Professional Documents
Culture Documents
Summarize in brief, significant information in the History, then ask is that correct?
Explain initial diagnostic impression (lay terms),clot in lung instead Pulmonary Embolism.
Explain the investigation needed, tell the pat some test need to be run blood test instead CBC.
FOR THE PSYCHIATRIC CASES, Mr,Smith, I am really consider your complain, Here in our hospital they r
running some supporting group they are really good, I am encouraging you to join them, I can arrange this for you.
Patient who cant afford the test, offer her social support team.
Example:
History (O-PDF-SC-LIQR/ABCO-AAA)
Tell more about it ?
PAIN C/O:
TO COVER THE ASSOCIATION SYMPTOMES FOLLOW THIS STRATEGY FOR ALL COMPLAINS & ask on 2
sections:
Symptoms related to the same system involved (according to the complaint):
Example: abdominal pain we will ask about vomit, diarrhea, constipation, change in weight.
Seizures: is there any shaking? During the LOC was there any dribbling of urine, Tongue
biting & Confusion after regaining consciousness.
APPETITE: Is there any change in appetite?
WEIGHT: Is there any weight changes?
DISCHANGE:
DISCHANGE as vomit/diahria/constipation / cough.
Amount: Can you estimate roughly the amount of---? A cupful/teaspoon / table spoon
Blood: Have you noticed any blood in it?
Color: What color was vomit/Discharge/Stool?
Consistency: what is the consistency? Is it watery, fatty or bloody?
Odor: Did you notice any unusual smell?
Now you need to summarize what you get from the patient briefly.
Always should use the transition statement between each section in the history:
Example, I am going now to ask you some Qs about your health in the past? Is that okay with you.
Past Hx (PAM-HS-FOSS)
Previous episode: - Did you have any similar episode in the past?
- What other medical problems do you have? HTN/DM/stroke.
Allergy: Do you have any kind of allergy?
Medications: Have you taken any Medications?
Hospitalization: Have you ever been Hospitalize? Or have you had any Surgeries?
Sleep: What about your sleep?
Family Hx:
Does anybody in your family have similar medical problem?
Do they have any medical disease?
OBGYN Hx:
If Menopausal: just ask about the LMP and move on.
If CBP:
1. When was your 1st period?
2. When was your last period?
3. Do you have any problems related to your menstrual periods?
4. Are they regular?
5. How often do you have your period? / What is the length of you cycles?
6. How long do they last?
7. How many pads do you use on a heavy day?
8. Do you have any pain during your period?
9. Do you have any spotting in between your periods?
10. Do you notice any mood changes?
11. Do you have any discharge from the vagina?
12. When was your last pap smear? How was it?
13. Do you have any pain during sex? Any vaginal dryness?
Social Hx (SAD+STEPl)
MR/smith Now Im going to ask a something very personal! But I assure you, All the information
will be kept confidential.
Do you smoke? How many packs /day? How long have you been smoking?
Do you drink alcohol? Who much do you drink? What type?
if you suspect that this is an alcoholic, just ask her how much you can drink every time? Then
proceed to:
Have you ever thought to cut down on your drinking?
Have you ever felt annoyed by criticism of your drinking habit?
Have you ever felt guilty about your drinking habit?
Have you ever taken a drink first in the morning as an eye opener?
Have you ever use recreational drugs? How do you take it? How frequently do you take it?
when was the last time?
Is there anyone in close contact have the similar condition?
Have you traveled recently?
Do you exercise regularly? Do you feel decrease of your energy?
Do you have any cats or dogs in your home?
Is there any change in your libido?
Sexual Hx
Are you sexually active? How many partners do you have? Male/female or both? Are you using
condom? Have you ever diagnosed with STDs? (councel, okay ms.your sexual practice put you at
risk of contracting a STD including HIV, every time you doing sex you should insist that your
partner use condom. I recommend you to do HIV test? But we will need your permission? What do
you use for contraception?
Counsel:
The reason, why Im asking you this, because smoking/ drinking of excessive alcohol/ taking drugs
puts you at a higher risk to develop many diseases. So being a concerned physician I must advice
you to either limit its quantity or ideally quit it absolutely. Do you have any plan to quit?
(Yes) excellent! (No) I understand the old habit die hard and it is very difficult to quit it
suddenly. In case if make up your mind in future, we have got a very well developed support
program. Please feel free to contact me anytime if you need any help-Id feel happy to help you in
this regard.
Summarize:
Closure
-
All right, Mr._____, thank you for your kind co-operation. First of all, let me summarize.
As you told me that you have.is that right?
According to the information I got from you and from the examination, I am considering
the possibilities like you may have.. But to confirm the diagnosis, I need to run some tests
like blood test and scanning of your________ . As soon as I get the results, we will meet
again. And at that time I will explain you in the details and we will also discuss the
treatment options. ok? ----
Have you understand what we discussed today? Do you have any questions for me? No- If
you have any question later on, you can call me at any time. Ok, Mr._____It was nice to
meet you. Bye. Take care. (shake the hand with smile and leave the room )
Wrapping up or counseling is MUSTMUST-Never leave the room without it!
IF You didnt finish Questions or PE-proceed to wrapping up: Ive got an emergency call on
my pager and Ive to leave within a few minutes. Ill get back to you as soon as I return
back. However, before leaving Id like to summarize my findings so ar(Then start
counseling)!
Nose: Is there any cold symptom, rhinorrhea (runny nose), hoarseness? Any noisy breathe?
Chest: Is there any cough? Any braking sounds? Brings up any phlegm? if yes, ABCO.
ABDOMIN:
Urinary symptoms: how many diapers of urine changed/day? if < 6 is worrisome of
dehydration.
Bowel symptoms: how many diapers of stool changed/day? For Diarrhea, constipation.
Shaking, Skin Rashes?
PAMHSPAMHS-Foss:
Has your child had any past serious illness?
Does your child have any type of allergy?
Do you give your child any recent medications?
Is there any Hospitalization before? Have had any surgery?
Is there any sick contact at home? Sleep? Social Hx of MOM (SAD)?
Is there any medical problem in the child`s family?
BIG DEAL
Birth history: Any complications during pregnancy/ Full term or preterm? NVD/CS? Any
complications during or after delivery? Did you child needed to be incubated?
Is your child`s immunizations up to date?
Growth: what about his growth is it normal? Or did you notice nay delay?
Are you taking your child to a day care center? Ill contact?
Eating: can you tell me about your child eating? Do you feed your child from breast or bottle?
How is your child`s appetite?
When was the last routine check up? Was everything Ok.?
Counseling
Explain the D.D (fever due to infection of respiratory tract or ear or both, could be due to urinary tract infection,
seizure is benign and due to fever)
Explain the importance of child being here.
D.D:
- Otitis Media.
- Meningitis
- Scarlet fever
- 5th disease
- Varicella.
Investigations
CBC with differential count and ESR
Urinalysis
Ear examination
Fundoscopy
Lumbar puncture
Sickle cell scrapings.
Varicella antibody titer.
not the only ones affected by a child's diabetes. Everyone in the whole family is affected. The dynamics of the
entire family undergo changes.
Be reassuring:
reassuring You need to stress that the disease can be managed, whether it's through diet
and exercise or medication. You might tell them that diabetes is a serious disease and our life is
going to be a little different now. You can emphasize that diabetes can be managed more
precisely than in the old days.
Be helpful. Provide him written materials I will print out handouts that might answer your Questions when
they come up or you can also buy books about diabetes and how to manage it.
Be firm: Be sure that the extended family understands the seriousness of the disease and the importance of
Fatigue
Step-1: Follow the principle of OPD FC AAA
Step-2: Follow Head to toe history in a modified manner.
Headache/Lightheadedness.
Loss of consciousness.
Neck (or other parts) glands.
Do you snore?
Chest pain SOB or cough.
Pain anywhere in tummy.
Problem with urination or bowel changes
Any weight change /appetite.
Step-3: Ask hypothyroid history:
Cold intolerance.
Depression (how is your mood).
Hair fall
Voice.
Step-4: Ask about depression FACE SLIPS+ see or hear anything.
Do you hold any idea that others want to control you or harm you?
Step-5: Ask about probable Cancer/Bleeding (Anemia)
Do you have black stools? Or passed blood in your stool?
Have you ever vomited blood?
Do you find any difficulty in swallowing food?
Step-6: PAMHSFOSS
Examination:
Examine mucous membranes for pallor
Palpate neck for mass or swelling
Check memory, orientation and judgment
Counseling:
DD:
PTSD
Anemia
Chronic fatigue syndrome
Depression
Occult medical disease
Investigation:
CBC
Peripheral smear
Thyroid function tests
Serum electrolytes
RASH
-
COUGH
-
Sore throat
When did it start? How long have you been in this? Does it getting worse or better?
Is there is any fever, cough, chest pain, joint pain/rashes, do u notice any glands in your
neck, is there any rashes? pain over sinus areas? nasal discharge?
Is there is any abdominal pains, did you notice any change in your eyes color?
Is there is any swelling in your feet, chest pain, cough, racing of your heart, fainting
attacks or dizzy?
- Have you checked your cholesterol regularly? What was the last result?
Examination
Perform eye examination with ophthalmoscope
Look for JVD
Palpate for PMI
Auscultat all over the heart and lungs
Percuss for liver span.
Check for pedal edema.
Check peripheral pulses
Counseling
Explain the physical findings and diagnosis
Explain further work up (Blood tests, chest x ray, EKG and Echocardiogram)
Explain the importance of lifestyle modifications by quitting smoking, alcohol, exercise
program and dietary modification it decrease hyperlipidemia.
-
Lipid profile
Angiography.
ABDOMENAL PAIN
Tell me more about your pain?
How long have you been in this?
Does it start suddenly or gradually?
Does it get worse or better?
Tell me exactly where is your pain?
From 1 to 10, how could you scale your pain?
How does it feel like?
Does it move anywhere?
Did you notice anything that may aggravate it or may alleviate it?
Is there any associated fever, chills, vaginal discharge? What is your LMP?
Is your pain related to any kind of food? Is it increase by eating or after a while of eating?
Is there any associated vomiting, jaundice, change in bowel movement or color of stool?
Have you notice any change in caliber of stool? Any blood in it?
Is there is any change in weight or appetite?
Did you notice any glands anywhere in your body?
Examination
Auscultate abdomen prior to palpation
Palpate abdomen superficially
Palpate abdomen deeply
Checke rebound tenderness
Looked for CVA tenderness
Percuss for liver span
Performed Psoas sign and Obturator sign
Counseling
Explain the physical findings and diagnosis
Explain further work up (Blood tests, ultrasound, abdomen x ray)
Explain the importance of lifestyle modifications by quitting smoking, alcohol.
D.D for this Case
Appendicitis
Meckel's diverticulitis
Perforated Peptic Ulcer
Intestinal Obstruction
Pancreatitis
Urolithiasis
PID
Investigations
CBC with Differential Count
Abdomen X-Ray
Ultrasound Abdomen
Pancreatic Enzymes
Upper G.I Endoscopy
JAUNDICE
GIT cases: ask always on relation to type of food, bowel movement changes, change in
color of the stool, notice in blood in stool, vomiting any blood, change in caliber of the stool,
any loss of weight or change in appetite.
Do you have any bleeding tendencies?
Did you notice any enlarged glands?
Have you traveled recently?
Examination: examine the abdomen as usual.
D.D for this Case
Infectious hepatitis
Alcoholic hepatitis
Drug induced hepatitis
Primary biliary cirrhosis
Malignancy
Investigations
CBC with differential
Urine for bile salts
Anti mitochondrial antibodies
LFTs
Hepatitis screen
Diaharea
Explain further work up (Blood tests, stool examination) explained the importance of safe
sexual practices and use of condoms.
Ask to perform rectal examination
Advise to take increased fluids.
D.D for this Case
Gastroenteritis
Giardiasis
Iso-spora infection
Drug induced diarrhea
Investigations
CBC with differential count
Stool for culture and sensitivity
Stool examination for cyst and ova
CD 4 count
P24 load
Constipation
How long have you been in this? Does it getting worse or better?
Is it complete or partial?
Can you estimate roughly the amount of stool passed?
What is the consistency of stool?
Did u notice any blood in it?
Do you feel urge to defecate?
Do you feel after the evacuation that u didnt complete it? tenesmus
Is there any associated pain? Vomiting? Abd. Pains? Fever? Jaundice?
Is there is any swellings in your neck?
Is there is an episodes of diarrhea in-between?
Is there any urinary problem?
Do you feel depressed, fatigue and loss of interest in life?
Do you have thyroid problems, or do u have cold intolerance, weight.
Examination: abdomen
Counseling
Explain the physical findings and diagnosis (functional constipation, due to colon disease
(could be due to colon cancer, hypothyroidism)
Explain further work up (Blood tests, Stool examination, and Colonoscopy)
Ask to perform rectal examination.
D.D for this Case
Functional constipation
Carcinoma of colon
Hypothyroidism
Diabetic autonomic neuropathy
Bowel obstruction
Investigations
CBC with differential
Rectal examination and Stool for occult blood
Colonoscopy
Thyroid screen
Blood sugar and Hb A1c
Difficulty in swallow
Ask about onset, intensity, location? Progression?
Do you have difficulty to swallow solid foods or liquids? Which started first?
Is there any relieving factors or any aggravating factors?
Is there any vomiting or nausea, pain, fever or change in urinary or bowel habits?
Have you had heartburn?
Do you notice any change in voice?
Have you ever had accidental corrosive swallow before?
Do you have any difficulty in breathing?
Do you notice any swelling or masses in neck?
Do you notice any changes in skin or nails (scleroderma)?
Examination:
Palpate neck for swelling
Examine mouth and throat
Give the Pt water and ask him to swallow.
Palpate axilla and above clavicles.
Examine the abdomen.
Ascultate lungs & heart.
Counseling:
Explain about physical findings & possible diagnosis
Explain further work up
Explain probable modalities of treatment
Explain importance of quitting smoking
Offer help in trying to quit smoking
Offer continuous support during treatment
D.D:
Cancer esophagus
Achalasia cardia
Reflux esophagitis
Scleroderma
Investigations:
CBC
Barium swallow
Esophagoscopy
Chest X-Ray
ANC(1st BOOKING)
What is your LMP? Calculate GA, if it wasnt given.
How do you know about your pregnancy?
Obstetrical history.
Menstrual history (Menarche, regular periods)
D you know your Rh type of your blood, have you taken any blood before?
Contraception history before getting pregnant.
Is there is any problems of pregnancy (vomiting, fever, abdominal pain, vaginal bleeding)
Past History: as usual PAMHUGS - FOSS but add
Ask about history of exposure to cats.
Ask about rubella immunization in the past.
Ask about families health ( Congenital/ birth problem in the family )
Examination
Examine my eyes ( for pallor )
Examine Oral cavity (For general hygiene )
Examine Legs (for edema & varicose veins )
Auscultate Heart and Lungs
Examine and Auscultate abdomen ( If less than 28 weeks just do Fundal grip; If more than
28 weeks do all the Leopolds maneuvers)
Measure the BP.
Counseling
Explain the findings and further work up ( Blood for Hb, TORCH screen, HIV ( took the
consent) , Hepatitis Screen, U/A, abdominal Sonogram )
Advise to stop usage of tobacco and alcohol consumption.
Advise for safe sexual practices.
Explain the need for vitamins, Iron supplementations and nutritious diet.
Explain the importance of avoiding sick contact (if Rubella ve titre)
Explain the importance of regular ANC visits.
Investigations
CBC with differential count, Blood grouping and typing.
Urine Analysis.
Ultrasound of Abdomen
TORCH Screening
Hepatitis B Screening
HIV Screening
Amenorrhea
When was that? When was your LMP?
Do you have a period every month? How many days it last?
How many pads do you use every time?
Investigation:
Pregnancy test and pelvic examination
CBC
Urinalysis
USG abdomen
Thyroid function tests and serum prolactin
DIFICULTY IN MICTURATION
HPI:
Does it start suddenly or gradual? How long have you been in this? Does it getting better
or getting worse? How frequent do you need to urinate? What about night?
If I asked you about the flow of your urine, is it continuous or interrupted? Do you notice
any blood in it? When at the beginning or last or all through your urination?
How difficult is it initiating or maintaining the flow?
Do you feel rush to urinate, burning sensation, fever or chills?
Have you got any trauma to spine? Or accidents?
Is there any weakness in legs?
Is there any change in bowel movements?
Are you taking any recent medicines?
Examination:
Auscultate abdomen
Palpate abdomen Suprapubic area (superficial and deep)
Palpate back (costovertebral angle)
Test reflexes in legs
Ask to perform rectal examination
Counseling:
Explain physical findings and probable diagnosis & the work up
Explain the importance of rectal examination
Explain how the beer intake may increase the frequency
DD:
Benign Prostatic hyperplasia
Prostatic carcinoma
Stone in urinary tract
Infection
Sphincter dysfunction
Investigations:
Per rectal examination
CBC
Urinalysis
Renal function tests and IVP
Prostate specific antigen (PSA)
INCREASED URINATION
Confusion
ask about daily activities which are:
Do you need any help getting dressed?
Do you need any help feeding yourself?
Do you need any help going to the toilet?
Do you need any help cleaning your house?
Do you need any help shopping?
Do you need any help bathing?
Do you need any help accounting?
Hallucinations/Psychosis
Just like a case of depression & add:
When did hallucinations 1st appear?
Would you plz tell me more about it? What are these voices telling you?
Was it sudden in onset?
How long have you been having this problem?
How frequent does it occur?
Do you see something? Feel something or being touched? Bugs crawling on body?
Do you feel as if other people are trying to harm or control you?
Are you taking any illegal drugs?
If yes: How long have you been taking this? How frequent? have you ever taken IV drugs also? Do you know your
HIV status?
Have you had any recent stressful event in your family or work?
Have you ever been diagnosed with mental illness?
Would you like to meet with a counselor to help u with your problem?
Insomnia
History:
Since when you have this problem?
How many hours do you use to sleep?
Do you have any difficulty falling asleep or staying asleep?
Cardiac arrhythmia
Drug induced othostatic hypotension
Seizure
AS.
Inquire about ADLs (active daily living): Dressing, Eating, moving about, Toileting.
Ask about IADLs (Instrumental activities of daily living): Shopping, housekeeping,
accounting, food preparation, transportation-driving.
Could you tell me about your living conditions briefly? Do you have any one to help you?
Is there any heat intolerance, voice change, hair loss (thyroid).
Are you feel sadness and loneliness? Have you ever felt like ending your life?
Examination
Examine eyes & neck
Examine heart and lungs
Examine MMS.
Examine touch, pain and temperature sensations in legs and hands
Test muscle power in limbs: rigidity, reflexes.
Ask me to get up and walk and turn around and sit again
Do finger nose test
Do alternating movements test
Do Romberg's test
Check jerks in limbs including planters.
Would you plz move your arms. (to see if the tremor disappeared with movement)
Counseling
Explain the physical findings and diagnosis
Explain further work up [Blood tests, blood sugar, MRI] .
D.D for this Case
Cerebellar disease [Alcoholic/Tumor]
Parkinsons disease (idiopathic/drug induced)
Diabetic neuropathy [Sensory ataxia]
Brain tumors
Hyperthyroidism
Investigations
CBC with differential
CT or MRI [ posterior Fossa]
Serum electrolytes
TSH, T3, and T4.
ECG
When did it start? Does it start suddenly or gradually? Does it getting better or worse?
Does it constant or comes & goes?
Is there is anything that may aggravate it or alleviate it?
Do you have any H/O fits, loss of consciousness, complete loss of vision, eye problems and
high blood pressure?
Do you experiencing any thirst lately?
Do you eating more than you usually do over the past few months?
Is there is any change of weight?
Do you have problems attaining and maintaining erections while having sex?
Do you have problems while walking? You feel pain while walking.
Is there is any numbness and tingling in a glove and stocking distribution?
Is there any associated headache or nauseating? When was that?
Examination
Check eyes with an ophthalmoscope
Did a focus neurological exam with special emphasis on Sensory examination of the
extremities
Test for vibration sensations on bony prominences proceeding from distal to the proximal
Listen to my carotid arteries
Do Heart exam (PMI palpation, Auscultation)
Felt for pulses in the lower limbs
Counseling
Explain the possibility of being afflicted with Diabetes
Explain the importance of weight reduction
Explain that diet would be a major part of my treatment regimen. Medications would be
secondary.
Explain the various precautions that I need to be taking to avoid injury to my feet
Show understanding of the SP problems with erectile dysfunction and discuss treatment
options.
Ask about family support systems.
Explain that regular follow-up would be necessary for my vision and other problems.
Explain that the SP can monitor his own blood sugar.
Motivate towards a better lifestyle.
Use appropriate transitions sentences while asking about sexual history (Mr. Jones. I am
now going to ask you some questions regarding your personal life. I assure you that they
will be kept confidential. Please do not feel embarrassed.)
D.D for this case
Diabetic retinopathy
Hypertensive retinopathy
Macular degeneration
Cataracts
Open angle glaucoma
Workup
CBC with differential count
Diabetic screening--Fasting blood glucose and Standard GTT
Urinalysis for microscopic proteinuria
Lipid profile
Doppler of carotids and lower limb vessels
Dizziness
HPI
When did it start? How long have you had this?
Did this related to posture? What brings it and what relieve it?
Have you ever lost consciousness?
Are there any associated symptoms: chest pain, rings in ears, dripping of urine, did you
notice any weakness in limbs?
Are you taking any drugs for BP control? From the vitals given?
Was there any recent change in medication or dosage?
Asked if there is any change in bowel or bladder habits?
Examination:
Check BP on both hands in sitting, standing and lying position.
Check motor power and sensations in all limbs
Check reflexes
Examine cranial nerves
Auscultate heart & lungs
Counseling:
Tell that you need to record BP in all limbs.
Explain physical findings and probable diagnosis.
Explain further work up & the treatment.
Explain the importance of quitting smoking and offered help
Explain the effects of medication change
Congratulate the pt for doing regular exercise and ask him to continue doing it regularly.
Explain the import of changing dietary habits (less salt).
DD:
Drug induced hypotension
Postural hypotension
TIA
Arrhythmias
Coronary artery disease
Investigations:
CBC
Doppler carotid study
Blood Glucose
Serum Electrolytes
EKG and Holter monitoring.
D.D.
Presbyacusis
Cerumen impaction
Ear drum damage
Infections of the ear
Otosclerosis
VIII Nerve lesions (CNS tumors)
Meniere's disease
Trauma to the ear
Drugs
Investigations
CBC & ESR
Audiometry
FOBT and sigmoidoscopy as a screening for his age
Lipid profile as a screening for his age
Seizure
HPI
When did it start? Does it start suddenly or gradually? How long did it last? How long have
you been in that?
Did you notice any trigger to this seizure? Anything make it go away?
Have you lost your conscious during the attack?
Have you Had a vague feeling of dizziness 10 min before each episode (Aura)
Tell me about the seizure was it jerking or thrashing movements of limbs?
Was there any biting of tongue? Have you passed urine or feces?
Tell me what happened after the attack, did you vomit, or did you feel any weakness in your
limbs?
Do you have or had any headache?
Have you had any recent trauma to your head?
DD:
Epilepsy
Tumor
Encephalitis
Meningitis
Trauma
Investigation:
CBC and electrolytes
CT Scan of head
Lumbar puncture
Blood and urine glucose levels
Serum electrolytes
IMPOTANCE
When did it start? Does it getting worse or better? Does it comes and goes or constant?
Does there any factor increase it or any factor that may decrease it?
Would you grade your impotence on scale from 1 to 10 where 1 is flaccid and 6 is adequate
for penetration?
Do you have any problems of sexual desire? ejaculation?
Do you have any pain in the legs (claudication)
Is there any anxiety or depression?
Do you feel that u became intolerant the heat or cold wither, weight changed, any racing of
your heart?
Examination: Palpate abdomen gently & Examine pulsations in lower limbs
Counseling
Advise home glucose monitoring & Advise to strict to diabetic diet
Advise about the importance of exercise program and quitting alcohol and smoking
Advise and explain some relaxation techniques
D.D for this Case
Diabetic neuropathy
Chronic alcoholism
Anxiety
Head injury with endocrine dysfunction
Spinal cord dysfunction
Investigations
Blood sugar
Postage stamp test
X-Ray spine
MRI of brain
Rectal examination
Investigations
HEENT:
1. X-ray, CT, MRI of head
2. Eye- Snellens chart, Visual acuity
3. Ear- Complete audiometry and tympanometry, Culture/Sensitivity for any discharge
4. Routine CBC with diff, ESR
CNS:
1. Routine CBC with diff, ESR
2. X-ray, CT, MRI
3. Lumbar puncture
4. Carotid Doppler study
5. EEG
6. EMG & Nerve conduction studies.
7. ECG
Musculoskeletal:
1. Routine CBC with diff, ESR
2. X-ray
3. Joint aspiration for culture/ sensitive, cytology, crystals
4. Rheumatic factor, HLA-B27.
5. Serum uric acid levels
6. Antinuclear antibodies, anti dsDNA
7. Muscle biopsy
CVS:
1. EKG and echocardiogram
2. Cardiac enzymes (CPK-MB, Troponin, LDH)
3. Chest X-ray
4. Lipid profile
5. Thyroid screen
6. Serum electrolytes
Respiratory:
1. Routine CBC with diff, ESR
2. Chest X-ray & PPD
3. Sputum studies (culture/sensitivity, gram stain, AFB)
4. Pulmonary function tests and spirometry
6. ABG and pulse oximetry
Abdominal:
1. Routine CBC with diff, ESR
2. Abdominal X-ray & Ultrasound
4. LFTs
5. CT abdomen/pelvis
6. Upper GI series-Barium swallow, endoscopy, ERCP
7. Lower GI series- enema, Colonoscopy
8. Test for fecal occult blood/rectal examination
9. Pancreatic enzymes (amylase, lipase)
10. Renal function tests
Endocrine:
1. Routine CBC with diff, ESR
2. Blood sugar
3. Serum electrolytes & calcium
5. Thyroid screen T4/T3/TSH
6. 24hr urinary catecholamines and metabolites
7. Urine for ketones and sugar.
Psychiatry:
1. CBC and ESR
2. CT and MRI of brain
3. Thyroid screen
4. Electrolytes
5. Urine analysis
6. Drug screen / HIV
CHALLENGING QUESTION
Tremor case: Do you think I will get better?
I think your tremor will improve with medication, but I dont know how long the
improvement will last. The tremor may be a sign of a larger movement disorder called
Parkinsons disease, and we need to do more evaluation to explore that possibility.
Passing out case: Do you think I have a brain tumor?
I think its unlikely. To make absolutely sure, however, we will do a CT scan, which is a
special x-ray test of the brain. That will help us see the structure of the brain and rule out
any bleeding or tumor.
Weight gain: I want to go back to smoking because I believe that I have started gaining
weight since I quit.
I understand that your weight is very important to you, but its clear that the health
consequences of smoking far outweigh those associated with weight gain. We also need to
determine what else might be contributing to your weight gain and then discuss strategies
to deal with it.
2ry amenorrhea in 35 age: Am I going through menopause?
I doubt it. It would be extremely unusual at your age. I need to learn more by asking you
about other symptoms and examining you, and then we can discuss possible reasons you are
not having periods.
Vaginal discharge case: When asked about vaginal discharge, ask, Do you think I have a
sexually transmitted disease?
There are many causes of vaginal discharge, only some of which are due to STD
infections. I will try to look for clues by asking you more questions and examining you, and
we will definitely send a sample of the discharge to the lab to check for infection.
Back Pain case: I dont think I can go to work, doctor. Can you write a letter to my boss
so that I can have some days off?
Youre right; heavy construction work can worsen your back pain or cause it to heal more
slowly. I will ask your boss to reassign you to light duty for a while.
Call encounter for mother c/o her baby has a diahrrea: How sick is my baby?
It is hard for me to give you an accurate answer over the phone. I would like you to bring
your baby here so that I can examine her and perhaps run some tests. After that, I
should be able to give you a more accurate assessment.
Hearing loss in elderly case: Do you think I am going deaf?
It is obvious from your symptoms and from the results of my exam that you do have
some kind of hearing deficit. We need to perform more complicated tests to fi gure out
the cause of the problem, to determine whether it is going to get worse, and to ascertain
whether we can halt its progression or improve your hearing. For the time being, I would
like you to stop taking aspirin.
Bed wetting case: Did I do something wrong to cause this problem? or
Is my child going to get better?
There are a few medical problems that can lead to your childs condition, but its just as
likely to be an isolated symptom. Bed-wetting is much more common than most people
believe, and there is no reason for you or your child to feel embarrassed or guilty. There
are a number of treatment options available for this condition, and after we have run a
few tests to rule out any physiologic abnormalities, I will discuss them with you.
Motor vheical accident case: Do you think I am going to die?
Your condition raises concern and is obviously urgent. We will start by taking some
images of your chest. Then, once we have a better idea of what might be wrong with you,
we can give you some medication to help you with your pain. If there is air or blood around
your lungs, there is a procedure we can perform that may release the pressure. We will be
monitoring you very closely from this point on, and if you have any signifi cant problems,
we will be available to make sure you keep breathing.
Old women with knee pain: Do you think I will be able to walk on my knee like
before?
Most likely, but that depends on the underlying problem and your response to
treatment.
HTN follow up case: I think it is my age. Isnt that right, doctor?
No, I dont think its because of your age. I worry more about your medications. However,
testosterone levels can decrease with age, and we will check for that.
Hematuria case:
case They told me this is because of my old age. Is that true?
No. Bloody urine is rarely normal.
HEADACHE in 35 yrs old women:
women Do you have anything that will make me feel
better? Please, doctor, I am in pain.
Yes, we have many options for medicines to relieve your pain, but first I need to learn as
much as I can about your pain so that I can recommend the best medicine.
Fatigue: either
Domestic violent: I want to go on a trip with my wife. Can we do the tests after I
come back?
It doesnt sound as if youre feeling well enough to be able to enjoy a trip. Lets do
some initial blood tests, and then we can see how youre feeling and decide whether
were comfortable letting you go away.
AIDS: I think that life is full of misery. Why do we have to live?
I am afraid that I might have AIDS.
This patient clearly has more to say. Silence is appropriate here, or some small
encouragement for the patient to continue talking. Alternatively, say, It sounds as if
youre losing hope. Have you thought about hurting yourself or tried to do so? Or
Tell me more about your concern about AIDS.
Alzheimer case:
case Do you think I have Alzheimers disease?
I dont know; we still need to do more testing. Tell me what you know about Alzheimers
disease.
Persistent cough:
cough Will I get better if I stop smoking?
Well, we still have to sort out exactly whats making you sick. Stopping smoking should
help your chronic cough, and over the long term it will significantly decrease your cancer
risk.
Young with Cough: Do I need antibiotics to get better?
Possibly. Antibiotics dont help with bronchitis because this condition is primarily caused
by viruses that are not sensitive to antibiotics. However, if we find that you have
pneumonia, antibiotics will be needed.
Child with a fever: Do you think that I did the right thing by coming here and telling
you about my childs fever? or Is my child going to be okay?
You absolutely did the right thing. Maria may have an infection that needs antibiotics; we
need to examine her here in the office and then decide whether she needs any more
testing or treatment.
Infant with fever: Is my child going to be okay? or Do you think I need to bring my
child to the hospital?
Well, I will need to examine your child first. Although I suspect that he has a viral
infection, I still need to make sure he does not have anything else.
Blood in stool:
stool My father had colon cancer. Could I have it too?
It is a possibility. Tell me more about the symptoms youre having that concern you with
regard to cancer.
Elderly with arm pain: Doctor, do you think I will be able to move my arm again like
before? I hope so, but first we need to find out exactly what is causing your problem.
Patient moving with extreme pain on the bed the moment you enter the room!
1. Introduce Yourself with appropriate soberness.
2. Say "I am sorry that you are in so much pain - I shall go through some quick questions and
physical examination - as soon as I am done, I shall promptly have my nurse give you something for
your pain. I only ask you to bear with me for a few minutes - Is that ok Mr. Clinton?"
3. Drape the SP
4. Start
"Dear Mrs. Bush, I understand the sensitive nature of this question, but be assured that this will not go out
of this room. The way clinical medicine works, there may be important clues hidden in this kind of information
and I want to do my best to help you. So shall we try answering these questions again ?"