening situation. Many
of the same reactions occur in a panic attack. But it's not known why a panic attack occurs when
there's no obvious danger present
Caffeine or other stimulant use should be reduced and controlled.
Alcohol use should be minimal; it should not be used to control anxiety.
Reduce the as-needed use of short-acting benzodiazepines as much as possible; ideally, such
use should not be continued for longer than 4 days.
Stress reduction, including relaxation training and time management, is often helpful initially.
Specific cognitive behavioural therapy (CBT) may be required;

he selective serotonin reuptake inhibitors (SSRIs) citalopram, escitalopram, fluoxetine, fluvoxamine,
paroxetine and sertraline are all effective in reducing panic
SSRIs and SNRIs have become first-choice agents in treating panic disorder with or without
agoraphobia.
2
There is usually a delay in response to these agents that may be accompanied by initial
agitation. Combining the SSRI or SNRI with a brief course of low-dose benzodiazepine augmentation
therapy (i.e., no longer than 8 weeks) can increase adherence to medication and produce a more rapid
response than with antidepressants alo

Panic Disorder with Agoraphobia

The pharmacologic treatment of panic disorder with agoraphobia is the same as for panic
disorder. However, much of the disability in panic disorder with agoraphobia arises from the
avoidance behaviour rather than the panic attacks. This can be addressed with cognitive
behavioural therapy (CBT), even if medication reduces or eliminates panic attacks. CBT can be
more effective alone than when it is combined with medication.
8
However, access to specialized
CBT is often limited.
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Personality
Disorders
Am I crazy?
There is no medical condition called like that, however sometimes patient have some
difficulties with their thoughts and reality, it is called schizophrenia.
Mental Status Exam:
Appearance wise...dressed, gromed
Behavioral wise:
Speach wise:
Mood wise:
Perception:
Thought processing:
Thought content:
Judgement:

Mini-Mental: delirium, dementia, post-concussion

Writing a chart (SOAP):
Subjective
Objective
Assessment
Plan

Borderline Personality
Work on this event and previous attempts.
If she was diagnosed have you ever seen by psychiatrist? What was the diagnosis? What you
didnt contacted your case manager/psychiatrist? ER or ICU or Weapons?
In Toronto contact with the case manager/psychiatrist.
What is the trigger that makes her come today?
In case of crisis do you have anybody to contact? Refer to crisis team/Social worker/
In order to determine if I can admit you or not I need more information...
Always the same pressure like today?
If the patient mentions work what do you do for work?
Anything happen recently? Have you had any other relations? Is it difficult for you to maintain
relation?
Mood, Anxiety, Drugs/Alcohol/

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22 yof wants to be admitted.
Borderline personality

When Pt wants to be admitted she may say,if you do not admit her,something bad may happen
like last time.
Pick up early when she says this ......
Start with EVENT:
Check previous attempts at suicide
Pick up early when she says something bad happened
Ask: WHAT happened?
If Suicide attempt.......
1. When & How many times before
2. Was she seen by psychiatrist?
3. Has she been to ER before?
4. Was she diagnosed & Rxed
5. Why can;t she contact her psychiatrist?
6. Was she admitted in ICU?
7. Which Rx programme does she have?
8. Does she have a crisis team & case manager?
9. Why didnt she contact them?
If repeated attempts at suicide:
Which treatment programme does she have?
Is admission one of it?
CRITERIA FOR BPD:
Fluctuating mood either very happy or sad
Splitting
Feeling of emptiness
Failure in maintaining a relationship both on social & employment areas
Impulsivity Drugs & Sex
Was sexually abused as a child
Let her go or admit
1
st
episode admit needs Psy assessment
Look for TRIGGERS that made her come in today
Do not let her manipulate you
I really like to help you,Im on Er duty
My job is to asses you & admit you Once admitted another Dr will asses you

Can you tell me why you want to be admitted?
I really want to help you...
What bad thing will happen?

In order to admit you or not, I need more info & therefore I need to ask you, & admitting you is
one option
If pt says Something Bad will happen
o What do you mean?
o When did it start?
o Did it happen before?
o How many times before?
NO EMPATHY
When did it happen the 1
st
time?
What was done?
Were you admitted to ICU?
In addition to slashing your wrists have you used any other methods?...Like weapons or
medications?
Pt says she feels some pressure
Ask if the pressure felt today is the same as the pressure felt last time
I want to help you looks like the last few days were stressful
Have you been seen by Psy?
What was the diagnosis?
Do you still see the Psy?
When was the last time you saw him/Her?
Why did you stop?
What medication were/are you taking?
In addition to psy is there a case manager?
In case of crisis do you have anybody to talk to/ or contact?
What prevented you from talking to them today?

Ask prior to Event?
What happened 6 wks ago?
How did you lose your job?
What sort of job were you doing?
What happened?
Prior to that what sort of job were you doing?
Is it difficult for you to stay in one job?
Have you tried to find another job?
Anything happened last night?
If Boy friend left her.....How long have you been together?
How does she feel about it?
Was he supportive?
At what age was she sexually active?
Does she find it difficult to stay in a relationship?
MOOD
DEPRESSED: Ask for HOMICIDAL ideation
Manic Ask Drugs/Spending/Impulsivity
ANXIETY
After boyfriend ask about fly support......
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Depression
Sleep
If comes Tired Sleep Energy Mood
Sleep how does it affect you?
DO you feel tired?
During the past month have you often been bothered by feeling down, depressed or
hopeless?
During the past month have you often been bothered by little interest or pleasure in doing
things?
MI PASS ECG (TO diagnose depression needs 5 out of the 9, in which one them should be
either M or I. In teenagers irritability can replace either M or I, in elderly it can come with a
somatic presentation)
If it is one episode it is called: Major Depressive Episode (need 2w in which most of the days
with depressed mood, and 4 more criteria). If there are 2 or more MDE within the same 2m it is
Major Depressive Disorder, if it is more than 2m it is Recurrent Major Depressive Episodes.

M
How do you feel recently?
How is your mood?
Any chance you are depressed?

I
What do you enjoy doing?
Are you still enjoy hobies?
Anything brings happiness to you?
Why dont you enjoy any more?
No time? No energy?

P
Do you think things are getting slower?
Do you think you need more time to do things you used to do before?

A
Any change in appetite?
Did you lose weight?
How much weight did you lose?
Was it intentional or not?

S
How about sleep?
How many hours do you sleep?
How long before you fall asleep?
DO you wake up at night?
Why do you wake up at night?
DO you feel refreshed at the morning?

S
Do you feel any chance that you might harm yourself, end your life, or any ones?
If patient says I wish I am dead, consider either he has only a feeling or a plan (active)
Do you have a plan? What is preventing you?
Did you leave a note? Did you start giving your belongings to others?
(These are definite questions for a plan)

E
DO you feel tired?

C
Do you find it difficult to focus on a specific task (for example if you are watching TV you can
stick to the same program all through? Can you finish an article?)

G
DO you feel there is no hope in your life?
Do you feel guilty?

Regardless of any specific psychotherapy, measures to enhance treatment compliance are useful;
e.g., providing psychoeducation with the following 5 simple messages is effective:
19

Take medication daily
Call this number for questions about side effects or other issues
Remember that it might take 24 weeks to see a noticeable effect from antidepressants
Continue to take medication even if you are feeling better
Do not stop taking the antidepressant without checking with the physician

42 yom hasnt been himself, his wife arranged for the
meeting.
INTRO:
As I understand youre here today,as your wife has some concerns about you.
Can you tell me more about it?
Give confidentiality.
Counseling (last 2-3m):
Based on what you told me your symptoms are consistent with a condition called depression. We
believe it is caused because of imbalance in some of the chemicals in the brain. Sometime there is an
event in life or cause that triggers that situation. It is common and treatable. We need to r/o other
causes and for that we need to do some blood work.
What did I do wrong to feel so depressed?
Depression does not occur because someone has done something "wrong". Like any other medical illness,
depression is caused at least in part by biochemical changes in the brain, which lead to depressive
symptoms. This is why medications which help correct chemical imbalances in the brain relieve
depression. In fact, if a chemical imbalance is not present, antidepressant medications will not have any
effect - they will not make a person "happy" when they are not clinically depressed.
How long before I feel better?
Generally speaking, people will start to notice improvement in symptoms such as sleep disturbances or
crying spells and energy levels a few weeks after starting their treatment. Improvement in depressed
mood is usually slower, and it may take six to eight weeks before people notice they are feeling much less
depressed. If someone has not improved after three to four weeks of therapy, the dose of the initial
medication may be optimized, a different drug may be added, or the initial drug may be substituted. Up to
80% of people with depression do get better with the right medication.
Will my depression come back?
The likelihood of depression recurring depends on how many previous episodes you have had.
For people who are experiencing their first depression, the likelihood of having a second episode is
around 50%.
For people who've had two depressive episodes, chances of having a third are around 70% and for
Those who've had three and more episodes, all but 10% will experience further illness.
Having someone else in your family who has depression makes it more likely your own depression will
recur. Other risk factors for recurrent depression are the presence of chronic medical problems, a history
of early trauma or abuse, dysthymia, onset of depression younger than 25 years or older than 60 years,
and a long pattern of negative thinking, low self-esteem and relationship difficulties. A depression which
does not completely resolve with treatment, as well as severe depression, also increase the likelihood
depression will recur.
This is why most people with depression need to be treated for at least six to nine months to prevent
relapse, and for greater than 12 months if someone is being treated for a recurrent episode. Depending
on the likelihood of depression recurring, some people stay on the same dose of their medication for
long-term maintenance therapy. The saying doctors have is, "The dose that gets you well is the dose that
keeps you well" and people will do better over the long run if the same dose is used throughout.
Can I pass depression on to my children?
Certain types of depression, especially, bipolar affective disorder, would appear to run in families.
However, even identical twins do not share an equal risk to develop depression, and depressive illness
appears to be a combination of vulnerability to depression (part of which may be inherited but not
necessarily), difficult life events and biochemical imbalances in the brain.
I have trouble reaching orgasm now that I'm taking an SSRI. Can I stop my medication on weekends to
improve my sexual function?
Some doctors recommend drug holidays where people stop taking their medication on the weekend. The
biggest concern about stopping and starting medication revolves around compliance issues, but there is
some evidence that people may not respond as well to the medication if treatment is continuously
interrupted. For these reasons, drug holidays are not recommended and an alternative antidepressant or
an additional medication to offset unwanted sexual side effects are better solutions.
Regardless of any specific psychotherapy, measures to enhance treatment compliance are useful;
e.g., providing psychoeducation with the following 5 simple messages is effective:
19

Take medication daily
Call this number for questions about side effects or other issues
Remember that it might take 24 weeks to see a noticeable effect from antidepressants
Continue to take medication even if you are feeling better
Do not stop taking the antidepressant without checking with the physician

There are good options to treat it. If you choose to go to talk therapy I can refer you to a psychology. On
the other hand we can use medications which are generally safe. Called SSRI similar to Prozac, however
like any other medical intervention have some side effects. Most of them are minor, usually improve
with time headache, sexual...however the improvement of your mood will lag behind your
improvement in your energy, we call that the window gap, and this is of concern to us.
All contracts are verbal, besides the drug contracts I promise I will not use ...again...

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Mania
DIG FAST
For diagnosis we need elevated mood + 3 criteria of the above 7 for a whole week.
Sometimes irritable you need 4 criteria.

D
DO you find it difficult to focus on one subject?
Are you working on more than one project on the same time?
How many projects are you working on?
Can you finish it on time?

I
Are you spending more money than before?
Are you borrowing money from others?
Are you maxing out on your credit card?
Do you drink alcohol?
Are you drinking more than before?
DO you smoke or take recreational drugs? (If taking recreational drugs feeling high)
If taking cocaine what happened first: the episode or the taking the drug?
How many partners have you had recently?
Have you used protection?
DO you have any problems with law?
Any speeding tickets?
Any fights?

G
DO you feel you are special?
Do you feel you deserve to be treated differently?
DO you have special powers?
Do you have special mission?

F
DO you have thoughts racing in your head?
What kind of thoughts?

A
How much time do you spend in your activities?

S
Lack of sleep?

T
Did anyone tell you that you are talking faster than before?

Manic
1 Manic episode = Bipolar I
Ask if it is the first time or has it happened before. How about the opposite. Have you ever felt
high? Greater than 7 days in a row?

Insomnia in elder
Difficulty in sleeping for 6 months
Can you tell me more about it since it started?
Did you seek medical attention?
OCD
Anything at that time?
From that time till now every night? When do you go to bed? Whe do you fall asleep? When
do you wake up?
Before you fall asleep what do you think? What comes to your mind?
When you sleep do you wake up?
Any nightmares?
If she says she has to wake up for breakfast ask why she has to wake up?
How old is your son?
Has he been always with you or is he left and come back?
Cant the prepare breakfast for himself?
Anybody else at home?
How about your husband?
CSx
PMHx
SHx
How does son support himself?
Is he under stress?
What is the nature of your relationship?
Give confidentiality?
Any financial concern?
Ask if son contributes to finances?
If son consumes Alcohol? (How much? Does he loose control/shouts?)
Does he get angry to swear to get physical?
Does he get accesses to your finances?
Did you talk with anybody about it?
Do you feel safe going back home?
Does he have access to fire arms?
DO you have suicidal or homicidal ideation?
Based on what you told me your sleeping troubles seems to be related to stresses in your life
called Elder Abused which is illegal and crime against law. It is nor your mistake and you
should not accept that. You need to call the police. From studies it has shown that police
interevention improves such situations.
Son needs help can you convince him?
Police will protect you and son will be sent to rehab and anger management.
Ill be giving you sleeping pills for three days and f/u within 3d.

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Marijuana Counselling
(Mother comes in to see you as she has discovered Marijuana in her sons belongings)

INTRO:
As I understand youre here because youre concerned about your son.
What is his name?
What is your concern?
How much did you find?
Did you ask him about it?
WHAT MAKES YOU BELEIVE IT IS MJ ?
Is he using it? Or Is he carrying it?
Is it the first time youve found it?
Did you notice any CHANGES in his behaviour?
Is he excited?
Laughing out of nowhere?
Is he preoccupied?
Does he stare at a wall?
Does he talk to himself?
Is he aggressive?
Any problems with the law?
Any fights?
Any criminal records?
Is he more isolated?
How is his MEMORY?
Is he more forgetful/lose his stuff?
Does he take more time to react?
Does he spend more time in his room?
How much time do you spend with him?
How much time is he out of the home?
How much time does he spend with his friends?
Do you know any of his friends?
What kind of activity are they involved in?
Does he have a lot of MONEY?
Does he ask for money?
Do you believe he steals money?
Do you think he smokes/or drinks alcohol?
How would you describe his MOOD?
Is he depressed?
Is he still interested in his hobbies?
Does he worry a lot?
Does he have excessive fears & avoid situations?
Do you have concerns that he may harm himself or anyone else?
EDUCATION:
How is he doing in school?
Have his grades dropped?
DIET:
How is his general health?
Have you ever seen a psychiatrist?
Fhx: SAD
COUNSELLING:
Based on what youve told me.There are no changes in his health & behaviour (assumed that
there were no changes in behaviour as per mum)
When it comes to Marijuana it is a commonly used drug by teenagers, sometimes only once for
experiment. When we talk about Substance Abuse & drugs we talk about different categories.
Marijuana is a SOFT DRUG,others like: Coccaine,Heroin& Amphetmanies are HARD DRUGS
Let us talk about Marijuana first.
It is from the Cannabis family & affects the brain by feeling happy, excited & enhances
experience.Sometimes with prolonged use or in high doses can cause side effects including
apathy.
It interferes with memory,& can interfere with his studies & function & fine motor skills & may
not be able to operate machinery
It impairs judgement & he might take risks.
Can cause Lung cancer
In some teens,in high doses unmasks schizophrenia & cause psychosis
Interferes with sexual function & can cause infertility & weight gain
By itself marijuana is not strongly addictive & hence he can stop it at any time with help.One of
the concerns of Marijuana though is it acts as a bridge to Hard drugs which are addictive i.e
youve to increase the dose to have the same effect,which is called TOLERANCE,& then one
cannot stop the drug as it causes withdrawal .
It is a crime to use,hold hard drugs.People can lose their jobs.
If injected increases risk of HIV,Hepa B & C
PLAN
If you like,bring your son here I can talk to him.
It is better to be a confidante to him. Try to be close to him, someone he can trust & can talk
to.Try to make sure whore his friends,& make sure you know what he is doing.Keep him busy
with activities.
If there are any druh prevention programmes in your community or his school,get him to attend
them & gets the knowledge.

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INSOMNIA:
The Sleep History
1. Time data (can also be collected as part of a sleep diary
1. Did you nap or lie down to rest today? If yes, when and for how long?
2. What time did you go to bed last night?
3. What time did you put out the lights?
4. How long did it take you to fall asleep?
5. How many times did you awaken last night?
6. How long was your longest awake period; when was it? What time did you
finally awaken?
7. What time did you get out of bed?
8. How many hours sleep did you get last night?

2. Questions about the sleep period
1. Do physical symptoms, such as pain, prevent you from falling asleep?
2. Do mental or emotional symptoms (e.g., worry or anxiety) prevent you from
falling asleep?
3. When you awaken during the night, what awakens you? (Snoring? Gasping for
air? Dreams/nightmares? Noise?)
4. When you get up for the day, do you have any symptoms? (Headache?
Confusion? Sleepiness?)

3. Questions for the patient's bed partner
1. Does your partner snore, gasp or make choking sounds during the night?
2. Does your partner stop breathing during the night?
3. Do your partner's legs twitch, jerk or kick during the night?
4. Has your partner's use of alcohol, nicotine, caffeine or other drugs changed
recently?
5. Has your partner's mood or emotional state changed recently?
6. What do you think is the cause of your partner's sleep problem?

Hygiene Guidelines

1. Keep a regular sleepwake schedule, 7 days per week.
2. Restrict the sleep period to the average sleep time you have obtained each
night over the preceding week.
3. Avoid sleeping in, extensive periods of horizontal rest or daytime napping;
these activities usually affect the subsequent night's sleep.
4. Get regular exercise every day: about 40 minutes of an activity with
sufficient intensity to cause sweating. If evening exercise prevents sleep,
schedule the exercise earlier in the day.
5. Avoid caffeine, nicotine, alcohol and other recreational drugs, all of which
disturb sleep. If you must smoke do not do so after 7:00 p.m.
6. Plan a quiet period before lights out; a warm bath may be helpful.
7. Avoid large meals late in the evening; a light carbohydrate snack (e.g.,
crackers and warm milk) before bedtime can be helpful.
8. Turn the clock face away and always use the alarm. Looking at the clock
time on awakening can cause emotional arousal (performance anxiety or
anger) that prevents return to sleep.
9. As much as possible, keep the bedroom dark and soundproofed. If you live
in a noisy area, consider ear plugs.
10. Use the bedroom only for sleep and intimacy; using the bed as a reading
place, office or media centre conditions you to be alert in a place that should
be associated with quiet and sleep. If you awaken during the night and are
wide awake, get up, leave the bedroom and do something quiet until you feel
drowsy-tired, then return to bed.
Note: Pharmacologic (or any) interventions will be less effective if these
guidelines are not followed. In mild cases of insomnia, sleep hygiene
guidelines, practised consistently and together, may be sufficient to reinstate a
normal sleep pattern.

Difficult sleeping for the last 3m
OCD
How did it start?
Suddenly / Gradually?
From that time is it all the time or on and off?
Shift to whom do you live with?
U:
How did that lack of sleep affect your life?
Give confidentiality.
R/O:
Depression,
Drinking (her or husband), How much? How often? Does he drink more? What is the reason?
Any change in your life? When your husband gets angry does he start shout at you? (Sometimes
when people are drinking it can

Did you go to the ER? How often you go to the ER? Did he ever shout at you? Does he
swear?/Shout?/Call your names? How does it affect your self esteem? Did he ever become anger to the
extent that he becomes physical? Pushing? Did he ever force you to have sex against your will? Did he
ever hit the children? Did he ever abused you in front of the children? Whos controlling spending? (If
she says that the children are safe you can say that children are smart and realize that).

Counselling
Based on what you told me it is called spouse abuse it is illegal, it is a crime and against the law. You
shouldnt feel guilty about that. We know from studies that this situation will deteriorate, and without
proper of help it might end badly. If you are concerned with the economic situation Id like to know that
there are a lot of resources. Ill give the number of social support that
We know from studies...he will have some restraining...usually situations might improve.
Always give them follow up in three days.
Back to Content
55 yo, believe that have strange feeling in hands. Do mental exam.
Either organic, late onset of schizophrenia, not complying with medication
INTRO:
3 ways:
1.How did it start?
OCD:
What happened at that time?

Ms Franco 55/F strange feeling in (R) hand x 6 mo in ER talk to her for 10 mins

Can U tell me about it?
Is it one or (B) hands?
How did it start?
Right now,how do you feel/
Right now u look concerened,anything bothering U?
Ure in the right place

What were U doing when it all started?
Anything special happened at that time?
Ask What events?.......
Or Do you remember how it started 1
st
time?
Is it all the time or off & on
Any particular time of the day
Any particular settings
What is special in that setting?
In your opinion what is responsible for it?
May show a pic
It may be like a radiation for you,but not for me

Where exactly do you feel it?
Anywhere else?Any weakness/numbess
Ask for HOMICIDAL/SUICIDAL ideation

Ask for Hallucinations:
P=PSYCHOSIS
HALLUCINATIONS:
9. Do you sense things that are not actually there?
10. Do you see things that others do not see?
11. What do you see?
You look preoccupied
REASSUARE HER THAT SHE IS IN SAFE PLACE

DO NOT LOSE NERVE
12. Can you describe what you see?
13. Does it have a message for you?
14. Does the message ask you to harm yourself?
15. How do you feel about it?
16. Is this the first time?
12. Do you hear voices other people cannot hear?
OR :
c) If youre alone & nobody with you, do you hear voices?
d) Do you hear voices inside your head?
13. How many voices?
14. Are the voices familiar?
DO NOT LOSE NERVE

15. Do you recognize the voices?
16. Do they talk to you?
17. Do they talk about you?
18. What are they asking you to do?
19. Do they ask you to harm yourself?
20. Do they ask you to harm anybody else?
If YES:
21. What is preventing you from doing this?........Screens for INSIGHT
DELUSIONS:
If YES: WHO & WHY?
13. Do you think any part of your body is rotting?
14. Do you feel everybody is falling in love with you?
MOOD
ORGANIC:
Since it is first time Im seeing you.Ive to ask you questions
Look for S/e of meds (Streoids,smoking,drugs)
Head Injury
Fever
Csx:
Look for Social Hx
Past Psy Hx
Self Care

Admit

If Pt asks: Am I crazy?
Thre is no medical condt called crazy.Sometimes some pts have difficulty in handling their thoughts &
this is called Schizophrenia

MSE
APPEARANCE:
1. Well dressed
2. Well groomed
3. Dress matches weather
4. Given age matches chronological age
BEHAVIOUR:
1. Agitated
2. Psychomotor retardation
3. Eye Contact
4. Co operative
5. Non hostile
6. No abnormal movts/Jerking/lip smacking
C/SPEECH:
1. Volume
2. Tone
3. Fluency
4. Articulate
MOOD& AFFECT:
Mood;Subjective Sx in pts own words
Affect (qarms)
1. Quality: Euthymic/depressed/elevated/Anxious
2. Appropiateness to thought content
3. Range:Full/Restricted/Flat/Blunted
4. Mood Congruence
5. Stability: Fixedt/Labile
PERCEPTION:
Hallucination
Illusion
THOUGHT PROCESS:
1. Coherence/Incoherent
2. Logical/Illogical
3. Circumstantiality/Tangentiality
THOUGHT CONTENT:
Suicidal/Homicidal Ideation
Low-- fleeting thoughts,no formulated plan,no Intent
Intermediate--More frequent ideation,well formulated plan,No active intent
High --Persistent ideation & profound hopelessness/Anger,well formulated plan,active
intent,believes suicide,homicide is only helpful option available
Obsession:
Recurrent or persistent thoughts,impulses or images that cannot be stopped which is
intrusive or inappropriate
Cannot be stopped by reason & Causes marked anxiety & distress
Preoccuption:
Overvalued Ideas:
Ideas of reference:
Delusions:
Magical thinking:
First Rank Sx of Shz:Thought insertion/T withdrawal/T broadcasting
COGNITION: MMSE
Level of consciousness
Orientation in time/place/person
Memory: immediate,remote,recent
Attention & Conc
Global evaluation of intellect: Intellectual Fns:
INSIGHT:
JUDGEMENT:
Back to Content

24 yo, brought by his roommate because hasnt been
himself in the last 10days.
D/d:
1. Ac. psychosis,
2. Substance abuse,
3. HIV,
4. Mania
If started 10 days ago, why brought in today? (could ve been homicidal or suicidal)
If carrying a book, ask Reason
Ask Delusions for grandiosity :Do you feel youve a special mission?--- if Yes Always ask what is
the mission? & probe deeper & enquire about Delusions
Mission imp May be Suicidal or Homicidal ideation

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17/M worried about contamination wants to be admitted to get rid from it.
10min counsel
Delusions: Dd:
1. Schizophrenia
2. Schiziod personality Disorder
3. Schizotypal PD
4. Isolated PD (older pt in 40s & usually delusions about fidelity)

Qns about Delusions
DELUSIONS:
If YES: WHO & WHY?
MOOD:
How is your mood,is it down,Up or N ?
ORGANIC:R/O
Head Injury
CSx: HIV/Meningitis
Medications: Steroids,smoking,alcohol,drugs
S/e of meds,Pt may have stopped anti psychotics due to Se

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35 yo, believes that the RCMP chasing him.
Persecutory delusions. Reassurance about his safety. DDx substance abuse.

INTRO;
Early on reassure pt that this is a safe place, & invite him to sit down

As I understand youre here because you have worries that the RCMP is chasing you.
I want you to know that this is a safe place & please come & sit.
I want to help you so please sit down
Make sure he sits in front of you.
Ask him:
Why chasing?
How long chasing?
How affecting him?
How does he handle it?
Does he talk to anyone about it?
Here there is persecutory delusion
Besides police does anyone else want to hurt him?
Does he have special powers?
FINISH the delusions
Go to Hallucinations
Do you sense things that are not actually there?
Do you see things that others do not see?
What do you see?
Can you describe what you see?
Does it have a message for you?
Does the message ask you to harm yourself?
How do you feel about it?
Is this the first time?
Do you hear voices other people cannot hear?
OR :
If youre alone & nobody with you, do you hear voices?
Do you hear voices inside your head?
How many voices?
Are the voices familiar?
Do you recognize the voices?
Do they talk to you?
Do they talk about you?
What are they asking you to do?
Do they ask you to harm yourself?
Also ask for tactile hallucinations
I see youre scratching your hands
Any other areas are scratching?
When & How long?.....Pt will answer.... I do not know .......
Jump to cocaine
Do you smoke/Take alcohol/Drugs
I f Pt stands, you stand, reassure him & bring him back & ask again about drugs
Did you take an increased amt recently?
How do you take it? Snort/Smoke/IV?
If IV ask about CSx;
MOOD
R/o Mania & depression
Suicide & Homicide
If Pt leaves tell I want to file form 1 & call security

Back to Content

17/M worried about contamination wants to be admitted to get rid
from it. 10min counsel
Delusions: Dd:
Schizophrenia
Schiziod personality Disorder
Schizotypal PD
Isolated PD (older pt in 40s & usually delusions about fidelity)

Qns about Delusions
MOOD:
How is your mood,is it down,Up or N ?
ORGANIC:R/O
Head Injury
CSx: HIV/Meningitis
Medications: Steroids,smoking,alcohol,drugs
S/e of meds,Pt may have stopped anti psychotics due to Se

A key feature of bipolar disorder is recurrent nonadherence to medication; including the patient
in decision-making, together with psychoeducation, promotes a strong therapeutic alliance and
enhances medication adherence.
Patients taking lithium need to maintain their usual salt and caffeine intake and monitor fluid
intake and output, making adjustments in the event of unexpected losses due to vomiting or
diarrhea.
During acute manic episodes, patients may exhibit increased tolerance to lithium.
Advise patients taking antipsychotics about antipsychotic-associated body temperature
dysregulation and strategies to prevent heat stroke (e.g., hydration, sun protection).
For lithium-associated cognitive impairment, check lithium level and thyroid function. Lowering
the dose or using a slow-release formulation may improve cognitive function.
Patients who experience tremor while taking lithium may benefit from elimination of dietary
caffeine, lithium dose reduction or addition of a beta-blocker such as propranolol or atenolol.
Patients who experience diarrhea while taking slow-release lithium preparations may fare better
with immediate-release formulations,
17
particularly the oral liquid citrate salt.
18

Back to Content

Pt wants to discontinue his Li
If stop Li Relaspe 1
st
time: disct Rx:40 60 %
2
nd
time:80%
3
rd
time:>95%
Can control BP1 but not cure
1. Want s to stop Li as handwriting not like before,
Ask if any other concerns .....
Seems reasonable....
INTRO:
As I understand, youre her cuz youve been diagnosed with BP1 3 yrs ago & want to disct
your Rx,during the next few minutes I will take Hx & towards the end hopefully we will
reach a working plan
Ask:
Why do you want to discontinue?
ASSES:
MOOD disorder whether Mania/Depression
Go back to mania specially when diagnosed
Li if SE
Asses:
Psychosis
Anxiety
Organic
Past Medical Hx
Fhx
Social Hx
Fhx of Depression & BP1
Suicidal 7 Homicidal ideation
Self care
COUnselling

INTRO
Can you tell me more about your decision?
Why?
Any other reasons?
These seem reasonable enough concerns & Im glad youre here today to talk about it
Let me ask some qns
How would you describe your mood today?
Even if he says good.....
Go through DIG FAST

Grandiosity:
Ask for opposite mood
Do U feel Low
MI PASS ECG
1. How were U Dsed as BP1?
2. What was done at that time?
3. Were U hospitalized?
4. Was there serious consequences?
5. Are you under reg F/U?
6. When was the last time you saw your Dr?
Li
1. Which medications are you on besides Li?
2. How much Li?
3. Is it measure d on a regular basis?
4. What was the level?
5. Any new meds/ or increase in dose?
6. How do you feel about taking Li?
Any SE
Have U got TSH measured?
When was the last time it was measured?
Do you feel cold? Inc wt/Dec conc?
Drink more/Pee more?
Any urine analysis?
Screen for Ataxia:Any shakiness/falls/difficulty in balance?
Nx/Vx/Abd pain?
If TSh Inc ct with Thyroxine
If Di early Stop later Ct with Thaizude
GI Stop
Tremor B Blocker

Have you ever discontinued Li in past few yrs?
TRANSITON: I know youve been asked this qn before, but I need to ask these qns
PSYCHOSIS
ANXIETY
Past MH
Fhx of depression/Suicide/BP1
How do u support urself financially?
COUNSELLING:
Compare between Mania & Depression
What is your understanding about Mania?
Mania is a condt that affects mood,in which people feel elevated it is one of the mood
disorders it is common. Most people have depression, where people feel low & lose interest
& Rx is often Talk therapy & medications.
The Rx for Mania is lifelong,similar to DM,in which we can control Sx,but not cure it.There is
a lot of research going on & ne day we hope to find a cure for it.
If you choose to discontinue it,your chances of relapse are high upto 60%
Coming to Li levels if 1.2 upper level of (N) & we can decrease the dosea bit & see how it
affects you. But youve to PROMISE me that at any time you spend more,sleep less etc
contact me or go to ER ASAP.
Pt may accept .
When it comes to writing Thought block is not one of the SE of Li,give it time ,& see if it
improves
If S/o depression it is the other component of BP1 & I will refer you to psy.

Therapeutic Tips
A key feature of bipolar disorder is recurrent nonadherence to medication; including the patient
in decision-making, together with psychoeducation, promotes a strong therapeutic alliance and
enhances medication adherence.
Patients taking lithium need to maintain their usual salt and caffeine intake and monitor fluid
intake and output, making adjustments in the event of unexpected losses due to vomiting or
diarrhea.
During acute manic episodes, patients may exhibit increased tolerance to lithium.
Advise patients taking antipsychotics about antipsychotic-associated body temperature
dysregulation and strategies to prevent heat stroke (e.g., hydration, sun protection).
For lithium-associated cognitive impairment, check lithium level and thyroid function. Lowering
the dose or using a slow-release formulation may improve cognitive function.
Patients who experience tremor while taking lithium may benefit from elimination of dietary
caffeine, lithium dose reduction or addition of a beta-blocker such as propranolol or atenolol.
Patients who experience diarrhea while taking slow-release lithium preparations may fare better
with immediate-release formulations,
17
particularly the oral liquid citrate salt.
18

Back to Content

21/2/2011
Introduction to physical exam:
...
If it is after history taking. Thank you for the information. Now Ill do some physical exam...hopefully
towards to the end well reach a working plan...

During the physical exam talk aloud. Verbalize everything.
Dont fail to drape the patient.
Doing after vitals and general inspection.
Lack of empathy (Warm hands and stethoscope and try it on your arm). You warn the patient before the
exam, but also before any manoeuvre.
If there is painful area dont repeat it.
If the patient having

34 physical exams, and 11 management stations (ER):
Physical Exam:
1. CVS
1.1. Essential Htn for the last 30y, 65 yo for f/u 10m
1.2. 35yo dgn recently with Htn, do focused physical exam (CVS) 5m
1.3. 25yo recently HTN, relevant physical exam 5m
1.4. 60yo, Pain in calf muscles history and physical
1.5. 35yo palpitations, history and physical. 10m
1.6. 30-40yo, Cardiac murmur. 5m.
1.7. 70yo A surgery 3d ago doesnt pass urine 4hours 10m (do JVP and vitals)
1.8. 50yo SOB, 3d ago had surgery, 5m focus physical exam (emboli)
1.9. Car accident 24 ago, SOB, P/E 5m (fracture, fat emboli))
1.10. SOB for the last, surgery 3d ago, 10m
1.11. History of heart failure for the last 10y, 3d ago SOB, 10m physical exam
2. RS
2.1. Cough, for the last 3d, focused p/e 5m
2.2. Female Hx breast cancer, mastectomy, chemotherapy and radiation 5y ago, a week cough or
SOB (Pulm. Fibrosis)
2.3. Coughing blood 1w, 67yo, history and p/e 10m
3. GI
3.1. Lower abdominal pain last 24hr, 22 yof, 5m focused p/e
3.2. 35 yof, came to the ER abdom. Pain 2h,
3.3. 22 yof Hx of Crohn, abdominal pain 24hr, 5m focused p/e
3.4. 30 yom abdominal pain, 5m focused
3.5. 61 yom Hx alcoholic patient vomits blood, 5m p/e
3.6. 25yof, epistaxis, bruising in skin, hematologic exam (ITP)
4. Neuro
4.1. HIV positive, headache for the last week do cranial nerve exam (wear gloves)
4.2. 40 yo, Difficulty in vision, Hx and p/e 10m
4.3. Crooked face (Bells palsy) - hearing and than 7th nerve, 5m focused p/e
4.4. Weakness in the Rt. Or Lt. Hand see the power, reflexes and tone, history and physical 10m
4.5. Diabetic foot do physical exam, 5m (monofilament test 10m exam)
4.6. Unconcious do neurologic exam for , 5m
4.7. Shakeness in his Rt. Hand (Parkinson) 5m
4.8. Back pain
5. M/S all joints except elbow.
5.1. Neck (level of the lesion)
5.2. Shoulder pain
5.3. Hand
5.3.1. Laceration in the wrist
5.3.2. CTS
5.4. 35 yom Hip pain (gonorrhoea), otherwise
5.5. Knee Osgood Schletter, Chondromalacia patella and osteoarthritis
5.6. AP cruciate ligament,
5.7. Ankle counsel patient. There is no fracture or rupture of ligaments. 10m
5.8. Back pain
5.8.1. Acute (3d ago)
5.8.2. Acute superimposed on chronic (fracture on metastasis)
5.8.3. Chronic back pain (young Ankylosing spondylitis, old spinal stenosis or osteoarthritis)

Intro
Vitals

GI (I, A, Per, PS-PD, ST), DRE, Pelvic exam for females
RS (I, Pal, Per, Aus, ST)
CVS (I, Pal, A, ST), PV exam and JVP in the neck
MS (I, Pal (Temp, Tenderness, Crepitus), ROM, ST) one below and one above joint.
Neuro (I and orientation, CN, U and LE, Coord., Cortical sensation)
InsBulk/PulpTonePowerReflexesSensation
SEADS (Swelling, Erythema, Atrophy, Deformity, Scars)

Vitals: BP, HR, Temp, RR (Based on the vital patient is stable I am going to do...)
If there are no vitals you will say I am going to start my physical exam by measuring the vitals by taking
BP, pulse, temp...)
If there are only 3 out of the 4 parameters Before I proceed Id like to know what is the
temperature...
Weight and height in pounds and inches. (5 feet is 150cm, 6 feet is 180, 5,6 is 165cm)
General inspection: lying down comfortably, no signs of distress
Specific inspection:
SEADS for each joint (Is it OK for you to lower your gown... )
Neck no scars, erythema, atrophy, + muscle contractions;
Normal cervical and thoracic curvatures.
Back no SEADS. From side normal cervical, thoracic and lumbar curvatures.
Shoulders both shoulders are symmetrical, clavicles deltoid and scapulae are in the same level and
angle.
Hand SEADS + thenar and hypothenar muscles.
Hip Id like to have full exposure. Hip joints are deeply seated joints I am looking for any obvious
SEADS and gluteal folds on the same level, and mentioning the lumbar curvature.

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Knee
INSPECTION:
(Stand, walk and lie down).
1.
Stands up:
By inspection
1. (B)knees are symmetrical
2. (B) knee jts are normally aligned
3. No genu varus or valgus.
2. ask him to WALK: & look for:
1. Gait
2. popliteal fossa.(no bulge in popliteal fossa)
3. LIES DOWN:
SEADS
(B) Quadriceps muscles are in the same bulk.
Ankle SEADS, no open fracture no bruises. The last thing in the ankle is the gait.
Gait do in every joint besides shoulder, arm and hand.

TTC (Temp, Tenderness, Crepitus)
If the patella is the same temp as the rest of the knee there is inflam.
Both patellae are the same temp. And colder as the rest of the leg.
Quadriceps, suprapatellar pouch, patella (press and swing) there is no signs consistent with
chondromalacia patella, along the ...press on the collateral ligament, press to the back, when bending
the knee: Up, Down, and In.
Crepitus no crepitus.
Effusion
Bulging sign and milky test.
Bend your knee all the way. Normal or limited flexion. Can you push against my hand and pull.
ST cruciate ligaments, medial/lateral, and anterior posterior.
Medial and lateral collateral ligament varus and valgus stress test.
McMeri test for the meniscus.
Examine the other knee, pulse (popliteal).
Examine above and below the knee (just mention it).
Patricks test (sacroiliac joint) and Thomas test (fist in the lumbar region in case of osteoarthritis they
need to do flexion by increasing their lordosis and feel less pressure).

KNEE
Intro: Good afternoon Mr XXX as I understand youve a pain in your (R) knee for the next few
minutes I will be examining you,& if you feel any pain please let me know.
I will also be reporting my findings to the examiner.
Is that Okay with you?
Can I proceed?
Can I get the vitals please?
On General examination:
Pt sitting comfortably in no obvious distress
Mr xxxx Can you please stand up?
Can you please hold up your gown?
By inspection
1. (B)knees are symmetrical
2. (B) knee jts are normally aligned
3. No genu varus or valgus.
Can you please WALK: & look for:
1. Gait
2. popliteal fossa.(no bulge in popliteal fossa)
Thank you,
Could you please turn around walk back & lie down,
Im going to drape you
LIES DOWN:
O/Inspection:
1. SEADS
2. (B) quadriceps muscles are in the same bulk
Im Going to feel your knee
PALPATION:
TTC (Temp, Tenderness, Crepitus)
1. Both patellae are the same temp & colder as the rest of the knee.
2. (B) Knees are symmetrical & there is no increase in temperature
3. (B)Quadriceps are normal in bulk
4. Suprapatellar pouch (N)
5. Patella (press and swing) there is no signs consistent with chondromalacia patella,
6. Go along patellar tendon & end on Tibial tuberosity
7. No tenderness of T Tuberosity
8. press on the Medial collateral ligament,
9. press on the lateral collateral ligament
10. press to the back, for pop[liteal fossa
Bend the knee: Open joint fully
11. Up for Femoral condyles
12. Down for ,Tibial condyles
13. In for the lateral & medial meniscus
Relax your knee,Im going to move your knee & examine for crepitus
EFFUSION:
Eliminate the suprapatellar pouch
Press on patella ------->Patellar tapping ------>Bounce = Fluid
No bounce on patellar tapping
Bulging sign
Milking Sign
ROM;
Can you please bend your knee all the way
(N) flexion Full flexion & extension
POWER:
I need to examine the stability of the knee:
3 tests:
1. Medial & lateral collateral lig Varus & Valgus stress test
2. Cx ligament: Ap drawer test
3. Meniscus : Mcmurray test
Examine other knee
POpliteal pulse
Dorsalis pedis pulse
I would like to examine one Jt below & one jt above
Ankle joint & back

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HIP JOINT
Intro:
Vitals
G/E:
Would you please stand up?
Do you need help?
Turn to (L) side------ go to back
Ask examiner:
Can I have full exposure?
Can you please Roll up shirt,Im going to look at your hip
INSPECTION
The hip is a deeply seated joint,however Im looking for SEADS
(B) hips are symmetrical
(B) gluteal folds are same level
Lumbar curvature Normal
PALPATION:
Im going to feel your joint,plz inform me if youve pain:
1. SI jt (N)
2. Post superior Iliac spine (N)
3. Iliac crest (N)
4. Ant superior iliac spine (N)
5. Greater trochanter (N)
Plz walk to the wall,do you need help?
Gait (N)
No limping
Can you please turn & come back?
When standing look for EXTENSION
Trendelenbergh test
Can you please lie down
DRAPE
I would like to continue my inspection anteriorly
SEADS
PALPATION:
1. Along inguinal ligament
2. Head of Femur
3. Symphysis Pubis
Examiner will say (N)
(Inspection & palpation done)
ROM
1. Extension done when standing
2. Bend knee to abdomen as much as you can (flexion)
3. Abduction & adduction
4. Passive & active
length
Discrepancy in true length Hip lesion

Patrick test
Thomas test
Sensory fn
Knee joint & Lumbar joint

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SHOULDER
Frozen shoulder active and passive are limited.
Rotator cuff four muscles.
Complete tear (initiation of abduction is lost 1
st
30 -60) swing the hand or tilting and
doing flexion and abduction. Cannot initiate and has painful arm and dropping.(DROP
ARM)
Partial tear or tendinitis or impingement with same presentation (u/s or MRI can help to
differentiate between them). Painful arch can move, but it may ease him to turn the
hand in supination. The empty can test his arms fall.
Anterior dislocation apprehension test positive. For posterior dislocation push the
elbow backward.
Bicepts tendinitis supination and flexion (Jargonson test).
Flexing against resistance (Jobs test).
Infraspinatus and teres minor external rotation against resistence. Internal rotation for
subscapularis (lift-off test).

INTRO:
Is it Ok to untie your gown & is it Okay to kep it in your lap?
INSPECTION:
1. (B) shoulders are symmetrical
2. (B) Deltoids are symmetrical
3. (B) clavicles are at same angle
4. (B) Scapulae are at same level
5. No SEADS
PALPATION:
Im going to feel your joint,
1. Temp (N)
2. Im going to press your joint
3. Sternal notch NT
4. (B) Sterno clavicular joint NT
5. (B) Clavicles NT
6. Acromio clavicular jts NT
Im going to focus on (R) shoulder & then (L) shoulder
Press on:
1. Acromian
2. Spine of scapula till medial aspect of scapula
3. Tip of scapula
4. Spinal process of neck
5. Insertion of Supraspinatous NT (Greater Tuberosity)
6. Glenohumeral joint NT
Sulcus Sign _ve (Pull down on shoulder)
CREPITUS
Relax Im going to move your shoulder & feel the movts
MOVE TO NECK & examine neck
To ENSURE that shoulder pain not related to neck pain
ROM:
Please put your gown back stand up & face me
Would you mind copying me
Full flexion & extension
Push back (extension)
Int rotation
Cross arms--- Adduction
Move to sides all the way up to the head------ Abduction Ct moving down. Hold below (No
painful arc)
No drop arm
SPECIAL TESTS:

POWER
PULSE

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Chronic back x 6m0
INTRO:
VITALS
G/E
Can you please stand up?
CAN YOU PLZ UNTIE YOUR GOWN?
INSPECTION:
If Hx,:1
st
inspection of face
1. Eyes for rednes
2. Mouth for ulcers
3. Nails: No pitting/ulcers/or skin changes
Look at back
Curvature ---Side:Normal cervical,Thoracic & Lumbar curvatures
Back: No Scoliosis
SEADS
PALPATION:
Warm hands & tell Pt:
Im GOING TO FEEL YOUR BACK, tell me if you feel pain
Feel temp
Press Spinous processes individually Identify C7
Iliac crest: L 4-5
Press; Para vertebral muscles
SI Jts
TIE THE GOWN BACK & Ask Pt to lie down DRAPE
Id like you to do some movts for me:
ROM
1. Can you touch your toes with your fingers without bending knees?
2. Arch your back backwards without bending your knees
3. Can you slide your arm along your thigh as low as you can?
4. Can you cross your arms & rotate the shoulder (Fix the hip)
Because I noticed you have restricted ROM of movements in all directions
Ill do a test called Shubert test. I will draw some lines on your back which are washable
Dimples of venus sacroiliac joints for line A
10 cm above ----- Line B
5 cm below ------Line C
Try & touch toes without bending back
the difference from line B it should be at least 15cm. Less than 15cm it is restricted.
The 5cm below is for control
WALK to wall:
Gait (N) No limping
Stand against wall
Occipital from wall test.(When there is Shubert test positive )
Stand On toes S1,
Stand on heels L5.
Pitting changes in the nails, psoriatic changes.
CAN You please lie down? DRAPE
SLR
Patrick test
Listen to his heart for Aortic Insuff.
Chest expansion measurement in max inspiration and expiration (changes should be more
than 5cm).

ACUTE BACK PAIN

Intro:
Always ask Pt if he prefers to lie down or stand
OCD:
ONSET:
Did you lift heavier than usual?
Did you hear a snapping sound? Did you have to stop what you were doing?
C
PQRST:
R: Does it move to the leg?,reach toe or thigh?
Which bothers you more,The Leg or Back?
EMPATHY...........
Did you try any pain killer?
A &A:
Lying down?
Stretching?
Bend/Move?
U:
V;
ASx:
1. Weakness
2. Numbness
3. Tingling
4. Loss of balance & falls
5. Do you need to drag your foot?
6. How about Urine & Bowel symptoms: Some patients with similar condition may soil
underwear
7. Numbness in buttock area?
8. H/O trauma to back?
9. Urinary: Dysuria/Flsnk pain?

SOCIAL Hx:
Smoke
Alcohol
Drugs: ......Particularly IV drug use

PE:
G/E:
Vitals please
Can you please turn to side (so examiner can see)
Can you please untie your gown?
Dorso lumbar spine looks (N) curvature
From Back: No scoliosis
SI Joints appear (N)
Tie gown
ROM:
Forward flexion & extension
WALK to bed & wall (Make sure that Pt does not FALL!!)
Walk on heels & toes (support Pt)
Im going to raise your leg, please lie down & if it causes pain please let me know
Can you please lie down?
SLR
SENSORY:
Start with Little toe:S1
1
st
Web:L5 (common peroneal nerve)
Medial malleolus:L4
Knee:L3
Mid thigh:L2
REFLEXES:
Knee
Ankle
Clonus
Babinski
DRE
Femoral stretch test
End with Dorsalis pedis PULSES

Red Flag Symptoms/Signs in Assessment of Low
Back Pain
Condition Symptoms/Signs Investigations
Herniated Nucleus Pulposus

Positive SLR (leg pain at < 60);
weak dorsiflexion of ankle (L4-5) or
great toe (L5-S1 or L4-5); reduced
ankle reflex (L5-S1); reduced light
touch in L4, L5 or S1 dermatomes
of foot/leg
1

MRI of lumbar spine
Cancer Age > 50; previous cancer history;
unexplained weight loss; failure to
improve after 1 mo therapy
2

Positive laboratory tests
(including elevated ESR,
reduced hematocrit)
2
and
imaging showing erosion
or blastic lesions
Spinal Osteomyelitis Intravenous drug abuse; sources of
infection (e.g., skin, teeth, urinary
tract, or indwelling catheter); fever;
vertebral tenderness
3

and imaging
Spinal
Fracture/Compression
Fracture
Age > 50, female gender, major
trauma, pain and tenderness, and a
distracting painful injury;
4
also
consider a history of osteoporosis or
corticosteroid use

including plain x-rays
Cauda Equina Syndrome Acute urinary retention or overflow
incontinence; loss of anal sphincter
tone/fecal incontinence; perineal
numbness; change in sexual
function; weakness of legs
1

Emergency laboratory
assessment and imaging

Factors Adversely Affecting Prognosis of Low Back Pain
Psychosocial Factors Mental Status Indicators of
Significant Anxiety or Depression
1. Duration of work absence
2. High levels of self-reported functional
disability
3. Self-report of extreme pain and constant
pain in multiple body areas
4. History of prolonged sick-listing after
previous injuries
5. Prior history of absenteeism
6. Delays/obstacles in work re-entry
process
7. Patients who believe that they will
never return to work
8. Adversarial attitude toward employer
9. Long-standing history of psychiatric
distress or maladjustment

1. Insomnia or nightmares
2. Irritability
3. Withdrawal
4. Panic episodes or anxiety
during the day or night
5. Persistent tearfulness
6. Poor concentration
7. Inability to enjoy (anhedonia)
8. Poor appetite/weight loss
9. Poor libido
10. Thoughts that life is not worth
living


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NECK EXAM
INTRO:
Vitals Pt stable
G/E:
INSPECTION:
Id like to take a look at your back, can you please untie your gown?
(N) Cxal curvature----
Look from side look from back
SEADS
PALPATION:
Im going to feel
1. (N) Temp
2. Press along individual spinous proceses (C1 to C7)
3. P Vertebral muscles
4. Trapezius
5. Sternocleido mastoids
6. Mastoid process
7. LN
8. Thyroid (ask the patient to swallow)
ROM: Im going to examine ROM
Copy me,
1. Touch chest to chin-----> Flexion
2. Look at ceiling -------> Extension
3. Turn to R/L Rotation
4. Touch shoulder to ear ---- R & L Lateral flexion
5. Check Streno Cleido mastoid by pressing against my hand & push to back (? Not done!)
6. Neck pain not associated with muscle spasm
7. Can you cough? ------ No neck pain with Valsavas manoeuvre
Part of my exam is to check your UppExt:
Can you roll up your sleeves?
INSPECTION:
1. (B) U extremities are symmetrical
2. No abnormal posture or contracture
3. Bulk is symmetrical
PALPATION:
See & feel deltoids, biceps, Triceps, forearm, Thenar & hypothenar muscles
TONE:
WRIST:
No cogwheel rigidity
Elbow
No Pb pipe
No clasp knife rigidity
SENSORY:
C6 C7 C8 C4 ------
REFLEXES
POWER:
In U/E Deltoid
Biceps
Fan fingers
Power of thumb
SPECIAL TEST: Spurling test
Ask Pt to stand: Check Clonus & gait
CNErve exam

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HAND
Laceration
Hx:
1. AMPLE + Tetanus
2. Mood
3. Handedness (occupation : can affect if Pianist, Speech therapist, Plastic surgeon)
4. X ray
5. 5.
6. Irrigate with NS
7. Antibiotic prophylaxis
8. NPO
INTRO:: As pt has an injury,I would like to get gloves for protection
Greet Pt & ask for vitals
G/E;
Remove bandage & describe the wound:
Position: wound on palmar aspect: 3 cm in length/2mm width/depth cannot be
assessed
5-10 cm proximal to wrist on Volar aspect
No active bleeding/No oozing/Margins clear & not elevated
(B) hands are symmetrical
SEADS
Colour similar
Im going to FEEL:
Temp (B) hands is normal
(N) Capillary refill
Im going to feel your hands to see if there is damage to the arteries (N) radial artery &
ulnar
SENSATIONS: Lt touch Ulnar/Median/Radius
Tenderness to PALPATION:
Distal radius/Styloid process/distal part of ulna & styloid process/base of thumb
Press carpal bones & metacarpal bones
ROM: try to do on table & not move elbow
Ulnar deviation
Radial deviation
MPOTOR FN OF MEDIAN N: OK Sign
Ulnar N :Able to hold peice of paper betn Adducted finger & resist pulling
RADIAL N: Extend thumb Thumbs up
THUMB: Make a fist & fan out fingers
Can you touch ........your thumb to the tip of your little finger? (flexion)
Take it all the way to other side ? (extension)
Point to ceiling (Abduction)
Put close to your hand?(Adduction)
Touch thumb to tips of fingers? (opposition)
FLEXION:
Can you bend your fingers one by one?----- Flexor digitorum profondus
Flexor Doigitorum superficilias
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CTS
Pain in (R) wristy x 2 wks: Hx & PE
OCD PRTY UV A&A ASx CSx
D/d:
1. CTS
2. Spinal stenosis/OA/Cervical disc herniation
3. TIA
4. Thoracic outlet syndrome
OCD:
O:
C:
How often?
Daily?
Since when daily?
Before that?
At Night?
D:
How long each attack?
What brings these attacks?
What relieves it?
What do you do for a living?
PQRST:
P: Can you show me where it is?
Q;
S:
U;
V:
A & A:
Movts/Medications/Repeated movts
Local Sx: Swelling/Numbness/Weakness/Other hand/Leg/Bladder & bowel disturbances
CSx:
AETIO:
Ive to ask you qns as to the presence of any condt that might have caused this:
1. Hx & Sx of DM:
2. Hx & Sx of Hypothyroid
3. Hx & Sx of Acromegaly
4. Trauma
5. Fall
6. HX of RA
D/d:
Neck pain
Past MH: HTN/any long term disease
Social Hx;SAD
Fhx:
Thank You for this information,I will now proceed to the PE
GE:
INSPECTION:
1. (B) hands are symmetrical
2. No SEADS
3. No Bouchardfs nodes
4. No Swan neck deformity
5. (B) Thenar & Hypothenar muscles equal bulk
FEEL:
1. Temp & capillary refill
2. Palpate distal part of radius of hand
3. Bulk of thenar & hypothenar muscles
ROM of wrist
THUMB:
Power check against resistance,pu;ll up & down & pull
Hook thumb ..
BICEPS: Check Power & Reflex
NECK: ROM to R/o C6
SENSORY:
1. Little finger :Ulnar
2. Ring Finger:Ulnar aspect for Ulnar nerve & radialaspect to R/o median nerve
3. 2 POINT DISCRIMINATION: Only in Index finger
SPECIAL TESTS:
1. Tinels Tap at medial aspect of wrist x3 times Ask if feels numb
2. Phalens sign
PULSE: Radial
T
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TREMORS
PARKINSONISM

INTRO:
Vitals:
G/E:
Pt is sitting There is an obvious tremor in (R) hand
(N) elbow
No tremor in shoulder
Ask patient to count from10 to 1 backwards: & observe the tremor....
Tremor does not disappear on mental activity but increases, which is consistent with
Parkinsonism, & R/O Anxiety related tremor
Please extend arms & fingers:
No fine tremors R/O Thyroid disease
No flapping tremors R/O Liver disease
Can you touch Finger to my finger & then to your nose? No intention tremor R/O
Cerebellar disease
There is no dysdiadokinesia
Pt has a limited facial expression
Limited eye blinking
No drooling

INSPECTION:
Tremors in (R) hand, which are pill rolling & involve the (R) arm
Pt does not have tremors in (L) hand, arm & shoulder
NO head nodding
I want to examine the TONE:
Cog wheel
Pb pipe
Clasp knife
Ask pt to please stand
There is difficulty in initiating movt
Stooped posture
Decreased arm span
Festinant gait
Turns in block
Ask Pt to say: British Constitution
(N) articulation
Ask Pt to write; Micrographia
I want to check for orthostatic hypotension
Difficulty in rapid alternating movts:
1.
2.
3.
I would like to arrange for a MMSE which can happen later.

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HIV Pt with HA/PE (Cranial nerve exam)
1
st
nerve. (Coffee and ammonia). Im going to skip the first nerve. Ill ask the patient if he has
any difficulty smelling.
2
nd
nerve.: OPTIC NERVE (5 tests):
ACUITY:
Ask Pt for best vision or if he wears EYE GLASSES
Hold Snellens chart with (R) hand & cover Lt. eye. Choose a mid-line, jump two lines below,
and finally last line.
COLOUR VISION:,
then the other eye, change eyes, ask colour first in a reversed order and if he sees in the same
intensity. Go straight to last line and ask to read backwards.
VISUAL FIELDS:
(DDx one eye blindness, bitemporal and homonymous hemianopia)
PUPILLARY REACTION:
I am going to shine the light in your eyes it might might bother you:
first shine at the (R) Look at the (R). Eye,
second shine in rt. Look at left side, 2 shine light in eyes & see pupillary reaction
: 2-3nerve (2- afferent, 3-efferent)
FUNDOSCOPY:
verbalize (DM: microaneurysms, cotton wool spots, neovascularisation; Htn: flame
hemorrhage, disc edema, nipping of veins)

3
rd
, 4
th
and 6
th

I am going to examine the nerves which cause movement of the eyes.
INSPECTION:
(B) eyes are symmetrical,
No deviation.
No head tilting (4
th
nerve),
No ptosis (3
rd
nerve),
No nystagmus.
Tell patient to look at the tip of pen and follow with eyes and when you see double vision please tell me.
Start from middle and create an H. Then go to centre and check conversion.
Normal extraoccular vision, no limitation, no nystagmus.

5
th
nerve: motor and then sensory.
INSPECTION:
No atrophy in temporal and masseter area.
I am going to examineSENSORY:. This is a piece of cotton, Ill put in on your chest this is how it feels.
Now I am going to touch different parts in your face while your eyes are closed. Whenever you feel it
touches you tell me. Then ask him if it is the same feeling.
MOTOR:
clench teeth and relax twice. Feel the bulk of the temporal and masseter they should be similar bulk.
Can you push your jaw against my hand?

7
th
is mostly motor. Sensory for the tongue (anterior 2/3). Corneal reflex efferent limb.
INSPECTION:
Face symmetrical,
Normal nasoliable fold,
No drooling,
No deviation of angle of mouth.
Now copy me: raise your eyebrows, frown, close your eyes and dont let me open them, puff cheeks and
dont let me blow out, show your teeth, and whistle.
I would like to check corneal reflex in the eye

8
th
nerve.
I am going to whisper words in your ear. Repeat after me (horse and house).

9
th
and 10
th

1. Normal voice, no hoarseness.
2. Swallow for me swallowing is normal.
3. Say AHAA soft palate symmetrical, uvula is central.
4. Gag reflex Id like to do.

11
th
nerve shrug your shoulders (Normal trapezius).
Turn your head to the right against resistant and feel the bulk of the sternocleidomastoid.

12
th
nerve no atrophy/ fasciculation of the tongue no deviation of the tongue. Wiggle your
tongue left and right.

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Unconcious Patient
INTRO: Hello, Mr.DO you hear me. If you hear me open your eyes. I am Dr. one the
physicians working in the clinic.
FIRST CHECK PUPILS:
Pupillary reaction pupils are round and symmetrical and reactive. Not dilated or constricted.
There is no pupillary discrepancy. If one is reacting & the other not reacting call neuro.
If you hear me can you move your eyes up and down? There is no locked-in syndrome.

Vitals (Cushing triad absent; If the patient has fever we will verbalize it).

GCS

Cranial nerve:
1. 2-fundoscopy,
2. 2-3 pupillary reflexion,
3. 3-4-6 eye deviation,
4. 5-7 corneal reflex,
5. 7 inspection of face symmetry,
6. 9-10 gag reflex

Upper extremity:
Inspection (symmetrical, normal position, no movement, no contractures), tone, reflexes
(biceps, triceps, brachioradialis)

Lower extremity:
Inspection (symmetrical, normal position, no movement, no contractures), tone, reflexes (knee,
ankle, Babinski)

Meningeal signs
Neck stiffness,
Kernigs,
Brudinsky
Babinsky

Special test:
Caloric test, Dolls eyes

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ER

Trauma Non-trauma
Hx + Transition
A
B
C
D
AMPLE
Head to Toe

Orders
ABCD
History of present illness
CC
PQRST (Head to toe)
ASx

PMHx (Risk Fcts)
Focused P/E
Orders

In ER dont be comfortable till after primary survey and IV lines.
If non-trauma patient in ER you do primary survey (shortened), more time on history and
focus on CC.

Case of Trauma
Id like to initiate ATLS protocol and Id like protection to my team and myself (gown, goggles,
mask, and gloves).
When walk to patient ask the nurse:
How is the patient doing? What was done till now?
If not wearing collar tell nurse to fix the head, tell patient not to move we need to fix your
neck collar for your neck.
Take a small history: how do you feel right now? (to see if he can talk).
If complains of severe pain (empathy: I can see you are in pain, please bear me with me for a
few minutes, as soon as I can I will give you a pain killer. At the moment I want to make sure
you are stable for that reason, I am going to give some orders to the nurse, and as soon as I am
done Ill ask you more questions).
A - Airway
Please open your mouth. Mouth clear, the
Flip your tongue: there are no clots, foreign bodies, broken teeth, and
Patient is talking to me that mean airways are patent.
B
Can I get the saturation?
Give oxygen. If saturation is 95% than you give oxygen ask if the saturation improved.
Oxygen + saturation is a part of B.
Open the neck collar and look for trachea deviation, Jugular vein.
Trachea J Veins Air Entry Heart Sounds
Normal Central - Bilateral S1, S2
Tension Pneum. Opposite side Increased Decreased same
side
S1, S2
Hemothorax Opposite side Low/Normal Decreased same
side
S1, S2
Cardiac
Tamponade
Central Increase Bilateral Muffled

Pneumothorax large bore needle in 2
nd
intercostals, midclavicular line, upper margin of the
third rib.
Hemothorax insert chest tube in 5
th
intercostals space mid-axillary line. Ask nurse how much
blood (If > 1.5litre ask for thoracic surgeon, also if greater than 800cc in 4 hours). If less
monitor.
Cardiac tamponade ask for thoracic surgeon.
Pericardiocentesis needle in mid-xyphoid 45 degrees towards the tip of the scapula and look
for blood. Continuous ECG.

C
Vitals (every 10 minutes), and blood orders.
Id like to get the vitals.
Comment if hypotensive tachycardia.
Id like to start 2 IV lines 16G in both anti-cubital fossa.
2 litre bolus Ringer lactate in one side, and from the other take blood.
If no improvement after 2 litres give another bolus. If deterioration in vitals give blood.
Finger prick glucose;
BLOOD for:
CBC, Lytes, Group, Cross match,
INR, PTT, LFT, BUN, Cr,
Toxoc screen, Alcohol level.
If unable to get the IV line insert intraosseous line (IO).
Order 6 units of blood: 2 O positive for male or negative for female in reproductive age
and add 4 units of cross matched blood (pRBC).
Continuous ECGcardiac enzymes (troponine, cpk-mb),
Ask the change in vitals again & results of blood glucose.
Ask if 2litres were given. If stable OK.
If UNSTABLE: look for source of bleeding.
Start with
ABDOMEN:
INSPECTION: listen, and palpation.
If bruising ask for surgical consult stat.
If not available ask for FAST.
If technician is not available then DPL (Diagnostic Peritoneal Lavage).
Then go for the
PELVIS: I am going to press on hips to see if there is any pain. If complain of pain tell I suspect
pelvic fracture Wrap sheet and call ortho stat.
Look at the LOWER EXTREMITY:
No internal/external rotation, feel there is any pain, difference in the legs. If you suspect
fracture ask for Thomas splint and check the pulse before and after.
Log roll check for spinal process and DRE.
D
D1- Deficit Gross Neurological:
Shine light to both eyes Both pupils normal size reacting to light.
Can you squeeze my finger, wiggle your toes.
Touch his sides of both upper and lower limbs can you feel my touch.
Patient is grossly neurologically intact.
If unconscious check papillary reaction and assess GCS.
D2 universal antidote
Thiamine, Glucose,& Naloxone.
D3 specific antidote.

AMPLE
Allergy
Medication
PMHx
Last meal, Last tetanus shot, LMP (if female)
Event describe the event (Rear end, T bone, Head on);
Were you driver/passenger/alone?
Have you had any head trauma? Do you remember anything before or after the event?
Do you have nausea/vomiting/headache.

Head-Toe examination

Orders

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Hypertension/Secondary
As I understand you came here today because you were diagnosed with increased blood
pressure. Ill do a physical exam on you.
Can I get the VITALS:please?
1. Patient have (B)systolic & diastolic blood pressure raised.
2. Patient does not have tachycardia, r/o pheochromocytoma and thyrotoxicosis.
3. Patient does not have bradycardia r/o hypothyroidism.
4. Id like to compare BP in upper and lower extremity to r/o coarctation of aorta.
5. Id like to r/o orthostatic hypotension for pheochromocytoma.
6. Check orientation: Time, Place, and Person
On general examination:
Patient sitting comfortably
No sign of truncal obesity
No cervical fat pad.
Face is symmetrical
No moon like face
EYES:
Normal eye brow,
No puffiness around the eyes
No exophthalmus,
Please Follow my finger there is no lid-lag or lid retraction.
Sclera for anemia or pallor.
No xanthelasma or arcus senilis
On fundoscopy there are no signs of Htn.
No loss of visual fields (acromegally).
NOSE:
Nose OK (septal perforation in cocaine abuse).
HANDS:
Symmetrical,
skin normal not dry or moist, no sign of drug abuse (needle puncture).
Normal capillary refill,
No clubbing
No nicotine staining.
Please stretch your hands no fine tremor.
Pulse regular, normal volume and contour.
Compare both pulses. (When lies down take radio-femoral delay.)
Abduct shoulders to check proximal weakness for Cushings.
NECK:
feel thyroid, swallow,
ask patient to lie down, put bed at 45 degrees and ask for JVP.
Check for carotid bruit (first listen than palpate)
BACK:
Listen between scapula for collateral circulation and bruit (COA)
Base of lungs for creps and heart failure.
Press on sacrum and ankle for edema.
CHEST: (lies down, please lower your gown)
chest is symmetrical.
No obvious pulsation.
I am going to feel.
Feel for apex beat, fine and identified PMI position and size, not enlarged not displaced,
not sustained.
No parasternal heave.
Listen to mitral area normal S1, S2
Move to bell and lie on side: no S3 and S4
ABDOMEN:
abdomen non-distended, symmetrical, no pulsation, no striae, no caffe au lait, no
obvious masses.
I am going to listen to the abdomen. 2 inches above umbilicus is the aortic bruit, renal is
2 inches on the same level, and the iliac are 2 inches below on 45 degree below.
Tap, feel dullness in renal area for masses. No supra-renal masses.
Femoral-radial delay,
No peripheral edema.
Neuro:
Kneel on chair and do ankle reflex a
Quick neuro.

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P/E of CVS
INTRO:
VITALS: (Thank you for the Vitals)
Both Sys and Dia BP are elevated, HR is normal.
Orientation: time, place, person
G/ E:no obvious obesity
HEAD: Eyes - pallor/arcus senalis, no xanthelasma
Mouth: no dehydration
FUNDOSCOPIC: exam
HAND:Temp/Capillary refill/Clubbing/Nicotine stain
Pulse: regular/normal volume and contour
NECK: at 45
o
look for JVP, listen to carotids one by one, then palpate carotids
CHEST: ask to lower gown
INSPECTION:
Sit and look for pulsation
PALPATION:
PMI
Feel apex/thrills/heaves
AUSCULTATION: Aortic/tricuspid/MV, lay patient on left side, no S4
Sit up and lean forward, breathe out and hold it listen if there is aortic regurgitation (?)
Listen to base of lung
Press on sacrum for edema.
Ask patient to lie down on bed
ABDOMEN: listen to bruit (aortic, renal and iliac)
LOWER EXTREMITY: temp, capillary refill, dorsalis pedis and peripheral edema

Three places you look for orientation:
Volume status
Malignant hypertension
Hypoxia and SOB

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Volume Status
79 Hip replacement 3d ago, nurse asked to come and see, not passed urine for four hours. Do
Volume status exam.

INTRO:
VITALS: (and mention that BP should be done twice while lying and sitting)
After measuring BP in one position, there are two minutes before you measure the second
position, meanwhile you do (the cuff of the BP should be on the same level of the heart).
Width of cuff is equal to 40% of circumference of arm.
1. ORIENTATION:Time, Place, and Person.
2. Listen to the base of the lung.
3. Look for sacral edema.
4. Look for sclera for pallor.
5. Mouth: open and look for dehydration. Flip tongue for central cyanosis.
6. Look for hands, skin (moist and dry).
7. Capillary refill should be less than 2s.
Measure HR again and BP.
If there is no increase in pulse more than 20bpm and no decrease in SBP more than 20 or DBP
more than 10 there is no orthostatic hypotension. If one of them is positive Orthostatic
hypotension.
Put patient at 45
o
to do JVP. Press on base to see if JV disappears. Measure.
Take deep breath and hold Kussmaul Sign absent.
Untie the shirt and do hepato-jugular reflex.
INSPECTION S3 and S4 and all cardiac exam.
ABDOMEN: percussion at suprapubic to see if bladder is full.
Pedal edema, than look at examiner and ask for:
input-output chart & weight charts.
(If there is cathter:) Id like to make sure that the catheter is not kinking.

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PVD
Pain in calf for three months.
Vitals (patient is stable), if patient is wearing socks ask him to remove them.
INSPECTION: (B) Feet: SEADS+3:
Normal hair distribution
Skin non-tight and shiny
No hypertrophy of nails

PALPATION: (I will feel your feet):
Peripheral temperature
Capillary refill
Pulse (both sides): DP, PT, Pop. & Femoral.
Drape the patient and listen to his abdomen for bruits.
Feet LIGHT TOUCH SENSATION:
Bergers test raise legs for two minutes any you feel tingling/numbness tell me.
After two minutes tell: no pallor, pain, numbness, tingling. Sit up and dangle his feet No
rubour on depandance.
I would like to do ANKLE BRACHIAL INDEX

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Diabetic Foot
Intro (As I understand you are here today cause you have DM for 2 y and ulcers in your Rt leg. I
have to do a P/E)
Vitals stable.
Drape and remove socks.
INSPECTION:
Look at sole of foot.
Ulcer 3cm in diameter, round, margin not elevated, no active bleeding or oozing, located at
base of 1st metatarsal.
I am going to look for other ulcers at the base of the toes (Between medial and lateral
maleolus.)
Check SEADS + 3.
PALPATION:
Temp and capillary refill.
Shift to NEUROLOGICAL EXAMINATION:
LIGHT TOUCH SENSATION in glove and stocking manner.
Start with big toe and go to level and than up and down until finding the right level.
Light touch absent or decreased at a level to distal point. For example above wrist.
And then say to the patient: Thank you and open eyes.
POSITION SENSE: close eyes and move the big toe up and down five to six times. Thank you.
Open your eyes.
VIBRATION SENSE: tuning fork put on sternum to show how it feels, then put it on the 1
st

interphalangeal joint. If doesnt feel vibration sense absent. Start with first joint, and second
joint (you check vibration also for (1) medial maleolus, (2) tibial tuberosity, anterior superior
iliac spine, sternum, chin, and forhead). (1) and (2) are for spinal injury.
ANKLE REFLEX:
MONOFILAMENT TEST:
press on sole or foot. Feel or no-feel.
Increase the pressure & bend the monofilament. He has lost light touch and pressure.
But if feels when pressure, say: pressure present but light touch gone.
You check the same way in 9 points on the sole.
PULSES: DP, TP
Auscultation (?) and ABI (Ankle-Brachial Index)

Acute Abdomen, Physical exam
Intro
General inspection: the patient is lying comfortably and I see no signs of distress. Can I get the
vitals please?
The patient is stable, normal temperature, BP and HR.
You are going to face can I take a look at your eyes: there is no jaundice, no sign of anemia.
Please open your mouth there is no sign of dehydration and obvious ulcer in the mouth.
Upper extremity: capillary refill is normal.
Abdomen (drape appropriately): please move the cover by inspection: the abdomen is not
distended, umbilical inverted, abdominal moves with breathing, no scars, no bruises. Ask
patient to look aside and cough twice (once look at his face to see for cough tenderness and
then for abdominal bulging).
Now I am going to listen (warm the sthetoscope): Normal bowel sounds, no bruits aorta,
renal, and iliac.
Percussion: I am going to tap show me where it pains. First tap away from painful area, than
tap over the 9 areas the painful area last.
Pulpation: I am going to feel no tender in epigastric/Rt. And Lt. Hypochondral/Rt. And Lt. Iliac
regions/ Umbilical / Suprapubic.
Deep pulpation: I am going to apply more pressure there is no guarding in deep pulpation,
there are no obvious masses.
Now I am going to feel your kidneys there is no enlargement of your kidneys.
Now I am going to do some special tests.
Murphy sign
Rebound tenderness.
McBurny sign.
Rovsing sign.
Psoas sign.
Obturator sign.
Please sit up. Now I am going to tap your back. There is no tenderness on costo-vertebral
angle. Now listening again to the base of the lungs. There is no crepitus at the base of the
lungs.
Id like to finish my exam by doing pelvic exam, vaginal exam for bleeding or discharge or
bimanual examinations. Looking for any cervical motion tenderness, and adnexal masses.
In DRE looking for any bleeding or haemorrhoids.

Acute on chronic abdomen (like Crohns Dis.)
Add to the above:
General inspection: moon faces, truncal obesity, redness in sclera, nails pitting and clubbing,
no skin rushes, no striae, no erythema nodosum on legs, sacroiliac joints look normal.

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Acute Abdomen, Physical exam
Intro
General inspection: the patient is lying comfortably and I see no signs of distress. Can I get the
vitals please?
The patient is stable, normal temperature, BP, RR and HR.
You are going to face can I take a look at your eyes: there is no jaundice, no sign of anemia.
Please open your mouth there is no sign of dehydration and obvious ulcer in the mouth.
Upper extremity: capillary refill is normal.
Abdomen (drape appropriately): please move the cover by inspection: the abdomen is not
distended, umbilical inverted, abdominal moves with breathing, no scars, no bruises. Ask
patient to look aside and cough twice (once look at his face to see for cough tenderness and
then for abdominal bulging).
Now I am going to listen (warm the sthetoscope): Normal bowel sounds, no bruits aorta,
renal, and iliac.
Percussion: I am going to tap show me where it pains. First tap away from painful area, than
tap over the 9 areas the painful area last.
Pulpation: I am going to feel no tender in epigastric/Rt. And Lt. Hypochondral/Rt. And Lt. Iliac
regions/ Umbilical / Suprapubic.
Deep palpation: I am going to apply more pressure there is no guarding in deep palpation,
there are no obvious masses.
Now I am going to feel your kidneys there is no enlargement of your kidneys.
Now I am going to do some special tests.
Murphy sign
Rebound tenderness.
McBurny sign.
Rovsing sign.
Psoas sign.
Obturator sign.
Please sit up. Now I am going to tap your back. There is no tenderness on costo-vertebral
angle. Now listening again to the base of the lungs. There is no crepitus at the base of the
lungs.
Id like to finish my exam by doing pelvic exam, vaginal exam for bleeding or discharge or
bimanual examinations. Looking for any cervical motion tenderness, and adnexal masses.
In DRE looking for any bleeding or haemorrhoids.

Acute on chronic abdomen (like Crohns Dis.)
Add to the above:
General inspection: moon faces, truncal obesity, redness in sclera, nails pitting and clubbing,
no skin rushes, no striae, no erythema nodosum on legs, sacroiliac joints look normal.
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Hematemesis
Because it is hematemesis Id like to initiate a ATLS protocol for me and my team, please can I
can get gloves, goggles, masks, and gowns.
Intro
I want to make sure you are stable and therefore Ill give some orders to the nurse. Once you
are stable Ill ask you some questions.
ABCD
Vitals
OCD + COCA
How did it start?
Forceful and retching?
Did you vomit once or more?
How much?
Dark /bright blood?
Any clots?
Any smell?
IMPACTPAIN
-PAIN Liver
+PAIN GIT

If No Pain:
Hx:
Any Hx of liver disease?
Any screening for liver disease?
Any bruising in body?
Increase in abdominal size lately?
Alcohol: how long? How much?
Hx of PUD
Heartburn
Any nausea
When was your last bowel movement? Colour? Any tarry stool/fresh blood?
Any Hx of bleeding disorder?
Any NSAIDs (Aspirin) how much? How long? Why? Who prescribed?
Any blood thinner?
CSx (Ask for weight loss)
Long term disease

Physical exam:
Vitals
If suspected liver disease (no pain):
Sclera no yellow discoloration, pallor
Enlargement of parotid glands
Mouth: Fetor hepaticus, mouth is clear no bleeding no clots
Hands: no clubbing, capillary refill, no atrophy of thenar or hypothenar, no palmar erythema,
no dupytrens contraction, no flapping tremor
Chest: no spider nevi, no gynecomastia, normal chest hair, no bruising
Abdomen: not distanded, umbilicus normal, caput medusa, collateral veins, no bruising.
Auscultation: bowel sounds normal, bruits (aorta, renal, iliac), no hepatic rub, hum, or bruit; No
splenic rub, hum
Tapping: four taps general percussion, percussion for liver (upper and lower margin), spleen
(Castle sign), shifting dullness
DRE
Testicular atrophy
Peripheral edema
Epigastric tenderness
Gastroenterologist consult and admit to ICU
Endoscopy and IV PPI
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Acute Abdomen management
Abdominal pain 24 hr with vomiting and diarrhea, BP 90/60, Pulse 140
Diagnosis: acute pancreatitis
Intro: As I understand... please bear with me, as your BP is low Ill give orders to the nurse, and
as soon as you become stable, Ill give you something to relieve your pain.
A
B Vitals, Oxygen saturation
C because he is hypotensive and tachycardic you give IV fluids;
Take blood to: (add amylase to the other blood work)
D Gross neurological exam

Hx
What happened?
Pain: OCD, PQRST, AA
Vomiting: how much, how many times, amount, forceful, blood/coffee ground
IMPACT
RF (Alcohol, Gall stones, Hypertriglyceridemia, DM, Viral infection, Medications)
Recent trauma
Alcohol: how much, when was last time, last drink (was it more than normal?)
Hx of gall bladder disease
Recent flu
DM
Medications
CSx
Hx of HTn (R/O Aortic dissection)
Chest pain
Cough, phlegm
Flank pain
Liver disease
PMHx
FHx
SHx
Vitals

2min stabilize, 4min Hx

P/E
Look for liver disease: sclera, tongue, and hands
Abdomen: Drape
No Cullens and Great Turner signs.
Look for cough tenderness.
Auscultate bowel sounds: no aortic/renal bruit.
Feel or tap abdomen
Groing exam
DRE
Orders: Meperidine, NPO, NG Tube, Admit to ICU, Foley catheter, Input-output chart,
Imaging: AXR, Abdominal U/S and CT, surgical consult

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MI Management
Hx
OCD
PQRST
(if it is suspected to be ACS - stop at R and start primary survey)
Primary Survey (If patient talks Airway preserved,
Take Oxygen saturation and start Oxygen Stat 4L/m through nasal prongs)
VITALS:
Auscultation:
Air entry (N)
S1 & S2 (N)
IV lines :
NaCl 50ml/hr to keep line open,
from the other side take blood for: Troponin, CK-MB, Cr, BUN, Lytes, CBC, INR, PTT, LFT, Toxic.,
Alcohol, Lipids; and finger prick for Glucose)
ECG 12 leads & continous monitoring
Portable X-ray (r/o dissection)

Ask about Allergy for Aspirin and Viagra (if negative)[12hrs for Viagra & 36 hrs for
Cialis]
Give ASA chewable (325mg)

Non-ST elevation
Nitro x3 (S.L)
Morphine
Continue now with:
PQRST
AA&A
How do you feel now?
Ask Hx:
CVS
GI (especially peptic ulcer)
CSx
RS
DVT

ST Elevation: do not go for DDx
Nitro (IV Nitro is C/I in IWMI)
Morphine (5mg if ALMI, and 1mg if PWMI)
VITALS: (again)
R/O Contra Indications for Thrombolytics:
Peptic ulcer & Recent surgery,
Pericarditis, Aortic dissection,
Brain tumor, & Stroke

Start Thrombolytics:
Tpa
Ask for heparin protocol
Start B Blocker

RISK FACTORS:
HTN
DM
FH
Coccaine
Nitro (2
nd
dose)
O/E:
JVP
Listen to heart
Base of lung
Compare BP in both Upper extremities to r/o coarctation of Ao
CXR
Once there is no Aortic Dissection Thrombolytics (should be clear to r/o: Peptic ulcer, recent
surgery, pericarditis, aortic dissection, brain tumor, and stroke)
Based on ECG counselling

Counseling
Based on your ECG it is most likely you are having an heart attack. If stable BP and HR are
stable, but it is a serious condition, however it is treatable. Heart attack means that greater
than one blood vessel supporting your heart is blocked by a clot that has to be reimoved. The
medications are called clot busters. Based on ECG and no sign of pericarditis or signs of aortic
dissection you are a good candidate for treatment. It is an effective medication, needs consent.
1% chance of stroke and we can start heparin.
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Respiratory System P/E
General inspection: comfort, colour, pursed lips, flare nose, intercostal retractions, auxiliary
muscles
Eyes, nose (perforated septum), mouth (ulcers, thrush in HIV, central cyanosis, moist
tongue)
Hands: peripheral cyanosis, clubbing, capillary refill
Cervix: trachea, lymph nodes
Chest: inspection (symmetry, expansion, intercostals retractions);
Palpations for any pains, estimating chest expansion
Tactile phremitus (99)
Tappings (including sides): dullness/tympanic, diaphragmatic excursion
Auscultation (including sides): vesicular sounds
Vocal phremitus: E
Whispering pectoriloqui: 1,2,3
Heart: pulses and auscultation (r/o AF and Rheumatic disease).
Other lymph nodes: axial, femoral, popliteal
Lower leg: no signs of Caposi sarcoma, DVT (Homan sign, measuring calf in case of
tenderness or suspicious calf swelling).

Diabetic Daughter 2y, Counsel
Either she is not doing well in school as she is not seeing well due to vision problems
Not playing well, as she is tired
DKA

Is it regular f/u or something special you wanted to discuss?
When was the last f/u?
How was she diagnosed?
What happen then?
What were the symptoms?
Any pain / vomiting?
Are you feeling eating/drinking/peeing more?
Any weight loss or blurred vision?
From the last f/u till now have you had DKA?
How about before?
Have you had low blood sugar?
Talk with the father:
Which medication does she take?
How does she take?
Do you take insulin or somebody else gave it to you?
Do you take it all the time?
DO you skip dose?
Does she need any help to take insulin?
DO you measure blood sugar regularly?
Do you record them in the machine? (The glucometer should be used by only one patient).
There is a blood work called Hemoglobin A1C it is done every three month did you do it?
Did you start new medication?
How about your diet?
DO you have your log book?
What do you eat?
Have you ever seen by a dietician?
PMHx
FHx

Counseling
A lot of people have diabetes and she is not the only one. Whats your understanding of
diabetes?
Whenever we eat food contains sugar it is absorbed in our stomach and goes to the blood and
from there to different parts of our body. Sugar act in our body like a fuel, in order for our body
to use this energy it needs insulin. Patients having diabetes have not enough insulin. Sugar will
be built up in your blood. The body tries to get rid or it, by peeing extra sugar this will lead to
thirsty and tiredness.
This can be avoided by controlling the blood sugar. If you control your blood sugar youll be
able to play again. If not controlled may end in DKA, hypoglycaemia and serious
consequences.
Always be aware of hypoglycaemic symptoms: loss of conscious, sweating, heart racing, hungry.
Since you might lose conscious it is important to carry MedAlert Caed or Bracelet which will
clarify your situation.

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Medical Error, Wrong blood transfused
When there is a mistake, always there is a kind of unintentional medical error.
(to the nurse) when informed about wrong blood ask: did you stop the blood?
say: Well done!
If she asks not to tell the patient...ask her what her believe she may lose her job, and it is too
early to determine who is responsible. Errors take place in medical practice. We dont know
what exactly happened. We will stabilize patient and ensure hes fine and later deal with this
issue.
Remove blood unit and keep cannula
(to the patient)INTRO:
I am the doctor in charge, and it looks like it was an unintentional medical error took place. We
need to make sure you are stable. We dont know who is responsible, there are at least 15 steps
and in each step could have been an error. We will fill an incident report and as soon as we get
result we will inform you. You can sue, it is your right at the moment it is my priority to stabilize
you.
I will start PRIMARY SURVEY:,
ABCD
A Open your mouth
(check for anaphylaxis, no swelling in mouth, ask for any itchiness, or difficulty breathing),
Oxygen saturation.
Normal air entry.
Normal S1, S2
VITALS: Pleaese
. Remove blood unit and keep cannula
C:
Start new IV line.
Once new line, dont give fluids if stable.
Send blood: CBC, Lytes, INR, PTT, LFT, Cr, BUN,
FDP, Haptoglobulin, Direct coombs test; Urinalysis: hemoglobulinuria
Unit to be sent to blood bank for cross matching.
Ask nurse to call the blood bank and keep original blood.

D
D1 Id like to shine a light in your eyes. Pupils are round, active, and symmetrical. Squeeze my
finger, wriggle...wriggle...
D2 (if febrile) give tylenol
Please prepare for me :
Benadryl (Diphenhydramine) 50mg.
Steroids (Hydrocortisone) and
Epinephrine

SECONDARY SURVEY:
Hx (two parts:)

1. Condition (how is he feeling now)
2. Why blood was given?

CONDITION:
Check out for Anaphylactic shock:
Do you feel warm? Chills? Itchiness? Tinglings? Diffculty breathing? Wheezing? Swelling in
lips / fingers? Hives?
Before transfusion did you have fever?
Check for Haemolytic reaction any back or flank pain?
P/E no oozing at IV line
Then press on flank and back no pain for haemolytic reaction.
Is it the first time?
WHY did you receive blood?
If received blood before was there any complications?

COUNSELLING:
Mr. X what do you know about blood transfusion?
It is a life saving measure, and a lot of measures are taken to make sure it is safe. However, like
any other medication with blood transfusion there could be side effects, and these side effects
could be serious.
The most common side effect is:
Febrile reaction (3%), usually it is self limited and can happen again. Next time you
receive blood we will give you tylenol.
Anaphylactic reaction. It is a severe allergic reaction, and it is very serious and we
cannot predict it. However, we have good measures to deal with it, and your symptoms
make it less likely that you have had an anaphylactic reaction.
The third reaction is more serious and called
HEMOLYTIC reaction. Usually happens when patients receive blood belonging to
another blood group.
The fact that this blood is same as your blood group, and the symptoms are not consistent
with haemolytic anemia make it less likely that this is not the case here. The blood is sent
to the blood bank and once results are back we will get final confirmation, we will able to
reassure you.
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Son has anaphylactic shock, is stable now.
Next few minutes Ill talk with you and hopefully will come to a good plan.
Yawning give empathy.
Hx (Short)
It happened at home you should take history.
If not dont take history.
Itchiness,
Swelling,
Hives.
Was he able to talk, wheezing, chest tightness,
Lost his consciousness,
Turned blue?
Start immediately with Epinephrine.
What have you done at the event? What did they do?
Any other children at home with anaphylactic shock?

Management
Based on the Hx your child has anaphylactic shock.
Explain: a kind of severe allergic or hypersensitivity, from birth or develop later. Usually people get
allergic to foods, medications, or chemicals.
Any questions?
At certain stage the immune system starts to interact with some elements of the peanut which are
called antigens. From now on when your son will be exposed to the same antigens it will lead to release
of some chemicals which will affect his skin, widening blood vessels which will become leaky and
different parts of your body will become swollen.
When not enough blood will reach the brain it will lose conscious, difficulty breathing. The concern we
have is that it might happen again. It is common.
Plan: the best treatment is prevention.
After that I need to go and talk with your child.
You have to check the ingredients of any food you buy make sure it is peanut free.
IF there are other children at home they must be informed as well.
In case that your child was exposed to peanuts by mistake, you should use EpiPen this is a special
pen, has a cap at the top, which is needed to be activated by removing the cap, press it against his
thigh for ten seconds. This increases the blood pressure for about 20 min, in that time you should
seek help.
Your son should carry with him two pens one at home and one on his bag.
he should carry Med Alert. In case your child become unconscious
I will refer him to allergist specialist.
Aspirin, stress test, and imaging...
Some children will outgrow it.

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Marijuana Counselling
(Mother comes in to see you as she has discovered Marijuana in her sons belongings)

INTRO:
As I understand youre here because youre concerned about your son.
What is his name?
How much did you find?
Did you ask him about it?
WHAT MAKES YOU BELEIVE IT IS MJ ?
Is he using it? Or Is he carrying it?
Is it the first time youve found it?
Did you notice any CHANGES in his behaviour?
Is he excited?
Laughing out of nowhere?
Is he preoccupied?
Does he stare at a wall?
Does he talk to himself?
Is he aggressive?
Any problems with the law?
Any fights?
Any criminal records?
Is he more isolated?
How is his MEMORY?
Is he more forgetful/lose his stuff?
Does he take more time to react?
Does he spend more time in his room?
How much time do you spend with him?
How much time is he out of the home?
How much time does he spend with his friends?
Do you know any of his friends?
What kind of activity are they involved in?
Does he have a lot of MONEY?
Does he ask for money?
Do you believe he steals money?
Do you think he smokes/or drinks alcohol?
How would you describe his MOOD?
Is he depressed?
Is he still interested in his hobbies?
Does he worry a lot?
Does he have excessive fears & avoid situations?
Do you have concerns that he may harm himself or anyone else?
EDUCATION:
How is he doing in school?
Have his grades dropped?
DIET:
How is his general health?
Have you ever seen a psychiatrist?
Fhx: SAD
COUNSELLING:
Based on what youve told me.There are no changes in his health & behaviour (assumed that
there were no changes in behaviour as per mum)
When it comes to Marijuana it is a commonly used drug by teenagers, sometimes only once for
experiment. When we talk about Substance Abuse & drugs we talk about different categories.
Marijuana is a SOFT DRUG,others like: Coccaine,Heroin& Amphetmanies are HARD DRUGS
Let us talk about Marijuana first.
It is from the Cannabis family & affects the brain by feeling happy, excited & enhances
experience.Sometimes with prolonged use or in high doses can cause side effects including
apathy.
It interferes with memory,& can interfere with his studies & function & fine motor skills & may
not be able to operate machinery
It impairs judgement & he might take risks.
Can cause Lung cancer
In some teens,in high doses unmasks schizophrenia & cause psychosis
Interferes with sexual function & can cause infertility & weight gain
By itself marijuana is not strongly addictive & hence he can stop it at any time with help.One of
the concerns of Marijuana though is it acts as a bridge to Hard drugs which are addictive i.e
youve to increase the dose to have the same effect,which is called TOLERANCE,& then one
cannot stop the drug as it causes withdrawal .
It is a crime to use,hold hard drugs.People can lose their jobs.
If injected increases risk of HIV,Hepa B & C
PLAN
If you like,bring your son here I can talk to him.
It is better to be a confidante to him. Try to be close to him, someone he can trust & can talk
to.Try to make sure whore his friends,& make sure you know what he is doing.Keep him busy
with activities.
If there are any druh prevention programmes in your community or his school,get him to attend
them & gets the knowledge.


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Pregnant 35 YO has concern about breast feeding.
Tell me more about your concern.
Is it: General information you like to discuss or some specific concerns?
If worried about pain: Ask:
Have you ever been pregnant before?
Have you ever breast fed before?
What makes you believe it is painful?
In addition to that any other concern?
Mostly my concern is...
It is a good concern,& Im gald you came in today.
How is your pregnancy?
When was your last F/U?
When is your due date?
Let us talk about the pain.....
Breast feeding is a natural physiological process & usually it does not cause any pain.
However, sometimes it might cause some discomfort.
If it pains there should be some reason for that.
Most of those causes are treatable
Most commonly cracks and fissures. They are caused because of not proper care of the nipple.
You have to make sure that they are moist, clean them, and dont use soap.
To learn appropriate technique it might take some time.
I can send you to some classes that might guide you.
Retracted nipple and inflammation of the breast (mastitis) you can still continue to breast.
Localized condition, like abscess, we still recommend to continue to feed breast from the other side.
Before we proceed further Id like to make sure if you are a good candidate for breast feeding.
Do you have any long term diseases,
Do you take any medication or radiation,
Do you smoke or taking any drugs,
Have you been screened for TB or HIV.
Do you plan chemotherapy or radiation therapy?
Based on what youve told me,youre a good candidate for Breast feeding
COMPARE BETWEEN BREAST MILK & FORMULA
The reason we recommend breast feeding is that we cannot match it with formulas.
The first 24 hours secretion is Colostrum ,it is a special kind of milk& has a lot of antibiotics,
immunoglobulin & essential amino acids, which are essential for your baby which will give him
protection.
With time the milk becomes more mature and suits the needs of your baby. It has the right amount of
carbohydrate & fat. The quality of the fat is better. It has more whey relative to casein. The iron is less
than cow milk but is more available (50% as to 20%).
Less load on the kidneys
There are other benefits to your baby and you there is emotional connection which is important to
both of you.
Babies breast fed have
Less chances of having allergies
Less chance of having diarrhea
Less chance of being obese
Less ear infection,
Some studies even suggest that they might have higher IQ.
There are some benefits for you (the mom)
It helps to lessen the postpartum bleedings (because the oxytocin) the uterus go back to its size
Helps you to regain the figure youd prior to pregnancy.
It is clean, available, always at the right temperature, even though you dont pay for it
It is one of the most important things you can give your child.
If chooses to breast feed:
I will send you to clinic who will teach you.
At the beginning the breast feeding is on demand & with time it regulates ,& you need to feed every
3 4 hours & at least 10 min in each breast.
Monitor weight gain to ensure that the baby is adequately fed.
Occasionally the baby may be jaundiced & sometimes stool may be loose.
If you choose to breast feed youve to be careful whenever you take medications or alcohol.
You can go back to work, after the Maternity Leave (ask for how long)
Breast feeding can be continued. You can use some special pumps. Even if there is engorgement you
can use the pump. Make sure it is always clean. Breast milk can be stored at 6hr in room temp, 24 hr in
fridge, and 6m in freezer. Dont put it in the microwave for heating.
Breast feeding is not reliable method of contraception. Recommend the minipill or barrier method.

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Febrile Seizure
A child brought to the ER because of febrile seizure.Next 10m counsel him.
EVENT
TRIGGER r/o meningitis.
EDUCATE & what to do next time
INTRO:
As I understand youre here because your child had a seizure 20 minutes ago,& my colleagues are
looking after him & he is stable. During the next few minutes Ill ask you few questions, and after that Ill
go with you to see him.
EVENT:
Describe the event.
What happened?
Did you see him? (Started to shake. All over his body? Bite his tongue / rolling up his eyes / wet
himself).
Did he fall from a height?
How long did it last?
Did he stop seizing by himself or did he need medical intervention?
How did he regain consciousness?
After the seizure does he have any neurologic deficits:
Was he drowsy
Did not recognize you
Able to move his arms & legs
Is it the 1
st
time? Or happened before
If first time:
Ask about fever?
(if it started a week ago did you seek medical assistance? Any ear discharge? Did they give you any
treatment? Did you give it to him or no?)
Why! Some studies show you can treat OM without antibiotics. If reason medication not given was
because parent was busy.....You should look for the reason not to give the antibiotics (negligence?).
Was he playful,eating,drowsy,
Is he having any vomiting?
Skin rash?
Coughing & phlegm SOB, Wheezing
Foul smelling urine & painful peeing
Head to toe...
If you find nothing ask when he got his last shot? (up to 72 hours he can have fever).
R/O meningitis, pneumonia.
Any family history of febrile seizures, epilepsy
BINDE (especially immunization to R/o Measles)
COUNSELLING:
Most likely on what youve told me, your child has condition called febrile seizure (FS).Do you know
what it is?
It is a special condition in children that might happen from 6m to 60m. We dont know exactly why we
believe it is a sudden change in the temp & as the brain is not developed fully thes e changes might lead
to the seizure. This condition might happen again. The best treatment is: PREVENTION
Therefore from now whenever your child has a temperature
Seek medical attention. Give Tylenol and sponge bath to decrease his temp.
Most of the children will outgrow this condition by the 6
th
year.
Chances of epilepsy later in life are higher
In FHx of epilepsy,it is a risk fct for development of epilepsy.
They dont recommend Diazepam because it might make him drowsy.
I will give you brochures

If it stopped less than 5m or more than 5m including neurological symptoms seek ER immediately.
Brochure.

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PHONE CASE:
This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER.As I understand,
youre calling as your child has swallowed some medication. I know that youre stressed & it is a difficult
time for you. I need your phone number now & it is important, as if we get disconnected I will call you
back.
What is your address?
How far away from the hospital are you?
Try & stay calm. Your son needs you, I am going to give you some instructions and you need to follow
them.
FIRST STEP:
Is your son is alert or not?
Is he conscious?
Can he talk to you?
Can he recognize you? (If he doesnt do you know how to do CPR and start with that.)
Hes crying?
What is his colour? Pink?
Hold him and try to calm & soothe him.
Try to hold him and check his mouth,if there are medications there,remove them.
Is he breathing?
Well send the ambulance for you.
When did it happen?
How long was he alone?
Which medications did he take?
Whose medications did he take?
Do you have the container?
(Dont go to the next room to bring them,when the paramedics arrive then you can go & get the
container).
Do you know what condition your father have (was it vitamins, sleeping pills, or any other?)
How much the amount?
Dont use any ipecac? Do not induce vomiting.
Is it happened before?
What is the weight of the child?
BINDE (was it full date, did he needed special attention after term, and does he have any special
conditions). Weight for two reasons antidote and estimate neglect.
Are his shots up to date?
Are there other children at home?
Have you visited the Er frequently?
Post encounter Q: what are the first four steps you do when he arrives?
ABC,
Monitor vitals,
IV line, NG,
Foley as needed,
Blood works CBC, Lytes, BUN, Cr, Osmolality, Coagul, LFTs, Tox screen blood and urine).
List three risk factors forneglect for this child.
What is the antidote for betablocker (glucagon) and for CaChannel is (Calcium gluconate).
CAS & Poisoning centre.

Second scenario Phone case: Febrile Seizure
This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER.As I understand,
youre calling as your childis having a seizure. I know that youre stressed & it is a difficult time for you. I
need your phone number now & it is important, as if we get disconnected I will call you back.
What is your address?
How far away from the hospital are you?
Try & stay calm. Your son needs you, I am going to give you some instructions and you need to follow
them.
While he is seizing just put him on the side, and not start any CPR.
Is he seizing right now? Try to put him on the floor on the left side (the right bronchus is shorter than
the lt.).
Observe him.
What is his colour?
Is he still shaking? You send the ambulance.
Can you tap on his shoulder?
If he is not responding can you do CPR?
Can you feel his pulse?
If stopped seizing...... Good
Is he alert?
Does he respond?
Can he talk to you?
Can he move his legs?
EVENT:
Can you describe what happened?
OCD
Fever +/-
Does your child have fever?
Did he have Hx/Nx/Vx/Skin rash/Neck stiffness
Any long term disease?
Did you seek medical attention? What prevented you from giving the medication?
Is it the same time or happened before. If it is the second time more than 15m he needs intervention.

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Post Concussion.

Hx & PE

INTRO:
As I understand you had a head injury 3 days ago when playing hockey.
Start with EVENT: Before & After
If LOC ask How long?
Do u remember what happened? What was done?Were you hospitalized?
Was a CT Scan done?
HOW DO YOU FEEL TODAY?
Full neuro assessment
Headache:
OCD PQRST U V A&A
Vomiting,bending,Nausea
Balance,vision falls weakness numbness
Difficulty finding words
Past Med Hx:
HEADDS
PE:
Vitals
CN
Power
Reflexes
Sensory
GAIT check Tendem gait

Conclusion:
I know youre eager to play hockey
Since youve headache youre not ready to play again as you still have active Sx.
If you start to play again your tolerance for injury is lower & if you are injured again,your tolerance is
lower & recovery time is longer & there might be serious consequences.
Why dont you wait till full recovery time
I will refer you to a PT & with gradual step up exercises you can get back to your game:
One week with warming up, after that stationary activity, after that skiing, than drilling without contact
(seven steps of rehab.).

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Osgood Schlatter

2 scenarios (Osgood schlatter and Post-concussion)
Decision will based whether the child can tolerate pain or not?

#1 About to see the father of 14yom with Osgood Schlatter.
Make sure that the child best interest are preserved. What was done to diagnose the child?
OCD PQRST compare to the other knee, is the first time or not, was any trauma.
What is the child wish? (Dont go for HEADDSSS since it is the father).

Counseling
What is your understanding of OS.
Let me explain to you what is the mechanism for OS.
Avoid him from playing, especially jumping. But he can continue with ice presses and pain killers. The
rule is that he can continue up to his limit of his pain.

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IMMUNIZATION
(Newcomer come to Canada from Ukraine, concerned about immunization)
May need interpreter: Ask:
Do you understand?
Can I talk slower?
Do you need interpreter?
INTRO: As I understand youre here as youre concerned about vaccines & my understanding is
that youre new to Canada, Welcome to Canada!
Pt: My neighbour told me vaccines are not safe
Dr: what do you mean?
Pt: Concerned about autism & vaccine
Dr: This is a reasonable enough concern,& Im glad you came here.
There is a misinformation about between vaccines & autism.The origin of this misunderstanding
is due to a study done in the UK & the author of that study found a connection between autism
& vaccines. Because vaccines are lifesaving & important for our childrens protection,further
studies were done,also in other countries,& then it was definitely proved that there is no
connection between autism & vaccines.The only connection was coincidence between time of
the vaccine & time when symptoms of autism were picked up by parents.
Another common concern is that mercury was used as a preservative for MMR vaccine.
It is no longer used now.
When we find out why this study gave such a result it was found out that there was a bias in
sample & thus led to the wrong conclusion.
Another common Qn pt may ask:
These diseases do not exist in Canada, so why give my child the vaccine if there is no disease
here.
The world is getting smaller & even though we do not have these diseases in Canada, because
we have the vaccines, it does exist around the world & people travel.So we do not want your
son to get affected whenever there is an outbreak somewhere in the world.
Hx: Let me ask some questions about your son:
How old is he?
Has he received any vaccines so far?
Were there any side effects?
Any reason why he was not vaccinated?
Does he have any congenital medical condition?
Does he have any allergies (egg??)
Any neurological history?
Inform that baby is a good candidate
As I told you vaccines are life saving, before vaccines many children died from measles, rubella.
The reason being children are not fully protected & may get the infection & die. Once
vaccinated, children get the immunity
Any Qns?
HOW:
We take different bugs like bacteria, viruses or products of these bugs & process them so that it
does not harm the body,& inject it into our bodies by needles. Our body reacts by forming
elements that fight these antigens, so later in life when your son is exposed to the real factor,
these antibodies will protect him. Some of these antibodies will last forever; some will need
booster doses.Because there are a lot of disease we need to minimize the number of injections
& weve to give greater than one needle for vaccination.
There is a combination vaccine e.g: PEDISIL = DPT + HiB + Polio
This is given as a single shot at 2,4,6 & 18 Mo.
We will give you a schedule to remind you each time youve to come to the clinic
Concerning the SIDE Effects, the benefits clearly outweigh the S/E,however:
A febrile reaction can develop & you can give Tylenol if this occurs
Pain & swelling at injection site
Some children can have prolonged crying
Others may become floppy
In still rare conditions can have a seizure
Very rarely,can gt an anaphylactic reaction
Since youre a newcomer & not got your insuarence there are some organizations that will help
you out.

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IUGR

INTRO:
As I understand youve just given birth to a baby,& my colleagues are looking after him,& Im
here to talk to you.
Have you seen your baby?
Did anyone tell you about your baby?
If at this point mother voices a concern that she saw her baby covered with green stuff.
Your baby was covered with Meconium one of the substances in the fluid surrounding your
baby.It is normal for the baby when under stress during delivery.
Ive been told that your baby has a condition called IUGR,& I need to ask questions as to why
it happened
Qns about Pregnancy:
Smoked/Alcohol/Drugs
Qns about Delivery:
Term or preterm
MGOS:
O:Previous pregnancy/abortions/miscarriage, & if yes how many?
G:If Hx of Cancer or chemotherapy
Any congenital disease in her or husbands family or Consanguinity
If she asks whether her mistake:
Dont reproach her it is NOT her mistake.
It is a multi-factorial condition. Can be due to various causes, some genetic, pregnancy, related to baby
Because safe levels of smoking, drugs & alcohol not known,
We always recommend not to smoke or drink for future pregnancies.
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CHILD ABUSE:
# Femur
# LE & (B) limbs
Spiral #
# post ribs
1.EVENT
2.1
st
time or prior
3.BINDE:
4.Past MH for osteoporosis imperfecta
4. COUNSELLING

INTRO:
As I understand youre here as your child had a #.My colleagues are looking after the child, who is stable
now.
EVENT:
How?......Describe what happened.if fall from couch: How high is the couch?
When? If time logWhy bring the child now??? If at night? Did he sleep or was he crying?
Were you there?
Did you see it?
Any LOC?
Is it the 1
st
TIME or has it happened before?
If before?
How many times?
Type of #?
Did you come to the same hospital or to a different one?
Any other children at home?
BINDE:
Planned pregnancy
Term pregnancy
Any cong anomalies
During pregnancy: SAD
Immunizations up to date or not
Weight today
Development: Is he a difficult child?
Environment:
PARENT-CHILD RELATIONSHIP:
Stress at home
Who is primary caregiver or who feeds the child?
How do the parents punish the child?
Financial problems
SAD
Any Psy Hx in either parent
PAST MH:
Here specifically ask about Osteogenesis Imperfecta
COUNSELLING:
I can see that youre going through a difficult time. Sometimes it is challenging to work & care for a
child. From the history you gave me about the injury is not enough to explain such an injury. Children at
this age have very flexible bones which are difficult to break by jumping off the couch. Im sure you
share my concerns with me about the safety of your child & in this situation we contact the CAS. The
CAS will come & ask questions & talk to you & your partner:
If does not accept & says will take my child.
Ask what makes you think like that? Do you have any experience about these matters?
It is not neccassarily,they will asses the situation & if the family is considered safe
If pleads etc: Tell Ive a legal responsibility to report to the CAS

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SUICIDE ATTEMPT
16/F suicide attempt ASA overdose
Sex:
AGe
Depression
Previous attempts
Ethanol use
Rational thinking loss
Suicide in family
Organized plan
No support (here put HEADSS)
Serious illness
INTRO:
As I understand,youre here because you overdosed on Aspirin last night & Ive been told that
youve been seen by my colleagues.My understanding is that youre stable now,& I can talk to
you.
(if she is playing around with phone etc ask her to disconnect & speak to you)
Can you tell me more about what happened?
Pt: I went home & took Aspirin
Dr; why?
Pt: I was frustrated
Dr: Why?
I can see that youre busy with your phone,is it important?
Can you stop for a few minutes?
Id Like you to know that whatever you tell me is confidential here
Give confidientiality
Dr: Why are you angry?
Pt:I made a car accident
When?
Were you alone,or with someone else?
Were you driver or passenger?
Was anyone else hurt?
How Much aspirin?
Did you talke aspirin alongwith any other medication?
Did you lose consciousness?
Who called for help?
Did You seek help ort someone else did?
Was it IMPULSIVE or PLANNED?
Did you leave a note?
Have you recently been giving away your belongings to others?
Is it the First time?
Any suicidal attempt in the family?
Do you usually take alcohol,or take drugs?
R What did you think about ending your life?
R/O Psychosis:
Sometimes when people want to end their lives they see a vision or hear voices,did you experience any
of such?
How is your mood, for the LAST 2 WEEKS (last 48 hrs make no difference)
HEADDSS
Do you have a drivers liscence?
What made you take the car?
It seems an important trip, where did you go?
After you leave the hospital, what do you plan to do?
Finish SAD PERSONS
If parents separted ask about the other parent
If score <4 can send home
Nancy I know this is a stressful time for you.Based on the interview I think it is OK for you to go home.
Do you feel safe at home?
PT: Would you tell my mum?
Dr: Why cant you tell her?
How is your relationship with your mother?
I do see your point,& it is better you tell her yourself,I can help you delivering the news.we can arrange a
meeting where a social worker be present & you can deliver the news.
Life is stressful & youve to learn how to handle these situations in the future.
I also want you to know in the future you may face a similar situation & if you ever feel like this
again,Please seek help
Call 911,go to the ER,Talk to your Family Physician

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ANOREXIA NERVOSA
Here inform parents as Pt lacks insight
* In Bulimia do not inform parents Pts can have Borderline personaliy disorder,Depression,Impulsive
behaviour or Kleptomaniac.
Here ther is Loss of Control, Large amount of food within 2 hrs & then feels guilty & induces vomiting
+ excessive exercise 2/week x 3 months
INTRO:
Hello,as I understand youre here today as your parents are concerened about your weight
Can you tell me more about their concern?
What about you?
Im glad youre here today,as I can reassuare your parents
* WEIGHT
1. When did you start losing weight?
2. What was your weight when you started?
3. What was your highest weight?
4. What is your target?
5. When you look into the mirror,how do you perceive yourself?
6. Do you like to dress in baggy outfits?
7. Why do you want to lose weight? (Often carrer choice is of,Model,dancer or actress)
8. How do you plan to achieve that?
* DIET:
1. Howre your meals?
2. What snacks do you take?
3. Analyse the meals
4. How many calories?
5. Do you eat alone or with others?
6. At any time did you lose control & consume a large amount of food which is more than normal?
7. & how did you feel with that?
8. Did you try & compensate by exercise or purging?
* EXERCISE:
1. How long and often do you exercise?
2. What other activities are you involved in? E.g: dancing,walking
* Any other measures to lose wt like:
Water pills,medications like Xenical,Meredia,stool softeners?
* How has this IMPACTED your health?
1. No periods? For how long?
3. Heart racing at night? Muscle cramping at night? (Hypokalemia)
4. Dry skin?
5. Constipation?
6. Fine hair on your body?
7. Pigmentation on your legs?
8. Any bone pain or fracture?
* MOAPPS
* HEADDDSSS
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22 /F Somatization disorder
4-2-1-1
If seen by a surgeon suspect somatisation.
INTRO:
As I understand youre here because youve abdominal pain for 3 weeks
Can you tell me more about it since it first started?
What did the surgeon tell you?
What investigations were done?
What Diagnosis was given?
Analyse pain TODAY
OCD
(PQRST) Non Specific
During the day or night.
U:How has it impacted your life?
How are you coping with It?
What happens at work
V:First time to have this pain or had it before
If BEFORE:
When
How often
Similar type
Seen by Dr?
Any Interventions?

CSx
Jaundice, white stool and dark urine
Foul smell, bulking, droplets in stool
Awakens at night?
Nx/Vx
Change in bowel movement?
MRI why do you think it is important?
To differentiate: Somatic pain disorder / Somatization
In addition to abdominal pain: do you have:
Any other pain?
Headache, joints, back, pain with intercourse
Any pain with IC
How is your interest in sex?
Do you feel interested after sexual activity?
NEUROLOGICAL:
Do you have tingling/numbness?
MOAPPS:
How is your mood?
Organic
Self Care? With whom do you live?
Is your partner supportive?
How do you support yourself?
Any FH of suicide?

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39 YOF Pregnancy. Counseling. 10m

Hx=4mins
Counselling = 6mins

35yo 1:180 (congenital) half of them Down synd (1:360)
45yo 1:45 (congenital) 1:20 Down (5%)
Always ask about concerns
Why worried about Downs
Take Hx: Age/FH/Ca/Cxt/RXT/Medications
M: LMP + Sx of pregnancy +Pregnancy test
G
O: Imp
S
Past MH: Risk Fcts
FH: Congenital
EDUCATION:
CVS Amniocenthesis
Accuracy
Age
S/E:
Results:
Risk of abortion:
97%
10-11 wks
Limb defects
48 hrs
2%
--
99.9%
14-16 wks
--
2 weeks
0.5%
Checks for other
conditions

INTRO: As I understand you came here today, because you found out you were
pregnant last night & have requested an urgent meeting with me. What is the
reason?
Not ask if it is planned or not.
Ask if was on any contraception.
Confirm pregnancy by exact date.
What do you feel about the pregnancy?
If she says it is her age or concern about Down;s
Ask: Any experience with Downs syndrome?
Any Fhx of congenital anomalies?
It is a reasonable enough concern & Im glad that youre here. There are some
measures we can take to screen for some deformities, yet it is not 100%

How do you know youre pregnant?
When did you find out?
LMP
Sx of pregnancy: Nausea/Vx/Breast tenderness/Inc visits to wash room to pee.
Prev pg?
Any contraception?
PAPs smear?
STIs?
FH of Cystic fibrosis
Did you discuss this with the father of the baby?
Any reason why not?
Past MH:
Medications
Chemotherapy
Radiotherapy Smoke/Alcohol/Drugs

COUNSELLING
If wants abortion,shift to abortion.There are some important figures you need to
know
Most of the time were concerned about Down;s SyndromeUsually the risk of
having a child with congenital. Abnormality at the age of 35 is around 1:180 and
half of these children are DS.
To r/o we do a test called amniocentesis, and the reason we offer it is because the
risk of complications of miscarriage is lower than the risk of congenital
abnormality. 0.5% (abortion) compared to 0.55% for DS.
If not willing then go to amniocentesis.
We can arrange for it. First we confirm pregnancy by US to get the exact date.
Then insert a fine needle guided by US into the womb & take sample of the fluid
surrounding your baby and send it to the lab. Usually we do it around 14-16w and
the results will come around 2w later. It is very accurate >99%.
Help us to r/o other conditions is very safe. Like neural tube defects
Risk of abortion is very low < 5%.
At the age of 35 the risk of having a miscarriage due to amniocentesis complication
is less than the risk of having a child with a congenital anomaly.
As always in medicine, weve to find a balance between risk & benefit.
If pt wants an earlier test.
Another option, not commonly done is Chorio venous Sampling
Here risk of abortion is 2%, & thus higher than amniocentesis.
The results are back in 48 hrs,however the chances of having a high false negative
is 3% when baby is still affected
Also there is a risk of limb injury
Genetic abnormalities: cystic fibrosis, thalasemia, etc. For that reason you should
be referred to a genetic counselling.

From Mayo Clinic:
Amniocentesis is a procedure in which amniotic fluid is removed from the uterus
for testing or treatment. Amniotic fluid is the fluid that surrounds and protects a
baby during pregnancy. This fluid contains fetal cells and various chemicals
produced by the baby.
With genetic amniocentesis, a sample of amniotic fluid is tested for certain
abnormalities such as Down syndrome and spina bifida. With maturity
amniocentesis, a sample of amniotic fluid is tested to determine whether the
baby's lungs are mature enough for birth. Occasionally, amniocentesis is used to
evaluate a baby for infection or other illness. Rarely, amniocentesis is used to
decrease the volume of amniotic fluid.
Although amniocentesis can provide valuable information about your baby's health,
the decision to pursue invasive diagnostic testing is serious. It's important to
understand the risks of amniocentesis and be prepared for the results.
Before amniocentesis, you can eat and drink as usual. Your bladder must be full
before the procedure, however, so drink plenty of fluids before your appointment.
Your health care provider may ask you to sign a consent form before the procedure
begins. You may want to ask someone to accompany you to the appointment for
emotional support or to drive you home afterward.

During the procedure
First, your health care provider will use ultrasound to determine the baby's exact
location in your uterus. You'll lie on your back on an exam table and expose your
abdomen. Your health care provider will apply a special gel to your abdomen and
then use a small device known as an ultrasound transducer to show your baby's
position on a monitor.
Next, your health care provider will clean your abdomen with an antiseptic.
Generally, anesthetic isn't used. Most women report only mild discomfort during
the procedure.
Guided by ultrasound, your health care provider will insert a thin, hollow needle
through your abdominal wall and into the uterus. A small amount of amniotic fluid
will be withdrawn into a syringe, and the needle will be removed. The specific
amount of amniotic fluid withdrawn depends on the number of weeks the pregnancy
has progressed.

You'll need to lie still while the needle is inserted and the amniotic fluid is
withdrawn. You may notice a stinging sensation when the needle enters your skin,
and you may feel cramping when the needle enters your uterus. The entire
procedure usually takes about an hour, although most of that time is devoted to
the ultrasound exam. In most cases, the fluid sample is obtained in less than two
minutes. The small amount of amniotic fluid that's removed will be replaced
naturally.
After the procedure
After the amniocentesis, your health care provider may use ultrasound to monitor
your baby's heart rate. You may experience cramping or a small amount of vaginal
bleeding immediately after the amniocentesis. Your health care provider may
suggest resting after the procedure. You may want to ask someone to drive you
home. You'll likely be able to resume normal activities the next day.
Meanwhile, the sample of amniotic fluid will be analyzed in a lab. For genetic
amniocentesis, some results may be available within a few days. Other results may
take one to two weeks. Results of maturity amniocentesis are often available within
hours.
If you develop a fever after amniocentesis or if vaginal bleeding, loss of vaginal
fluid or uterine cramping lasts more than few hours, contact your health care
provider.

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39 YOF high grade squamous endometrial ca.,
ASK HER ABOUT RISK FACTORS
In Lab work you always ask Why?
And is it the first time?
SPIKE
Explain
Local symptoms
CSx
MGOS
PMHx
Plan (colposcopy)

INTRO:
...because it is the first time I want to ask you some questions so as to get a better
understanding of your results.
Why? Is it the first time? When was it done?
Any reason prevented you from doing it?
What was your result at that time?
If done long ago?
Some people want to know in
Are you the kind of person who prefers to know all the details about what is going
on?
How much information would you like me to give you about your diagnosis and
treatment?
Would you like me to give you details of what is going on or would you prefer that
I just tell you about treatments I am proposing?
If not anxious:
What do you know about Pap smear?
Yes, we look for changes in the cervix including cervical cancer
What do you know about Ca Cx?
It is a common cancer & we pick it up with Paps smear & if detected early, outlook
is good
What are your expectations of todays visit?
The results are back & I wish I had better news for you but unfortunately it
shows you have some changes in the pap smears, & these changes are called
HGSIL.& these changes if Ca or not are not detected by PAPs smear. We need to
do further assessment to determine whether it is Ca or not.

Let me ask you some questions to see if you have some symptoms related to it:
Local, Meta, Constitutional
LOCAL: Vaginal bleeding/Discharge/Ulcers/Blisters/Warts?
Pain with intercourse
Bleeding with intercourse
Lumps, bumps in groin area?
Fever,wt loss,Back pain?
MGOS
M:At which age you had your first period,
G: Any Gyn surgery
Contraception?
O: Have you been pregnant?
How many times?
At which age was your first pregnancy?
S: At what age were you sexually active?
How many partners did you have?
With whom do you live? How long have you been in this relationship?
Before this relationship,How many partners did you have?
STDs, Smoke,
How do you support yourself financially
Past Medical Hx
Family Hx
I have bad news. The colposcopy result came back and consistent with cervical
cancer.
We need to take further steps & I will refer you to a gynaecologist.
If you want future babies they will use local options & do something called a Cone
biopsy
If you do not want any more children the uterus & cervix will be removed & the
prognosis is excellent

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Allergic Rhinitis, Counsel
Intro
OCD (seasonal: caused by pollens from trees. Summer, spring, early autumn usually last several weeks,
disappears and recurs following year at the same time; Perennial: occurs intermittently for years with no
pattern or may be constantly present);
P: is the nasal congestion is only in one side (allergic rhinitis) or varies from side to side (vasomotor
rhinitis)
COCA-B (should be clear rhinorrhea, under microscope it contains increased eosinophils);
Watery/mucoid: allergic, viral, vasomotor, CSF leak (halo sign)
Mucopurulent: Bacterial, foreign body
Serosanguinous: Neoplasia
Bloody: Trauma, neoplasia, bleeding disorder, hypertension/vascular disease
A:
Allergic rhinitis (hay fever): most common inhaled allergans - house dust, wool, feathers, foods,
tobacco, hair, mold; most common ingested allergans wheat, eggs, milk, nuts;
Vasomotor rhinitis: caused by temperature change, alcohol, dust, smoke, stress, anxiety, neurosis,
hypothyroidism, pregnancy, menopause,
Drugs: parasympathomimetic drugs and estrogens (OCPs, HRTs);
Beware of rhinitis medicamentosa: reactive vasodilation due to prolonged use (>5 days) of nasal drops
and sprays (Dristan, Otrivin)
Sx: Itching eyes with tearing, frontal headache and pressure, hypothyroid symptoms, change in
menstruation (pregnancy/menopause); MOAPS (especially anxiety, neurosis, and drugs);
Complications: signs of sinusitis (pain in the face, post nasal drips, fever, severe headaches, teeth pain,
PMHx of sinusitis); Ask for diagnosis of nasal polyps or obstruction in breathing through the nose when
there is no sign of allergy; Ear pain (especially serous otitis media)
SHx:

Counsel:
From the Hx Ive just taken it is most likely that you suffer from a condition called: allergic
rhinitis/vasomotor rhinitis. This condition is very common and is caused by exposure to irritants in the
environment which are called alergans. These alergans trigger the immune system to release substances
which cause the congestion in your nose. Finding and eliminating the appropriate trigger/s can prevent
this condition. For that reason I am sending you to do some allergy testing.
Meanwhile I can recommend several options to alleviate your symptoms.
For allergic rhinitis:
Nasal irrigation with saline
Spray, nasal drops, or tablets with antihistamines (e.g. diphenhydramine, fexofenadine)
Oral decongestants (e.g. pseudoephedrine, phenylpropanolamine)
I wouldnt recommend to use topical decongestants since they may lead to a condition called
rhitinitis medicamentosa which may increase and deteriorate your condition. In case of necessity
you may use a topical decongestant up to five days.
There are many other medications that might help in case of serious condition like steroids
(fluticasone), or for prevention (disodium cromoglycate), also ipratropium bromide. If very severe
oral steroids may be used.
Desentization by allergen immunotherapy is also an option in some cases.
For vasomotor rhinitis:
Some relief can be achieved by exercise (increased sympathetic tone)
Drugs that called parasympathetic blockers (e.g. Atrovent nasal spray)
In serious conditions steroids (e.g. beclomethasone, fluticasone)
There are also some invasive procedures that might be used in stubborn cases. Surgery (which is
often with limited lasting benefit), electrocautery and cryosurgery which use hot or cold instruments
to affect the lining or your nose.
Overall this condition can be annoying but it is not dangerous and there are many ways to treat it.
However, in most cases it is repeated and the benefit of each treatment should be well balance against
its risks.

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Enuresis
Intro, ask about the concern
Ask about the name and age of the child
OCD - Analyze the problem:
Since when is he wetting his bed? Is it primary or secondary?
Does the child lose control on his bladder during day or only at night?
When did the child control his bladder and toilet?
How does the child feel about it? How do his caregivers feel about it?
R/O organic causes (red flags):
DM: Drinking too much, going more often to pee, feeling tired, lost weight
DI: Hx of meningitis, encephalitis (brain infection), head trauma
Seizure
UTI: Dysuria, odd smell or colour of urine
Neuro: Bowel dysfunction, leg weakness or numbness, trauma or surgery to back
Stress: Any stress or problem or new event
Others: Sickle cell disease, pinworms, constipation, and the most common cause for diurnal
dieresis is micturition deferral
PMHx including medications (diuretics) and allergies
FHx
BINDE (briefly because the child is 8-9 y.o)
How was the pregnancy (any problem)
How was the delivery (NVD vs. C/S)
Term or pre-term
Are his regular shots up to date?
How is his nutrition (does he eat well balanced diet)?
How is his school performance?
Who is the primary care giver? Who else live with them at home? Is he the only child?

Counsel
Explain what is happening say it is m/p regression of his development because of the
current stresses in his life
It is caused by maturational lag in bladder control while asleep. It is self limiting and you
need to give the child some time and he will adapt very well to the changes. About 20%
of the children resolve spontaneously each year.
The prevalence of this problem: 10% of 6 y.o, 3% of 12 y.o, 1% of 18 y.o
Treatment by changing life style: limiting nighttime fluids and voiding prior to sleep,
engaging child using rewards, bladder retention exercises, scheduled toileting
You can try a method called conditioning: wet alarm wakes child upon voiding this
method has 70% success rate
As last resort you can try even medication: DDAVP by nasal spray or oral tablets, but
there is high relapse rate and it is costly. Other medical options: oxybutynin (Ditropan),
imipramine (Tofranil) the latter is rarely used since it is lethal in overdose and has
cholinergic side effects.

Important Drugs to Remember

Enuresis
Desmopresin 0.2-0.6mg at bed time

Torticulosis
Treatment: Diphenhydramine 50mg

Warfarin counselling
Enoxaperin 20mg OD (low risk)
Enoxaperin 40mg OD (high risk)

Want to stop Li
Normal level 0.5-1.2

Breast feeding counseling

Osce Basil.

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Please note that this is only a draft version based on several sources, including: Dr.

Basel Mohasens lectures,

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