Copyright ©2011, 2012 CS Note by dnt

Clinical encounter (15 minutes)
(“Examinees, you may enter the room”)

Doorway information (10-20 seconds) recall DDx, write down Ms. /Mr. … (LAST
NAME), … yo, F/M, CC, abnormal VS, OFPPLIQRAAA PAMHUGSFOSS, (no PE in pediatric
case).
Knock on the door (3 times), pause and breathe in and out, and enter the room with a smile.
“Hello, Ms. /Mr. …? (Verify the patient’s name) My name is Dr. … I’m your doctor today
(Introduce yourself). Nice to meet you.”
Shake patient’s hand if sitting or touch shoulder gently if lying, and make eye contact.
“I’d like to ask you some questions, and do a physical exam. Is that okay?”
Patients in severe pain: “I can see you are really suffering, I’m going to do everything I can to
help you. Let me just ask you a few questions and do a physical exam. I’ll be as quick as I can.
Okay?” (Making empathic statements)
Put down the clipboard on the side table. Unfold the drape on the stool, and cover the
patient from the waist down to the feet.
“All right, let me cover you up here.”
Sit down on a stool and keep the clipboard on your lap or keep standing (2 feet between
yourself and the patient) so that the patients can see you without turning their heads.

Taking the history (7-8 minutes)
“So, how can I help you today? (An open-ended question for chief complain) Oh, I’m so
sorry to hear that. Could you tell me more about it?” ------SAY “HOW CAN I HELP YOU
TODAY” INSTEAD OF “WHAT BRINGS YOU IN TODAY” (PATIENTS MAY ANSWER “BY
BUS”).

HPI (History of present illness): OFPPLIQRAAA ------SEE HPI Case-By-Case Guide




Onset When did it start? (“2 weeks ago”) Nodding, “2 weeks ago.” (Paraphrased
information throughout the encounter)
Psychiatric case: When did you start feeling this way?
Frequency Is it constant, or does it come and go?
\ˈkän(t)-stənt\
If intermittent: How often do you get this pain? When your pain starts, how long does
it last?
Precipitating factors Do you have any ideas of what might have brought it on? Have
you had a … injury recently?
Knee pain: Have you noticed a recent tick bite?
If Infection, ASK SICK CONTACT: Have you been around someone who is sick?
If fall: Could you tell me more about it? Did you pass out?
Progress Is the problem getting worse?
Location Please show me exactly where your pain is.

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Copyright ©2011, 2012 CS Note by dnt



Intensity
If physical pain: On a scale of 1to10, with 10 being the worst pain of your life, how
would you rate your pain?
Weight gain/lost: How many pounds have you gained/lost?
Tremor/memory loss: How does it affect your daily activities? ADL (Activities of Daily
Living): Do you need any help transferring from your bed to the chair? Going to the
bathroom? Bathing? Getting dressed? Feeding yourself? IADL (Instrumental Activities of
Daily Living): Do you need any help shopping? Cooking? With your housework? Paying
bills?
Quality
If physical pain: Could you describe the pain for me? Is it sharp/ dull/ pounding/ burning/
crushing/ cramping/ stabbing/ pressure-like/ tearing?
If vomiting, diarrhea, constipation, cough, vaginal discharge, vaginal bleeding: What does it
look like?
If vertigo: What does it feel like?
If dementia: What kind of things are you forgetting?
Psychiatric case: Can you describe what you have been feeling?
Radiation Does the pain travel anywhere else?
Alleviating factors Does anything make it better?
Aggravating factor Does anything make it worse?
BPPV: Does changing in your head positions make it worse?
If abdominal pain: Is there a relationship between food and the pain? What type of food?
If tremor, insomnia: Do you drink coffee? How much?
Associated symptoms Besides the ..., have you had anything else? How about …?
(ask questions pertinent to the chief complains and differential)

Cough, vomiting, diarrhea, constipation, vaginal discharge, vaginal bleeding:
OFPPQAAA







Onset When did it start?
Frequency How many bowel movements do you have per day?
Precipitating factors Do you have any ideas of what might have brought it on?
Progression Since the problem started, is it getting worse?
Quality What does your stool look like? /When you cough, does anything come up?
Amount Can you estimate the amount of your phlegm/vomitus/stool/discharge?
\ˈes-tə-ˌmāt\ \ˈflem\ \ˈvä-mə-təs\
------SAY PHLEGM, NOT SPUTUM!
Blood Is there any blood in it? If yes: Can you estimate the amount of blood?
Color What color is it?
Consistency Is it loose or watery?
Odor How does it smell?
Alleviating factors Does anything make it better?
Aggravating factor Does anything make it worse?
Associated symptoms Besides the ..., have you had anything else? How about …?

Past medical history (PMH): PAMHUGSFOSS (PAM HUGS FOSS!)
“Okay, Ms. /Mr. …, now I’d like to ask you some questions about your health in general.
Is that okay?” (Transition)
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Copyright ©2011, 2012 CS Note by dnt

Previous event of chief complain
 Have you had anything like this before?
 Have you had any other medical problems? How about …?
Diabetes, chest pain, HTN: Have you had diabetes? High blood pressure? High cholesterol?
Heart problems? Strokes?
CNS: Have you ever had strokes? Headaches? Seizures?
CVS: Have you ever had heart problems? Like heart attacks? Heart failure? High
cholesterol level?
RS: Have you ever had lung problems? Like TB? Asthma?
GIT: Have you ever had stomach/gallbladder/liver problems? Like ulcers?
GUS: Have you ever had kidney problems? Like kidney infections? Kidney stones? Have
you ever had any problems with your prostate?
Thyroid: Have you ever had thyroid problems? (If weight loss/gain, depression, abnormal
menses)
Cancer: Have you ever been diagnosed with any type of cancer?

Allergy Are you allergic to anything?
\ə-ˈlər-jik\
If rash, shortness of breath, rhinorrhea, conjunctivitis: Are you allergic to medications?
...Pets or plants? ...Foods? ...Coldness? ...Or dust? Could you tell me more about your
allergy? How often do you get it? Are you taking any medications for that? What kind of
allergy related reactions did you have?
Medication Are you taking any medications right now? Any prescription medication?
Any over-the-counter medications?
Cough: side effect of ACE inhibitors.
You don’t know that drug? “Oh, there are so many drugs out there; I’m not familiar with that
particular one. What are you taking that for?”
------MOST FREQUENTLY MENTIONED MEDICATIONS: Tylenol, HCTZ
(hydrochlorothiazide), Aspirin
brand names vs. generic names
Tylenol = Acetaminophen
ˈt -lə-ˌn l\
Advil Ibuprofen
ˈad-(ˌ)vil ˌ -byu-ˈprō-fən\
Allegra = Fenoxifenadine (allergy relief)
\ə-ˈleg-rə\
Maalox = Antacid (Aluminum Hydroxide and Magnesium Hydroxide)
Mylanta = Antacid (Mg. OH and Ca. Carbonate)
\m -ˈlan-tə\
Nexium = Esmoprazole
\ˈnek-sē-əm\
Prilosec = Omeprazole
\ˈpril-ə-ˌsek\
Zantac = Ranitidine
\ˈzan-ˌtak\
Lopressor = Metaprolol
\lō-ˈpres-ər\
Augmentin Amoxcillin Clavulanic Acid
g-ˈment-ən\
Zyban = Bupripion (Antidepressant + smoking cessation)
\ˈz -ˌban\
synthroid= levothyroxine
\ˈsin-ˌthr id\
Benadryl = diphenhydramine
\ˈben-ə-ˌdril\

History of hospitalization/surgery
 Have you ever been hospitalized? When?
 Have you had any surgeries? When?
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\(ˌ)ant-ˈa-səd\

Are you following a special diet?  Any changes in your weight lately? Over what period of time?  Sleep pattern changes Do you have any problems sleeping? “Okay. Is that okay?” (Transition)  Family history (FH)  Does anyone in your family have serious medical problems? How about high blood pressure? Diabetes? Diabetes: How about high blood pressure? High cholesterol? Heart problems? Strokes? HTN: How about Diabetes? High cholesterol? Heart problems? Strokes? \kə-ˈles-tə-ˌrōl\ CNS: How about strokes? …Headaches? …Seizures? CVS: How about heart problems? …Like heart attacks? …Heart failure? …High cholesterol level? RS: How about lung problems? …Like TB? …Asthma? GIT: How about stomach/gallbladder/liver problems? …Like ulcers? GUS: How about kidney problems? …Like kidney infections? …Kidney stones? Have you ever had any problems with your prostate? Thyroid: How about thyroid problems? (If weight loss/gain.  Have you had a Pap smear before? When was your last one? Was it normal? “Okay. /Mr. Is that okay?” (Transition) \ˌkän-fə-ˈden(t)-shəl\  Sexual history (SxH)  Ms. 2012 CS Note by dnt   Urinary changes Have you noticed any changes in your urinary habits? \ˈyər-ə-ˌner-ē\ Gastrointestinal changes  Any changes in your bowel habits? \ˈbau(-ə)l\  Any changes in your appetite? If diabetes/HTN: Tell me more about your diet. Pt. now I’d like to ask you some questions about the health in your family. NOT OCPs. …. abnormal menses) Cancer: How about cancer? Offer compassions if death was less than a year ago or if pt’s facial expression suddenly becomes sullen (Pt. female. are you currently sexually active?  How many partners do you have? If one: How many partners do you have over the last year? If multi-partners: Are they male. now I’d like to ask you some questions about your female health. or both? Do you always use condoms? Have you ever had a sexually transmitted disease? Have you ever been tested for HIV? \ˈkän-dəm\ 4 . OB/GYN history  When was your last menstrual period? Is your period regular? \ˈpir-ē-əd\  Have you been pregnant? How many times? How many children do you have? Any problems with your pregnancy? Any problems with your delivery? If SLE: Any miscarriages or abortions? How many times? In which trimester?  Do you use any methods of birth control? ------SAY BIRTH CONTROL PILLS.Copyright ©2011.: Thank you. Doc: What medical problems did she have? Pt. Whatever you tell me will be kept confidential.: Pancreatic cancer. Is that okay?” (Transition)  If it’s a female. Doc: And how is your father’s health?) “Okay. Doc: Oh. now I need to ask you some important questions about your personal life. depression.: My mother died last month. I am sorry.

Copyright ©2011. now I’d like to ask you some questions about your life style. how can I help you today?” HPI: OFPPLIQRAAA PMH: PAMHUGS BFCID (Baby has a kFC ID!) “Okay. Is that okay?” (Transition)  Previous event of chief complain  Has she had anything like this before?  Does she have any other medical problems?  Allergy Does she have any allergies? Does anybody in your family have allergies?  Medication Is she taking any medications right now?  History of hospitalization/surgery  Has she ever been hospitalized?  Has she had any surgeries?  Urinary changes Any changes in her urinary habits?  Gastrointestinal changes  What type of food is she eating?  Any changes in her bowel habits?  Any changes in her appetite? 5 . /Mr. Then.) “I’d like to ask you some questions. …? Are you …’s mother? My name is Dr. more than one drink/day for females: CAGE Have you ever tried to cut down on your drinking? Have you ever been annoyed by criticism on your drinking? Have you ever felt guilty about your drinking? Do you drink alcohol early in the morning? (Eye-opener) ------ONE DRINK: One 12 oz.” (Shake hands and make eye contact. Ms. 2012 CS Note by dnt “Okay.  Alcohol Do you drink alcohol? How much do you drink per week? How long have you been drinking? If essential tremor: Does alcohol make it better? If more than two drinks/day for males. beer/ One shot of 80 Proof liquor/ One 5 oz glass of wine. /Mr. …. Is that okay?” (Transition)  Social history (SH): SODASET  Smoke Do you smoke? How many packs per day? For how many years?  Occupation What kind of work do you do? If hearing loss: Are you exposed to loud noises?  Drugs Do you use any recreational drugs? \ˌre-krē-ˈā-shnəl\ Which one? How long have you been using it? Have you ever injected drugs? When was the last time you used the drug? ------MOST FREQUENTLY MENTIONED DRUGS: pot (marijuana). … Nice to meet you. Okay? So. cocaine. now I’d like to ask you some questions about her health in general. Ms. we’ll discuss everything.  Stress Do you have any stress from work or your family?  Exercise Do you exercise regularly?  Travel Have you traveled recently? Pediatric case: “Hello.

Physical exam (2-3minutes) I’m going to …  Inspection: take a look at your …. 2012 CS Note by dnt  Any changes in her weight?  Sleep Does she sleep well?  Birth  Was she born full term? Any problems with the pregnancy?  Was it a vaginal delivery or a C-section? Any problems with the delivery?  Family history Does anyone in your family have serious medical problems?  Checkup When was her last routine checkup?  Immunization Are your child’s immunizations up-to-date?  Development and Day care Have you noticed any problems with her growth and development? Does she go to a day care center or stay at home? Does anybody have a similar problem in the day care center? “Thank you. shall we start?” (Transition) HEENT: SP-sitting Head I’m going to press on different parts of your head and face. Do the maneuver “Okay. HEENT problems headache Palpation of the head. now I need to do a physical exam. …. /Mr. Please look at my finger. …. / Okay. headache EOM –CN 3. Please follow my fingers without moving your head.) I’m going to shine the light into your eyes and check the back of your eyes. 6 Thank you. /Mr. Please hold your right hand over your right eye. vertigo Inspection . Turn off the faucet with the paper towels. DM.  Percussion: tap on your …. excuse me. ears I’m going to take a look at your ears.  Auscultation: listen to your …. Let me dim the light. …. Is that okay? Let me wash my hands first. sinuses visual change Inspection of conjunctiva and sclera All 4 quadrants of visual fieldsprolactinoma PERRLA Ophthalmoscope-HTN. let me summarize. Rub your hands together if they are cold. Any pain with that? eyes I’m going to take a look at your eyes. Ms.Copyright ©2011. /Mr. You said … (CC+3 positive symptoms) Is that correct? Is there anything else you want to tell me that I didn’t ask?” (Summary) “Okay.4. just look at my left ear right here. I’m going to shine the light into your eyes. Ms. (Dim the light.” (Transition) Wash your hands with soap and water and dry them carefully.6 Hearing loss. and with your left eye. Can you see this finger moving? I’m going to check your eyes.  Palpation: press on your …. Can you look down for me? Can you look up for me? I’m going to check your visual fields. Ms.

please repeat them …doctor …hospital. Can you stick out your tongue for me? Say AH. shortness of breath. Please breathe in and out through your month. I’m going to take a look at the front of your chest. Again. Can you take a deep breath for me? Please repeat 99. Please swallow. pelvic pain Heart: SP-sitting I’m going to press over your heart. Do you hear that tone? (Yes) As soon as you don’t hear it let me know. Neck: SP-sitting I’m going to press on your neck. I’m going to tap on your chest. Please breathe in and out through your month. pedal edema Palpation of PMI Auscultation Abdominal pain. Do you need a cup of water? Chest: SP-sitting (3 levels on the back. Let 7 Inspection . DO NOT PERCUSS OR AUSCULTATE OVER SCAPULAS!) I’m going to take a look at the back of your chest. May I lower your gown? I’m going to press on your chest. constipation. palpations. hematuria. 2 levels on the front. Let me help you to lie down.Copyright ©2011. loss of consciousness. wheezing. I’m going to listen to your lungs. bloody stool. cancer Palpation of thyroid-memory loss. Abdomen: SP-lying Let me retie your gown. chest pain. fatigue Cough. Does it sound equal or one side louder than the other? I’m going to put the tuning fork back here. I’m going to check your belly. 1 level under each arm. I’m going to whisper some words in each ear. May I untie your gown? I’m going to press on your chest. diarrhea. I’m going to listen to your heart. Palpation Otoscope Hearing test Weber test Rinne’s test Sore throat Inspection of the throat Inspection of the tonsils Palpation of lymph nodesinfectious mononucleosis. Can you take a deep breath for me? Please repeat 99. 2012 CS Note by dnt I’m going to press on your ears. URI symptoms Inspection Respiratory excursion \ik-ˈskər-zhən\ Tactile fremitus \ˈfre-mə-təs\ Percussion Auscultation Inspection Respiratory excursion Tactile fremitus Percussion Auscultation Chest pain. I’m going to listen to your lungs. I’ll just pull out the leg extension and make you a little more comfortable. Again. UTI symptoms. (No) Do you hear it in your ear? throat: Doc-wear gloves I’m going to take a look at your throat. I’m going to put the tuning fork on top of your head. vomiting. Any pain with that? I’m going to check your neck. Please open up your mouth. Any pain with that? I’m going to look inside your ears. jaundice. shortness of breath. I’m going to tap on your chest.

Bring it up. Squeeze my fingers. 2012 CS Note by dnt me bring the gown up and lower the sheet a little bit.Biceps reflex. Bring it up. I’m going to check your sensation. Do this. Do this. Auscultation Percussion Tenderness Rebound tenderness Murphy sign-upper abd McBurney’s sign-lower abd Obturator sign-lower abd psoas sign-lower abd CVA tenderness-lower abd Join Pain. Any pain with that? I’m going to press in on your belly. extremity pain. Bring it in. Bring it down. fatigue Inspection Palpation. Please take a deep breath. May I untie your gown? I’m going to press on your shoulder. Bring it out. and internally rotate. Bring it down. pulses ROM (Range of motion) Muscles strength for UE Reflexes for UE. Any pain with that? I’m going to have you raise your right leg against my resistance. Please close your eyes and tell me what 8 Sensation for UE Inspection palpation. I’m going to press on your wrist. This is dull. I’m going to check your arm strength. I’m going to check your shoulder movements. I’m going to check your sensation. Any pain when I removed my hand? I’m going to press in on here. Do this. pulses ROM Muscles strength for UE Reflexes for UE Sensation for UE . Don’t let me squeeze your fingers together. swelling. Do this. Bring it out. I’m going to tap on your arms. I’m going to check your hand movements. Do this. I’m going to take a look at your belly. This is sharp. muscle weakness. stiffness. Do this. Any pain with that? I’m going to flex your right knee and hip. I’m going to listen to your belly. Do this. Don’t let me squeeze your fingers together. triceps reflex I’m going to tap on your arms. Wrist : SP-sitting I’m going to take a look at your wrist. This is dull. I’m going to press lightly on your belly. Any pain with that? I’m going to check your pulse. Do this. Do this.Copyright ©2011. Any pain with that? I’m going to check your pulse. Any pain with that? Any pain with that? Musculoskeletal (START WITH THE ONE THAT DOESN’T HURT) Shoulder: SP-sitting I’m going to take a look at your shoulder. This is sharp. I’m going to tap on your back. I’m going to tap on your belly. Please bring your knees up. Bring it in. Please close your eyes and tell me what you feel. Any pain with that? I’m going to press in on here. Any pain with that? Please turn to your left side. Do this. Squeeze my fingers. I’m going to check your arm strength.

Copyright ©2011. time. Any pain with that? I’m going to check your pulse. Bring it down. I’m going to flex your knee and juggle it around. Do this. This is sharp. I’m going to check your leg strength. This is sharp. Flip your hands over. Bring it up. and hold it there. Any pain with that? Keep your hands together like this. Any pain with that? Knee: SP-sitting/lying I’m going to take a look at your knee. Let me know what you notice. Ankle jerk reflex. Tinel test Phalen test Inspection palpation. Calf pain: SP-sitting I’m going to extend your foot. pulses ROM Muscles strength for LE Reflexes for LE-knee jerk. 2012 CS Note by dnt you feel. I’m going to check your leg movements. Bring it back. Kick it out. Bring it up. Do this. This is dull. I’m going to check your sensation. Do this. Any pain with that? I’m going to check your pulse. Do this. This is dull. Please close your eyes and tell me what you feel. Sensation for LE I’m going to pull and push on your knee. Keep your knee straight. I’m going to tap on your wrist. confusion. I’m going to check your sensation. Any pain with that? Lower back pain: SP-sitting I’m going to take a look at your back. Do this. Knee join effusion Anterior /posterior drawer sign: anterior/posterior cruciate ligament Medial /lateral Collateral ligaments McMurray's test : meniscus Homan’s sign-DVT Memory loss. pulses ROM Muscles strength for LE I’m going to tap on your legs. Kick it out. Bring it down. Let’s see if you have any swelling. Ankle jerk reflex I’m going to tap on your legs. person . Bring it down. I’m going to check your leg strength. Reflexes for LE-knee jerk. Bring it up. Bring it back. May I untie your gown? I’m going to press on your back. Bring it up. psychiatric problems Neuro: SP-sitting MMSE Now I’d like to ask some questions to check your 9 Orientation to place. I’m going to check your back movements. I’m going to pull on your knee outwards and inwards. Sensation for LE Straight leg test Inspection palpation. I’m going to take your leg up. Please close your eyes and tell me what you feel. Do this. May I lift up the sheet? I’m going to press on your knee. Bring it down.

Now the other side. Just relax. Please stick out your tongue and say. I’m going to bend your hip and knee.Copyright ©2011. Please smile and show me your teeth. or genital exam. Please close your eyes and tell me what you feel. This is dull. I’m going to touch your face lightly. I’m right behind you. breast. cover it immediately. I need to see how you walk.) (“Examinees. I’m going to check your sensation. “ah”. Don’t repeat painful maneuvers! After you have examined a given area. Any pain with that? immediate memory Concentration short-term memory 3. apple. Do you remember the 3 objects I told you? Cranial nerves I’m going to check your nerves. Please touch your nose with this finger and then touch my finger.) 10 . or to sit up): “I know you’re in really bad pain. Do you feel that? How about that? Is it the same? (do for all 3 branches) Please raise your eye brows. Meningeal signs: SP-lying I’m going to move your chin down toward your chest. Please close your eyes. I’m going to tap on your arms and legs. pelvic. Please stand up. I’ll be just as gentle and quick as possible. Please walk to the door and come back. Please clench your teeth. 2012 CS Note by dnt memory and concentration. But it’s totally necessary for me to do this physical exam/ I’ll get a better result if I can help you sit up.” (You do try it first. Babinski reflex Sensation Finger to nose Romberg's Test Gait meningitis Brudzinski sign Kernig sign Patients who refuse to be touched. rectal.10 11 12 Muscle strength DTRs. I’m going to tickle your feet lightly. book.4. Please Shrug your shoulder. Close your eyes. to move. Please follow my fingers without moving your head.” By this time you should be halfway through your physical exam. Where are you right now? What's the date today? What’s your full name? Now I will name 3 objects. table. Please repeat after me.6 5 7 9. Please spell "world" backwards.) (Don’t perform corneal reflex. So let me help you. you have 5 minutes left for this encounter. put your feet together and hands to you side. Cerebellar: SP-sitting and standing I’m going to check your coordination. MRS I’m going to check your muscle strength. Please stick out your tongue and move it from side to side. This is sharp.

such as ….” (No) “I understand it is very difficult to change an old habit. now I’d like to sit down with you and talk over what I think so far. From what you have told me and my physical exam. (Transition) From what you have told me and my physical exam.” Elderly abuse “One more thing. I think you may have an infection in your … / a blood clot in your lung vessels/ a venous clot / gallstone/ kidney stone/ inflammation of the tissue in your heel/ clinically depressed/ a vascular problem/ a stone in your urinary tract/ a brain disease that causes slow movement and tremor/ effect of diabetes on your nervous system (initial diagnostic impression). Ms. So I need to run some tests. as your doctor. I think little … may have …. as your doctor. I think you may have a brain disease that slowly destroys memory and thinking skills. Although everything we discuss is confidential. I will also bring back some support group information where you can go for help. Is that correct? From what you have told me. which could be fatal. /Mr. now I’d like to sit down with you and talk over what I think so far. Ms. I would like you to know that I am always here to help you whenever you need it. heart problems and lung disease/ STDs. I’ll also need to do a rectal/pelvic exam. As soon as I get the test results. Alzheimer’s disease: “All right. If you wish to stop drinking/ quitting smoking. I am concerned that alcohol/ smoking/ unprotected sex puts you at a higher risk of liver disease/ cancer. I would like to ask your permission to speak with your family. they can help me with the diagnosis. unexpected pregnancy. They will find the community resources to help you at home. Let me assure you that you are in good hands. I would recommend you to stop drinking/quit smoking/use a condom every time. Sometimes living with a family can be very stressful. …. 2012 CS Note by dnt Closure (3 minutes) “All right. But there are other possibilities. I think it will be best at this time if you can bring him to the hospital so that I can do a complete physical exam. But I want to assure you that whenever you are ready. we will meet again and discuss the final diagnosis and treatment options. However. HIV. I will be here to help you. such as …(DDx). I will order some blood tests/ a urine test/ a stool test/ X-ray (which is just to take a picture of your …)/ ultrasound (which is just to use sound waves to look inside your body)/ ECG (which is just to record the electrical activity of your heart)/ draw fluid from your knee/ colonoscopy (which is to use a flexible tube connected to a camera to look inside your colon)/ MRI (which is to use a large magnet to take a picture of your …). which is called XXXX (initial diagnostic impression). and run some tests. From what you have told me and my physical exam. I’ll do everything I can to make you feel better (appropriate reassurance).Copyright ©2011. I would just recommend you to avoid contact sports because of the possible risk of traumatic rupture of your spleen.” Domestic violence: “All right. But there are other possibilities. …. and more accurate imaging studies may be necessary as well. such as …. Right now. Ms. I am really concerned about your safety and your relationship with your husband. but I must involve child protective services if your children are being abused. and then we will discuss final diagnosis and treatment options. I am concerned about your safety. /Mr. we have many ways to help you. /Mr. You said ….” Counseling alcohol/smoking/unprotected sex “One more thing. I’m concerned about …. I would also like you and your family to meet with our social workers to evaluate the home-safety and supervision. now I’d like to sit down with you and talk over what I think so far. …. …. thank you for answering my questions. Have you ever considered moving 11 . (Infectious mononucleosis)” ri-ˈk rd\ \i-ˈlek-trikəl\ \ˌin-fləˈmā-shən\ \ˈti-(ˌ)shü\ Pediatric case: “All right. Ms. Let me summarize. /Mr.

so we will keep it in mind and try to rule it out. Since I stopped smoking. Can I go back to work? Unfortunately. and your family history does put you at a higher risk of …. First I have to make sure your illness is not life threatening. 2012 CS Note by dnt to an assisted-living community? If you are interested. heart problems and lung disease. imaging studies will help us rule out that as a possibility.” “Do you have any questions for me?” Challenging questions ------CAN BE BROUGHT UP ANY TIME My child is at home alone.” Diabetes/HTN “One more thing. our social works will help you take care of your child. Later on. I want to go back to smoking. I would recommend you to eat less fat/ do regular exercise/ weekly observe your feet. I understand you are concerned about …. I will also need to do a physical exam and perhaps order some tests. / It’s possible. as your doctor. Yes. Do you have anything that will make me feel better? I am in pain. 12 . I can’t give you a refill without reviewing your history. work may actually worsen your condition. as your doctor. To better understand your need for this medication. I must leave. I am concerned that eating fatty foods/ not doing regular exercise/ not watching your feet regularly puts you at a higher risk of getting complications of diabetes/HTN. Is it serious? Do I have cancer? Do I need a surgery? Am I going to die? Will I be able to move my arm again like before? I don’t know for sure. There are healthier ways to lose weight than smoking. but your problem may have other causes that we should rule out. So I’d like you to promise me that whenever you feel like hurting yourself. but first I need to learn as much as I can about your pain so that I can recommend the best medication. I think it’s normal at my age to have this problem. But at this point. I am always here to help you. we have social workers who can help you find the resources you need. Regardless. we have many options of medications to relieve your pain. we don’t know what we are dealing with.Copyright ©2011. So let’s go step by step. Drug seekers Since this is your first visit. such as exercise and diet. / You symptoms are of considerable concern. such as certain diseases or medications. We have social workers who can help you find the resources you need. I don’t have money/ transportation. contact me. I’m afraid I might have AIDS. Tell me more about your concern about AIDS. / I hope so. Therefore.” Suicidal ideation “One more thing. Age may play a role in the change you are experiencing. I am concerned about your safety. I have gained weight. After I figure out the cause of your problem. My father had a pancreatic cancer. could I have it too? Your symptoms are very unusual for pancreatic cancer. Smoking puts you at a higher risk of cancer. we can decide on the best way to help you. / It’s not life-threatening. I will ask your employer to give you light duty for a while. I can write a letter to your employer explaining your situation.

Rectal exam/ pelvic exam/ breast exam/ physical exam (Pediatric case)/ visual acuity by Snellen test 2.Copyright ©2011. no other major illnesses. I am so sorry you had to wait so long. and I will completely focus on you and your concerns. non-radiating. aspirin. HPI: -Abd pain is constant. CT-abd. I will be able to give you a more accurate assessment. -Meds: None / Ibuprofen. / …1 month ago. I would like you to bring her here so that I can examine her and run some tests. -No fever/chills/N/V/abd pain/…. exacerbated by …. After that. 2012 CS Note by dnt I think life is full of misery. I’ll be right back. at least 3. /Mr. hospitalization. all blood tests (be specific) 3. Tylenol. worsening over time. Ms. Why do we have to live? Life can be challenging. \ig-ˈza-mən\ “Do you have any other questions? (No) Okay then. abd 5.”) If you do not finish on time: “Excuse me. We had some unexpected delays with a few of the earlier patients. …. …. Bye and take care!” Shake hands or touch shoulder and leave the room. most likely to least likely. -Asso. -Alleviated by …. treatment. propranolol. up to 5) DIAGNOSIS WORK-UP (Do not order consultation. (“This encounter is now finished. -NKA/NKDA / Penicillin causes rash. all stool/urine tests (be specific) 4. Ms. treated with antibiotics.” Patient note (10 minutes) TYPE PNs IN FOLLOWING ORDER: DDx------WORKUP------Hx------PE! DIFERENCIAL DIAGNOSES (No abbreviation. w/…. HCTZ. But I am here now. I’m being paged. How sick is my baby? It’s hard for me to give you an accurate answer over the phone. thank you for coming in. lovastatin -Hosp: No hosp/trauma/surgery. /Mr. 7/10. XR-chest. Is there something in particular that is bothering you? Have you thought of ending your life? I have been waiting here for the whole day. in RLQ. after …. PMH: -No HTN/DM/high chol. cramping. up to 5) 1. / Hemorrhoid surgery 4 yrs ago 13 . pevis HISTORY … yo F c/o abd pain for … mins/hrs/wks/days/yrs.

/ 1 PPD for …yrs. RRR. nl. NT in 4 Qs. soft. CTAP bilat. Rinne: AC>BC on L ear. Back: Mild paraspinal muscle tenderness b/l. Weber no lateralization. nontender to palpation -Canals WNL. Abd: No scars. 2-3 beers/wk. No change in urination/bowel habits/weight. HEENT: -NC/AT. ND. no LAD. no r/r/w. / No oral lesions. Pediatric case: HPI: Offered by mother. no pharyngeal erythema or exudates. +BS or hypoactive/hyperactive BS. Neck: Supple. no m/r/g. good dentition. OB/GYN: LMP 2 wks ago. no warmth/erythema. TMs clear. occasional cocaine (last use yesterday afternoon). (-)STD. menarche at age 13. oropharynx WNL. 14 . monogamous or w/ husband only / unprotected sex w/ multiple partners. no carotid bruit. (-)psoas sign. G1P1 SxH: Sexually active. no JVD. stopped 3 months ago. ….Copyright ©2011. regular periods. SH: No tobacco/EtOH/illicit drugs. 2012 CS Note by dnt -No change in urination/bowel habits/appetite/weight/sleeping. -EOMI. -Mouth. funduscopy WNL or no papilledema. T 102. CV: PMI not displaced. PERRLA. no regular exercise/walks 20 minutes every morning. poor appetite/sleep BH: 40-wk uncomplicated vaginal delivery FH: No major illness Immunization Hx: UTD Development Hx: WNL. -Tenderness over …. S1/S2 nl. Chest: Nontender. PHYSICAL EXAMINATION VS: WNL except BP 165/95. -Breast-feeding / formula milk. nl thyroid. tactile fremitus WNL. FH: No major illness / Father died of … at age …. -NKA -Meds: Tylenol / amoxicillin \ə-ˌmäk-sē-ˈsi-lən\ -No hosp/trauma/surgery. (+)condom. RLQ guarding. PMH: -No major illness /Jaundice in the first wk of life. no HSM. CAGE 0/4. Ext: -No c/c/e / Erythema/swelling present. no CVA tenderness. visual fields full to confrontation. GA: NAD / in pain. nl ROM. last checkup 2 wks ago. / Direct and rebound RLQ tenderness.

Neuro: -A&O x 3. -Motor: Strength 5/5 in UE b/l / Unable to assess muscle strength due to pain.Copyright ©2011. -Sensation: intact to sharp and dull touch -(+)Homan’s sign on R ….”) (“You time is now finished. -2+ symmetric brachial and radial / popliteal and dorsalis pedis pulses. -DTRs: 2+ symmetric. -Sensation: intact to sharp and dull touch -Cerebella: (-)Finger to nose test.”) 15 . 2012 CS Note by dnt -Pain and restricted ROM on flexion/extension/abduction/external rotation of R …. (“You have 2 minutes left. (-)Babinski b/l. (-)Kernig. (-)Romberg -Gait: nl -(-)Brudzinski. good concentration and memory -CN II-XII intact -Motor: strength 5/5 throughout except 3/5 in L arm -DTRs: 2+ symmetric.

During the headache. Is there a relationship between stress and the pain? tension headache Do you feel confused? Do you have any problems speaking? Any weakness and numbness of your body? Subarachnoid hemorrhage. ESR CT-head MRI-brain LP-CSF analysis Meningitis CBC w/diff. do you have a runny nose and tearing red eyes? Does it happen at the same time every day? Does the headache wake you up from sleep? cluster headache Bilateral pain at the end of the day. 2012 CS Note by dnt HPI Case-By-Case Guide CC HPI (WRIT E DOWN ON YOUR CLIPB OARD) “Last A” (Associated symptoms) (ASK BOLD QUESTIONS. Temporal arteritis LP-CSF analysis myocardial ischemia or infarction. Before the headache.Copyright ©2011. \ˈvi-zhə-wəl\ Migraine \ˈm -ˌgrān\ Male. Do you feel confused? Did you feel nauseous? Did you throw up? Do you feel extremely sensitive to light (photophobia)? Is your neck stiff? pseudotumor cerebri Frontal pain. troponin ABG 16 . CPK-MB. intracranial mass lesion Did you feel nauseous? Did you throw up? Do you have blurred vision? OCP use. Sinusitis Unilateral temporal pain. do you have any visual changes? Like flashes of light? FH of migraine. cocaine-induced myocardial ischemia ECG CBC w/diff. Do you have nasal discharge? h/o sinusitis. ESR CT-head and sinus MRI-brain CBC w/diff. Unilateral temporal pain. Do you have blurred vision? Do you have any pain in your jaw while chewing? Do you have shortness of breath? Did you sweat when you had the pain? Do you feel any heart racing? FH of early MI. UNBOLD INFORMATION CAN BE GOTTEN FROM OFPPLIQRAA or PAMHUGSFOSS) DDx Workup (FOR PATIENT NOTES) Physical pain Headache Headache & fever Chest pain O F P P L I Q R A A A O F P P L I Q R A A A O F P P L I Q Unilateral temporal pain lasts for hours.

functional dyspepsia Rectal exam HIDA scan Rectal exam. hepatitis CT-abd H/o infectious mononucleosis. Intestinal obstruction H/o atrial fibrillation. amylase. clay-colored stool. gastroenteritis Do you have vaginal discharge? Multiple partners. lipase. gastritis. urine hCG U/S. pulmonary embolism CT-chest with contrast Uncontrolled HTN. pelvis CT-abd. Diverticulitis Recent cold. high-fat diet. Lowfiber. pelvic exam CBC w/diff UA. cholecystitis U/S-abd Dark urine. AST/ALT/GGT/ ALKP After fatty food.Copyright ©2011. ruptured ectopic pregnancy H/o abdominal surgery. Low BP. aortic dissection Echocardiograp hy Do you cough? When you cough. spleen rupture Upper endoscopy Did you feel nauseous? Did you throw up? Do you have diarrhea? Constipation? What’s the color of your stool? Is there any blood in it? Acute appendicitis. 17 peptic ulcer disease. 2012 CS Note by dnt R A A A Upper abdominal pain ------MUST KNOWN CASE Lower abdominal pain O F P P L I Q R A A A O F P P L I Q R A A A Pericarditis Costochondritis CXR Recent immobilization/surgery. does anything come up? Is there any blood in your phlegm? pneumonia Esophageal pH monitoring Do you have belly pain? Diarrhea? Constipation? Did you feel nauseous? Did you throw up? Do you have diarrhea? Constipation? What’s the color of your stool? Is there any blood in it? GERD Alcoholic. pancreatitis CBC w/diff. h/o gallstone. pelvis Mesenteric angiography . high HR and RR. PID Do you have any vaginal bleeding? How many pads or tampons do you use? When was your last menstrual period? Spontaneous abortion.abd. Pain>>PE Mesenteric ischemia/ infarction Alternating diarrhea and constipation.

Irritable bowel syndrome Do you have any pain during urination? Flank pain. Metastatic prostate cancer Insist on requesting a week off from school/work. Lumbar muscle strain. weight loss. Vertebral compression fracture. arm MRI-shoulder Arm pain Back pain O F P P L I Q R A A A O F P P L I Q R A A A Do you have pain in other joins? Do you feel any weakness of your arms and hands? Any numbness? Do you have any pain in other joins? Do you feel any weakness of your legs and feet? Any numbness? Have you ever lost control your bladder? Bone density scan Disk herniation. rotator cuff injury. Hematuria: Is there any blood in your urine? Fall on outstretched hand. No nausea. 2012 CS Note by dnt Pain is relieved by defecation. osteoporosis. Lumbar spinal stenosis Strain to urinate. Bursitis (Sac inflammation) DEFORMS shoulder dislocation XR-shoulder. UTI. malingering 18 Rectal exam PSA XR-L-spine MRI-L-spine Bone density scan . vomiting. Nephrolithiasis Could you tell me about your home life? How is your relationship with …? Do they treat you badly? Do you feel safe at home? elderly abuse NA (not available) humeral fracture. Myositis.Copyright ©2011. Alternating diarrhea and constipation.

ANA. OCPs use. retrocalcaneal bursitis. SLE Tick bite. Is your calf swollen? Is it red? Is it warm? Do you notice swollen veins on your legs? Do you have chest pain? Do you have shortness of breath? Lyme arthritis Deep venous thrombosis \ˈvē-nəs\ NA Cellulitis. anti-ds DNA. Disseminated gonorrhea CBC w/diff. Multiple partners. Myositis. Baker’s cyst rupture. uric acid NA. synovial fluid analysis CBC w/diff. RF. SPORTS Septic arthritis. fatigue. pain improves with walking. 2012 CS Note by dnt Knee pain ------MUST KNOWN CASE Calf pain Heel pain Calcaneusheel bone O F P P L I R A A A O F P P L I Q R A A A O F P P L I Q R A A A Is your knee swollen? Is it red? Is it warm? Rash on limbs. Miscarriages.foot calcaneal stress fracture Training for a marathon. Achilles tendinitis. XR-knee. Recent immobilization.Copyright ©2011. CPK. vaginal discharge. Pseudogout \ˈsü-(ˌ)dō\ UA NA Osteoarthritis Do you have any pain in other joins? Are your joins stiff in the morning? How long does it last (>1 hour)? Rheumatoid arthritis Have you ever have any pain in your big toe? Tophus (Gout) Have you lost hair more than before? Do you have a rash? Any ulcers in your mouth? Fever. PTT Doppler U/Sleg plantar fasciitis XR-leg MRI-leg XR-foot MRI. hands MRI-knee Arthrocentesis. PT. obesity. hematoma Do you have any pain in your joins? Do you feel any weakness of your legs and feet? Any numbness? When does it hurt the most? With the first few steps. D-dimer. tarsal tunnel syndrome NA Do you have any pain in your joins? Do you feel any weakness of your legs and feet? Any numbness? 19 Bone scan .

diabetes. did you feel light-headed? Did you have heart racing? Did you see. incontinence. memory loss. confusion O P P I: ADL. strokes.Copyright ©2011. Shaking (minutes). did you feel confused? Do you have a headache? Any changes in your vision? Do you have any problems speaking? Any weakness and numbness of your body? Do you have any problems speaking? Any changes in your vision? Do you feel any weakness and numbness of your body? HTN. Holter monitoring Palpitations. hear or smell anything unusual? When you passed out. did you have any shaking of your body? How long did it last? Did you bite your tongue? Did you lose the control of your bladder? After you gained consciousness. TSH LP-CSF analysis . myocardial infarction. LOC ------MUST KNOWN CASE O F P P Last A Echocardiogra phy Did you fall? Did you fall after you passed out? Before you passed out. Seizure CBC w/diff. Drug-induced orthostatic hypotension MRI-brain Cardiac arrhythmia. IADL Q A A A EEG CT-chest VANISHED Vascular (multiinfarct) dementia CT-head or MRI-brain NA Alzheimer’s disease Do you have problems walking? Have you ever lost control of your bladder? Normal pressure hydrocephalus NA intracranial tumor Head injury. Lytes. Pass out. Convulsive syncope Orthostatic vital signs Warning prior to passing out. Lytes. 2012 CS Note by dnt Multi-systems Falling and shaking (seconds). Hypoglycemia ECG. prolonged confusion. Diuretic use. tongue biting. Do you have a headache? Have you ever passed out? Subdural hematoma Is your skin very dry lately? Can you Hypothyroidism 20 CBC w/diff. glucose.

cholesterol 24-hour urine free cortisol . relieved by alcohol. Depression Is your skin dry lately? Can you tolerate cold environments? Has your voice changed? Do you have constipation? Have you had any changes in your menstrual periods lately? When did the change start? Do you have any problems sleeping? Do you feel sad? hypothyroidism Smoking cessation TSH Urine hCG Weight gain O I Last A 21 Glucose. Lungs. Drug-induced tremor Sleeping problems TSH. AST/ALT 24-hour urinary copper MRI-brain Is your skin very moist lately? Have you lost more hair than before? Can you tolerate hot environments? Hyperthyroidism NA Wilson’s disease Do you have a headache? Have you ever passed out? Any changes in your vision? Speaking? Any weakness and numbness of your body? Stress. Caffeine-induced insomnia Urine toxicology Do you snore during sleep? Obstructive sleep apnea Have you been feeling depressed most of the day? Quit smoking. 2012 CS Note by dnt tolerate cold environments? tremor O P P I: ADL and IADL Q A A A Diabetes. Resting tremor. O P P I Q A A A Parkinson’s disease Liver biopsy Stress-induced insomnia Polysomnogra phy Coffee. Essential tremor Exacerbated by anxiety/sleep deprivation/fatigue/caffeine. Ceruloplasmin . Liver. Hypoglycemia Have you been feeling depressed most of the day? (Emotional problems) Depression with pseudodementia Problems with heart. Kidneys. Physiologic tremor B-agonists/nicotine/neuroleptics. Is your movement slower than before? Delirium Action tremor.Copyright ©2011.

Do you notice any abnormal hair growing on your face or body? polycystic ovary syndrome LMP pregnancy Have you been feeling depressed most of the day? Depression Recent stressor. Adjustment disorder CBC w/diff. Orthostatic hypotension due to dehydration ˌ r-thə-ˈsta-tik\ CT-abds ears Dizziness . lithium-related obesity. vertigo O F P P I Q A A A Dizziness on moving the head. diuretic use. serum B12 Recent stressor. VDRL/RPR. Lytes MRI-brain Electronystagm ography audiometry . Do you have nightmares? Post traumatic stress disorder Urine toxicology Is your skin dry? Can you tolerate cold environments? Hypothyroidism Stool for occult blood Do you snore during sleep? Do you feel sleepy during the day? Obstructive sleep apnea polysomnogra phy Do you feel safe at home? Domestic violence ambulatory nocturnal pulse oximetry Fatigue increases gradually during the day. ferritin. Hearing loss. ˈres-p(ə-)rə- 22 Benign Paroxysmal positional vertigo \ˌpa-rək-ˈsiz-məl\ Vestibular Dix–Hallpike test Orthostatic vital signs CBC w/diff. TIBC. Meniere’s disease \mənˈyerz\ Diarrhea. Recent URI.Copyright ©2011. hearing loss. TSH. 2012 CS Note by dnt Fatigue ------MUST KNOWN CASE O P P I A A A Taking lithium. iron level.room spinning. Do you have any changes in vision? Myasthenia gravis HIV antibody NA Anemia MRI-brain Epigastric discomfort radiating to the back Pancreatic cancer U/S-abd Multiple partners HIV infection Tinnitus.

fatigue. smoker. infectious mononucleosis Fever. Smoker. Fever. acid-fast stain and culture Do you have shortness of breath? Do you have wheezing in your chest? Asthma SOB. LAD.Copyright ©2011. fatigue. peripheral smear Monospot test Anti-EBV antibodies HIV antibody and viral load Throat swab for rapid streptococcal antigen and culture Upper respiratory infection. Tuberculosis PPD SOB on exertion and at night. fever. 3 monthsX2years. sore throat. Labyrinthitis \ˌlab-ə-rin-ˈth təs\ Tinnitus: Do you hear ringing in your ears? \ˈti-nə-təs\ Hearing loss: Can you hear things clearly? Do you have the feeling of fullness and pressure? Do you have discharge from your ears? Did you feel nauseous? Did you throw up? Do you have belly pain? Do you have Diarrhea? Do you have a headache? Have you ever passed out? Do you fall often? Res Sore throat Wet Cough O P P A A A O F P P Q A A A Sick contact. Lung cancer PFTs Do you sweat at night? Last PPD. acute HIV infection CBC w/diff. bacterial pharyngitis. Do you have a headache? Do you have swollen glands? Do you have a rash? \ˈswō-lən\ Do you have a runny nose? Do you have chest pain? Do you cough? Do you have belly pain? Did you feel nauseous? Did you throw up? Recent runny nose. multiple partners. CHF Pulse oximetry 23 . Chronic bronchitis CXR Do you have chest pain? Pneumonia CT-chest Hemoptysis. other viral pharyngitis IV drug abuse. TB exposure. 2012 CS Note by dnt ˌt r-ē\ neuronitis. LUQ discomfort. Weight loss. Acute bronchitis CBC w/diff Sputum Gram stain.

abdominal pain. watery diarrhea. diverticulosis Young. ova and parasitology. watery diarrhea. C. abdominal pain. Crohn’s disease colorectal cancer NA hemorrhoids Do you have any pain during a bowel movement? anal fissure \ˈfishər\ Chronic constipation. sphincter of Oddi disfunction Alcoholic hepatitis ERCP Acetaminophen liver toxicity gastroenteritis Rectal exam Recent antibiotics. Abdominal cramps. PT. 2012 CS Note by dnt GI. pseudomembra nous colitis CBC w/diff. ulcerative colitis Recent antibiotics. tenesmus. Fever. cholangiocarcin oma. abdominal pain. Traveler’s diarrhea Watery diarrhea. Did you feel nauseous? Did you throw up? Do you have belly pain? O F P P Q A A A Pancreatic cancer.Copyright ©2011. viral hepatitis serologies U/S: abd Viral hepatitis CT: abd Sick contact. PTT. Abdominal cramps. Fever. pelvis Colonoscopy Did you feel nauseous? Did you throw up? Do you have belly pain? Do you have diarrhea? Do you have constipation? Tenesmus: Do you feel as though you strain to go to the bathroom but nothing comes out? \tə- 24 Barium enema \ˈe-nə-mə\ . culture. leukocytes. PT/PTT. pseudomembra nous colitis Recent in Mexico. Abdominal pain. Irritable bowel syndrome Diarrhea. bilirubin. Weight loss. Watery diarrhea. Weight loss. low-fiber diet. Do you feel bloated after milk ingestion? Lactose intolerance Abdominal cramps relieved by defecation. Diarrhea. GU Jaundice O P P A A A What’s the color of your stool? What’s the color of your urine? Do you feel itchy of your skin? Do you have belly pain? Do you have nausea and vomiting? Do you have diarrhea and constipation? Diarrhea Blood in stool O F P P Q A A A CBC. Lytes stool for occult blood. ALT/AST/GGT/ ALKP. constipation. CEA CT-abd. difficile toxin CT-abd colonoscopy Rectal exam CBC w/diff.

PTT. Prostate cancer UA. Painless. BUN/Cr. serum hCG Is your skin dry? Can you tolerate cold Thyroid disease UA 25 . Polycystic kidney disease Do you feel nauseous? Did you throw up? Frequency: Do you urinate more often than before? Are your breasts full and tender? pregnancy Is your skin dry? Can you tolerate cold environments? Thyroid disease Do you have a headache? Any changes in your vision? Do you have nipple discharge? Prolactinoma Do you notice any abnormal hair growing on your face or body? Polycystic ovary syndrome Do you get hot flashes? Vaginal dryness? Do you sweat at night? Menopause. \ˈbrüz\ Coagulation disorder CBC w/diff. testosterone UA. Bladder cancer CBC w/diff. painter.Copyright ©2011. TSH. TSH. bladder CT-abd. Painless. urine cytology Weight loss. prolactin. Do you have flank pain? Urolithiasis HTN. PT. Flank pain. PSA. pelvis cystoscopy GYN amenorrh ea Vaginal bleedingyoung O P P Q Last A O F P P Q A A NA Pelvic and breast exams CBC w/diff. Glomerulonephr itis Family history. PT/PTT Nocturia: Do you have to wake up to urinate at night? Hesitancy: Do you have to wait before urination? Straining: Do you have to strain during urination? Stream: Is the flow of your urine weak? Dribbling: Is there any dribbling after urination? BPH. Frequency: Do you urinate more often than before? Do you have any pain during urination? Urgency: Do you have to rush to urinate? Bloody urine O F P recent injury P Q A A A UTI Rectal and genital exam Heavy smoker. urine hCG U/S-pelvis Pap smear Pelvic exam H/o easy bleeding or bruising. edema. LH/FSH. 2012 CS Note by dnt ˈnez-məs\ Fever. Premature ovarian failure Dysfunctional uterine bleeding U/S-kidney. Renal cell carcinoma History of renal stones.

Vaginal bleedingelderly O F P P Q A A A Do you have belly pain? If yes. Dysmenorrhea. whiff test Profuse. Cervicitis Unable to conceive. HbA1c.Copyright ©2011. dyspareu nia \ˌdispə-ˈrü-nēə. KOH prep. h/o PID. grayish-white. KOH prep. white. Atrophic vaginitis Bacterial vaginosis Endometrial biopsy Vaginal discharge Pain during intercour se. Cervicitis. OFPPLIQRAA. Cervical cancer Pap smear NA Cervical polyps. foul-smelling O F P P Q A A A Pap smear pelvic exam Thick. odorless Candidal vaginitis Wet mount. malodorous Trichomonal vaginitis Cervical cultures NA cervicitis CBC w/diff Do you have vaginal discharge? vulvovaginitis. frothy. greenish. Endometriosis NA Vaginismus Do you have hot flashes? Vaginal dryness? Do you sweat at night? Atrophic vaginitis Have you been feeling depressed most of the day? depression Do you feel safe at home? Domestic violence laparoscopy How long have you had diabetes/high blood sugar? See FA Genital exam U/S-pelvis pelvic exam Wet mount. cottage cheese-like. “Whiff” test Cervical cultures CBC w/diff U/S-pelvis Follow-up Diabetes follow-up O Are you taking any medications? If insulin: Where do you inject the insulin? How often? Are you compliant 26 CBC w/diff. BUN/Cr . O F P P L I Q R A A A Pelvic exam CBC w/diff Thin. 2012 CS Note by dnt A environments? U/S-pelvis Spontaneous abortion Belly pain. Serum glucose. Nulliparous \ˌnə-ˈli-pə-rəs\ Ectopic pregnancy Endometrial cancer NA Endometrial hyperplasia U/S-pelvis Post coital bleeding.

2012 CS Note by dnt with medications? Do you feel itchy in your skin around the injection site? Do you feel your heart racing and you start to sweat sometimes? Have you ever passed out? UA Doppler U/Spenis Nerve conduction study How often do you measure your blood sugar? How do you measure it? What are your blood sugar levels? When did you measure your blood sugar last time? What was the reading? When did you check HbA1C last time? What was the reading? \ˈhē-mə-ˌglō-bən\ How are you feeling today? Do you have a headache? Have you ever passed out? Do you have any problems with your vision? Do you have any weakness and numbness of your body? Do you have chest pain? Do you have shortness of breath? Do you cough? Do you have belly pain? Do you feel nauseous? Do you have diarrhea? Do you have any problems with you sexual life? Do you have foot infection? How long have you had high blood pressure? Are you taking any medications? Are you compliant with medications? Any side effects? HTN follow-up O See FA Genital exam Serum glucose. testosterone. LH/FSH. BUN/Cr How often do you measure your blood pressure? How do you measure it? What are your blood pressure levels? When did you measure your blood pressure last time? What was the reading? UA How are you feeling today? Do you have a headache? Have you ever passed out? Do you have any problems with your vision? Do you have any weakness and numbness of your body? Do you have chest pain? Do you have shortness of breath? Do you cough? Do you have belly pain? Do you feel nauseous? Do you have diarrhea? Do you have any problems with you sexual life? Any leg pain while walking? MRI-brain Peds 27 Doppler U/Spenis ECG .Copyright ©2011.

Lytes Viral URI pneumonia gastroenteritis UTI UA. your husband. parasitology AXR Physical exam CBC w/diff. and her? Child with Neonatal jaundice Child with Diarrhea Child with Fever ------MUST KNOWN CASE O F P P Q A A A O P P I Last A Do you notice shaking of her body? Does she pull her ears often? Does she have a runny nose? Does she cough? Did she throw up? Is her belly distended? Does she cry during urination? Does she have a rash? bronchitis physiologic jaundice See FA ABO or Rh incompatibility neonatal sepsis breastfeeding jaundice familial neonatal hyperbilirubine mia Rotavirus infection bacterial diarrhea Rotavirus enzyme immunoassay CBC w/diff. urine culture Stool leukocytes.Copyright ©2011. 2012 CS Note by dnt Does she cough? Was the cough barking in nature? When she coughed. culture CXR 28 . culture. Lytes malabsorption UA UTI intussusception Do you notice shaking of her body? Does she pull her ears often? Any ear discharge? Does she have a runny nose? Does she cough? Does she have difficulty swallowing? Did she throw up? Does she have diarrhea? What is the color of her stool? Was there any blood in it? Does she cry during urination? What was the color of her urine? Does she have a rash? Meningitis otitis media Stool leukocytes. did anything come up? Any blood in the phlegm? Does she drool a lot? Is her voice hoarse? Does she have problems swallowing? Child with Noisy breathing foreign body aspiration See FA croup laryngitis epiglottitis Do you notice shaking of her body? Did she pull her ears often? Did she have a runny nose? Did she cough? Did she have difficulty swallowing? Did she throw up? Did she have diarrhea? What was the color of her stool? Was there any blood in it? Did she cry during urination? What was the color of her urine? Did she have a rash? What are the blood types of you.

fifth disease. urine culture Stool leukocytes. 2012 CS Note by dnt Child with Fever & rash O P P I Last A Do you notice shaking of her body? Does she pull her ears often? Any ear discharge? Does she have a runny nose? Does she cough? Does she have difficulty swallowing? Did she throw up? Does she have diarrhea? What is the color of her stool? Was there any blood in it? Does she cry during urination? What was the color of her urine? meningococcal meningitis \ˌme-nən-ˈj -təs\ LP-CSF analysis Physical exam CBC w/diff.Copyright ©2011. Rubella. culture Throat swab for culture How long has she had diabetes/high blood sugar? How does it affect you and your child? Is she taking any medications? If insulin: Where does she inject the insulin? How often? I she compliant with medications? Does she feel itchy in her skin around the injection site? Does she feel her heart racing and start to sweat sometimes? Has she ever passed out? Child with Newly diagnose d diabetes O I Last A How often does she measure her blood sugar? How does she measure it? What are her blood sugar levels? When did she measure her blood sugar last time? What was the reading? When did she check HbA1C last time? What was the reading? \ˈhē-mə-ˌglō-bən\ How is she feeling today? Does she have a headache? Has she ever passed out? Does she have any problems with her vision? Does she have any weakness and numbness of her body? Does she have chest pain? Shortness of breath? Does she cough? Does she have belly pain? Does she feel nauseous? Does she have diarrhea? Does she have foot infection? 29 See FA LP-CSF analysis See FA . Lytes scarlet fever measles. Roseola. varicella UA.

.. ABCDEFG: Are you afraid of your husband? Are you being physically or emotionally abused? Are your children being abused? Does your husband drink alcohol? Do you have an emergency plan? Do you have any family members who know about the abuse? Do you have a gun at home? Sexual problems: Do you have any problems with you sexual life? Do you have morning erections? Have you lost the interest in sex? Are you able to reach an orgasm? Do you have any feelings of depression because of this problem? 30 . 2012 CS Note by dnt Associated symptoms Non-Peds case. PAIN: When was your last menstrual period? At what age did you have your first period? How often do you get your period? How long does it last? How many pads or tampons do you use on a heavy day? Do you have any vaginal bleeding? Do you have any bleeding after intercourse? Do you have vaginal discharge? Do you have belly pain with your periods? Depression: Have you been feeling depressed most of the day? If yes. does she have a fever? Is she breathing fast? Is her mouth dry? How has she looked? Is she playful? Drowsy? Irritable? Does she cry? Is her cry weak? Vaginal discharge. ASK PERIOD+BLEEDING. START BY ASKING CONSTITUTIONAL SYMPTOMS: Besides the .Copyright ©2011... DISCHARGE.. have you had anything else? How about fever? Chills? Do you feel tired (fatigue)? Peds case. pelvic pain. START BY ASKING GENERAL STATUS: Besides the . vaginal bleeding.. fatigue (domestic violence). SIGECAPS: Do you have any problems sleeping? Have you lost interest in doing things that you once enjoyed? Do you feel guilty? Have you lost your energy? Is it hard for you to concentrate? How is your appetite? Have you been moving or speaking so slowly that other people could have noticed (Psychomotor disturbances)? Have you ever thought of ending your life? Do you have a plan? Have you ever tried to kill yourself? (Suicidal thought/plan/attempt) Hyper/Hypothyroidism: Is your skin very dry or moist lately? Have you lost more hair than before? Can you tolerate hot/cold environments? If yes: Has your voice changed? Do you have constipation? Have you had any changes in your menstrual periods lately? When did the change start? Do you have any problems sleeping? Do you feel sad or nervous? Domestic violence: Do you feel safe at home? If no.