+ L I Q R (If Pain)

Doorway Information
Location:
Would you please show me the exact location of your
pain ?
Write Name, VS, CC, DDx & mnemonics
Knock the Door 3 times, wait 3sec, Go!!! It’s Showtime!! Intensity:
Introduce Yourself: On a scale of 1 to 10, how severe is your pain? (with
10 being the most severe pain of your life)

Doc: “Mr. Smith?” SP: Yes
Doc: "Hi, I am Dr. …., the physician on duty today. It’s
nice to meet you (Handshake)
Doc: "Is everything ok in the room? SP: Yes
Ok now just let me make you more comfortable"
(Drape Pt.)
Doc: "I hope you don't mind if I sit and take some notes
as you speak"
Doc: “So Mr. Smith, how can I help you today?” SP: ….
“Oh I am sorry to hear that, I will do best to
help you”
HISTORY OF PRESENT ILLNESS (HPI)
Chief Complaint (cc) Use your mnemonics.
HPI ( History of Present Illness): O P P C
(LIQR-ABCO)AAA
Onset:
When did it start first?
Was the onset sudden or gradual?
How long have you been feeling this way? ( I feel a
bit down)
Precipitating factor:
What were you doing when it started?
Do you remember anything which could be
responsible for it?
Progression:
How did it progress? Did it get better or did it
become worse?
Constant v/s intermittent:
Is it constant or does it come and go?
Quality:
How will you describe your pain? burning, Cramping,
dull or sharp, pressure like, pulsating, Piercing?
Radiation:
Does the pain travel anywhere else?
-------------------------------------
+A B C O (If Vomiting, diarrhea, constipation, cough,
vaginal discharge)
Amount:
Can you estimate the amount of xxxxx( blood,
phlegm, discharge, vomitus)? a teaspoon, a table
spoon, or a cupful?
How many times per day did you have diarrhea? Was
it watery, fatty or bloody?
Blood:
Have you noticed any blood in it?
Color:
What color was vomitus/discharge/stool?
Odor:
How did it smell –any specific odor?
-------------------------------------
A A A ( for all cases)
A Alleviating factors: Does anything make it better?
A Aggravating factors: Does anything make it worse?
A Associated problem:Do you have any other
associated problem like
Nausea,Fever,headache,Neck stiffness,Limb
weakness,Numbness or tingling, ….

(If intermittent: PAST MEDICAL HISTORY

Frequency:
How often does it happen? Before PMH
How many episodes/times per day do you have it? “Now I am going to ask you some questions about
your past medical Hx”
Duration: PAM HUGS WAT FOSS
How long does it last each time?) P (PMH) (Déjà Vu)
Doc Have you ever had similar problem before? Was
it diagnosed? Was it treated?
Doc: “Do you have any other medical conditions?, like
High blood pressure, Diabetes, high Cholesterol?...
1
A (Allergies) Doc: “Are you sexually active?”
Doc: “Are you allergic to anything, food or medicine?” Doc: “In the last year how many sexual partners have
you had? Are they male, female, or both?”
M (Medication)
Doc: “Have you noticed any changes in your sexual
Doc: “Are you taking any medications? Prescribed or
function?
over the counter?
Doc: “Do you always use condoms?” “Have you ever
HITS had any STD Sexual transmitted disease? Did you
(Hospitalizations, Injuries, trauma, Surgeries) get any treatment? And your sexual partner?
Doc: “Have you ever been hospitalized? Any surgeries
in the past? Any injuries or accidents? Have you ever Before Social History
received transfusions?” Doc: “Now let me ask you some qs about your
U (Urination) lifestyle”
Doc: “Have you noticed any changes in your Urinary S (Social history) L SODA WET
Habits?”
L “Who do you Live with?”
G (Gastrointestinal)
Doc: “What about in your Bowel Movements?” S “Do you smoke?” How many packs a day? For how
S (Sleep) many years?
Doc: “Are you sleeping ok? O “Do you drink Alcohol? What do you drink? How
W Weight: Have you had any significant change in many glasses, beers a day, how many days a week?
your weight recently? D “Do you use any recreational drugs? What do you
A Apetite: Have you had any change in your use? When was the last time you had it?
appetite? A “How is your appetite? How is your diet? Any recent
T Travel: Did you have any recent travel weight changes? How many pounds? Over what
period of time?”
Before Family Hx W “What kind of work do you do?” Is it stressful?
“Now I am going to ask you some qs about your E “How often do you exercise?”
Family’s health” “ T “Have you recently traveled?”
F (Family Hx)
Doc: Does anybody in your family have the same
problem?
Are there any medical conditions that run in your Finishing Qs & Before Physical Exam
family? like Diabetes, High blood pressure, “All right Mr. Lee thanks for answering all these
Cancer? questions. Now I’ll need to do your physical exam, so
“Are your parents healthy?” I’ll just wash my hands first.

Before Obstetric Hx Ok Mr./ Ms……. According what you said/ So as you

“Now I am going to ask you some qs about your said “………….”
Obstetric Hx Ok? Is there anything else you’d like to tell me ?
O (Obstetric Hx)
Wash hands
Doc: When did you have your first menstrual
period?
“When was your last menstrual period LMP?
Was it regular?
Doc: “How many times have you being pregnant? Any
abnormalities or complications? Any miscarriages?
At how many weeks?
Doc: “How many children do you have? Are they
healthy?
Doc: “What are you using for birth control?”

Before Sexual History Doc: “Ok Mr. Smith, now let me begin
“Ok Mr. Smith, now I am going to ask you some very by…”
personal qs, but let me re-assure you that
everything we talk will be kept confidential ok?” HEENT - HEAD
Inspection:
S (Sexual history)
2
Doc: “Ok Mr. Smith, now I am going to
start by examining your head, let me
look at your head first…
Palpation:
Doc: “Now I am going to press on some
areas on your face, to examine your
sinuses, please let me know if you feel
any pain.”
Conjunctiva:
Doc: “Let me check your eyes, can you
look up for me please?”
TMJ:
Doc: “Please bite really hard?”
Cranial Bones:
Doc: “Now I am going to press on some
areas of your skull, if you have any pain
just let me know please?”
Lymph nodes: NECK
Doc: “Now I am going to check if you
have any swollen glands, please let me
know if you have any discomfort”
Supraclavicular: “Please take a deep
breath in, in, in…..out”
Thyroid Gland
Doc: “I am going to examine the gland
in front of your neck for that I need you
to swallow when I ask you, do you need
a glass of water? Please swallow? Ok,
thanks”
EYES: 1) Pocket Snellen Chart
Doc: “Mr. Smith, could you please cover
one eye and read the smallest line
possible? now with the other eye?”
2) Visual Fields: Remove glasses (yours and
pt’s), 2 feet std
Doc: “Could you please cover your right
eye, and with your left eye look at my
nose only, when you see my finger
moving, please say “yes”
Doc: “Can you see this, what about
here?” SP: Yes/No
Patient (L) Doc(R)
3) Pupillary Response to Light and
Convergence
Doc: “Mr. Smith, please look ahead, I am
going to shine this penlight on your
eyes?, Continue to look ahead, as I shine
this light from the side”
1st: Look for the Direct Pupillary Reflex
2nd: Look for the Consensual Pupillary Reflex
4) EOM Function: Cardinal Position of
Gaze:
Doc: “Mrs. Clark, I’d like you to follow
my finger with your eyes only, please do
not move your head, follow it out here,
here…”, “Now, I want you to watch my
finger carefully as I go very close”
(Convergence Test)
5) Fundoscopy: Ophthalmoscope
Remove yours and the patient’s glasses, prove the
light.
Law Of The Right – Right / Left - Left:
Doc: “Mr. Clark could you look to a fixed
point on the wall please, I am going to
check inside your eyes?”, thanks.
EARS
1) Othoscope
Doc: “Now I am going to check your
ears, let me pull your ear first, do you
feel any pain, now let me check inside,
now the other.
2) Tuning Fork Test: Rinne and Weber
Test
Doc: “Now I am going to strike this
tuning fork on my hand and place it on
the back of your ear.
Doc: “Can you hear this? Can you hear
better now?
Rinne Test Weber Test
Usually: AC > BC
Doc: Now I am going to place it on the
top of your head. Do you feel anything? SP:
Yes, vibration
Doc: s it the same in both sides? SP: Yes
NOSE
3
Doc: “Mr. X, could you please extend
your neck? I am going to lift the tip of
your nose to check inside”
THROAT - MOUTH
Doc: “Mr. X. could you open your mouth
for me please?” “Stick out your tongue,
move it side to side” (XII Cranial) Now I
am going to place this tongue
depressor, say Ah (IX and X) you can
put your tongue back, thanks.
Cranial Nerves:
I∅
II, III, IV, VI done√ “H”
VIII. - Vestibulocochlear (auditory) done
√ again, again…”
IX & X. - “Say Ah” done √
XII. Done√
V. Trigeminal Opht & Maxil → S
Mandible→ S & M
Sensory Function: forehead, cheeks and
jaw
Doc: “Mr. X, I’m going to take this
gauze pad and touch some places on
your face with it, please close your
eyes” “Did you feel this… did it feel
similar or not?”
VII. Facial
Doc: “Smile for me please?” “Big
Smile”
Doc: “Could you frown for me?”
XI. Spinal Accessory Grab Pt’s shoulders
Doc: “Could you push up your
shoulders against my resistance?”
LUNGS
Doc: “Please let me untie your gown so
I can examine your lungs”
Palpation:
Chest Excursion
Doc: “Now I am going to hold your
back, please take a deep breath, again,
again, ok thanks”
Tactile Fremitus:
Doc: “Could you cross your arms in
front? Please say 99 every time I place
my hands?” 99?, again, again…”
Percussion
Auscultation
Percussion:
Doc: “I am going to tap on your back”
Auscultation: Warm the Stethoscope
Doc: “I am going to listen to your lungs,
please open your mouth and take a deep
breath, in and out through your mouth”,
“Ok, now breath
normally, Thanks.”
HEART
Palpation:
Doc: “Now please lean forward, let me
check your heart” First, I am going to
press on some areas on your chest to
feel your heart impulse”
Aortic Area: 2° ICS (Left), Pulmonary Area: 2°
ICS (Right)
Tricuspid Area: 3° ICS (LLSB) Mitral area: 5° ICS
& Midclavicular Left Line
Auscultation: On 4 cardiac areas
Doc: “Please lean forward”
“ABDOMEN”
Inspection:
Doc: “Mr. X, let me uncover your belly
to examine it” “Could you please turn
your head to the other side & cough for
me?”
Auscultation: “Now please, let me listen
to your
belly
. Liver
Percussion: Now I need to tap on ur tummy.
Palpation: Look at the pt’s face expression.
Light palpation: One hand. I need to press
lightly on ur stomach area.
4
Doc: “Any tenderness here?”(6 points) Radial & Femoral Pulses: (if thinking on
Check the reno ureteral points for pain. Coarctation of Ao)
Deep Palpation: 2 hands, rolling motion. Popliteal Pulses: place thumbs on the patella.
I need to press a little more deeply now.
Doc: “Any tenderness (pain) here?
Here?”
Doc: “I know it feels a little Post Tibial Pulses: press fingers against
uncomfortable, but if you feel pain malleolus
please let me know”
Special palpation: Liver, Spleen.
Liver Palpation Dorsalis Pedia Pulses:
Doc: “Take a deep breath in … out” “Neurological Exam”
Mental Status - Cranial Nerves √ - Sensory
Spleen Left to the navel. function
Motor function - Reflexes - Cerebellar
Special Tests function
Murphy’s Sign → Cholecystitis Mental Status
Doc: “I am going to press on the right Quick Minimental
side below your ribs to feel your liver, Doc: “Mrs. Smith, I am going to ask you
please take a deep breath in, in … out. few questions
Thanks.” Any pain?” SP: yes (+) to asses your attention and memory
ok?”
Murphy Mc Burney → Orientation:
Appendicitis • Can you please tell me your full name?
Doc: “Now I am going to press on the • What is the date today?
left lower side of your belly, please • Can you tell me what city are we in?
take a deep breath and let me know if Where are you now?
it hurts?” Memory:
Rovsing's Sign.- (contra lateral pain)
Doc: “I am going to press on this side, • Mrs. Smith please say these words:
where do you feel the pain, ? boat, table & pencil. (Immediate
Rebound Tenderness.- pain when removing recall). I am going to ask you to recall
the pressure (Peritonitis) these words later ok.
Doc: “Now I need to press in on your Attention & Concentration:
stomach area. Tell me if it hurts more • Now spell the word "WORLD"
when I press in or let go. backwards for me please?
Psoas sign.- Pain on passive extension of the Language Test
right thigh • Can you close your eyes put your hands
Doc: “Mr. X, please lay on your left together and bring them on to your
side, I need to lift your leg and pull it belly and then on to your back?
back . Do you feel any pain? * Mrs. Smith I want you to recall the 3
words that I told you few minutes ago.
(Delayed Recall)
Psoas Obturator
Spatial Ability:
Obturator sign. – Passive internal rotation of
the flexed thigh • Can you copy the following
Doc: “Mr. X, I am going to move your drawing?
leg to the side while I press on the side Sensory Function:
of your knee, do you feel any pain? Position Sense: Proprioception
CVA tenderness: I m going to tap on Doc: “Mr. X, could you close your eyes
your backnow. Let me know if it hurts? and tell me where did I just touch
you?”…….. Hand, foot,
Extremities Doc: “Did that feel similar?”
Radial & Brachial Hold the finger

5
Doc: “This is up and this is down” Doc: “Walk towards me; now, on your
Doc: “Tell me, what is this?” SP………. toes, now on your heels”… thanks.
Vibration: Use the Tuning fork “Walk, one foot in front of the other in a
straight line”
Doc: “Close your eyes please? Do you
feel anything?” What do you feel?”…
Vibration
Doc: What about now?
Doc: “Stronger now? Weaker? Or the
same?” toes.
Sharp and Dullness:
Doc: “Close your eyes, this is dull and
this is sharp”
Doc: “What is this?” “Sharp or dull?”
Upp & Low limbs

Reflexes DTR

Biceps Patella (Knee) Achilles

Motor function
Upper Limbs
Doc: “Grip my hand, don’t let me go…
relax” Obstetric and Gyn History:
Doc: “Make a fist. Don’t let me open, “Ok Mrs. Smith now I would like to ask few questions
relax” regarding your gynecological health, Is that ok with
Doc: “bring your arms in front, palms you?”, continue as follows:
up like this, don’t let me push you If it is not a Obstetrical/Gynecological case just ask :
down, now palms down, don’t let me 1. “When was your last menstrual period?”.
push up… ok relax” 2. “Are/Were your cycles regular?”.
Lower Limbs If it is a OB/Gyn case enquire about
Doc: “Push your legs forward against SPECIFIC HISTORY QUESTIONS
LMP RTV CS PAP
my resistance, now backwards…relax
LMP !! "When was your last menstrual period?”
now ” Menarche "How old were you when you had your first
period?"
Cerebellar function Period ( lasts .... days?) "How many days does your
Finger to Nose Test period last?"
Reglarity ( every .... wks?) "Are your periods
regular?"
Doc: “I am going to place my finger Tampoons/Pads # per day "How many pads do you
here, please touch my finger and then use in a heavy day?"
touch your nose”, now do the same Vaginal discharge, itching , dryness
while I move my finger in different "Have you ever had any vaginal discharge?"
positions” If YES, then ask “What is the color of the discharge?
Romberg test Does it have any bad odor? Do you have any vaginal
itching?"
"Have you had any sores or infections around the
vagina?"
Doc: Please stand still with feet Cramps (Dysmenorrhea) "Do you have abdominal
together and open your arms aside . cramps/pain with your periods?"
“Have you ever had any pain in your belly?”
Close your eyes and balance yourself.
If YES continue with all the questions given under
Don’t worry I will be behind you in case pain in present history
you need some assistance. “Do you have any problems controlling your
Examination of Gait bladder?”
6
Spotting ( intermenstrual / post coital )
"Have you ever bleed between cycles?"
"Did you ever notice any bleeding after
intercourse?"
Pregnency ( Hx & complications)
“Have you ever been pregnant?”. "How many
times?",
"How were the births?"" Have you had any
complications during delivery?".
Abortion /miscarriage
"Any miscarriages or abortions?".
If YES “How many times did you abort? In which
month/week of your pregnancy? Do you know the
reason (s) for the abortion?”
"Have you had any other problems or complications
with the pregnancies?".
PAP smear ( last time result ?, Hx of past abnormal
result ?/ "Have you been getting regular pap
smears?", "When did you have the last Pap
smear?".

Urinary complaints:
If the case is not related to urinary system just ask:
“Have you had any problems with your urination ?”
If related to Genitourinary system the take a detailed
history.
“Have you noticed any change in the color of your
urine?”
Is it constantly the same color through out the day?
FINISHED PUBS
Frequency ( How frequent do u Ux)
Incontinence( Do u hav trouble holding Ux)
Nocturia ( do u hav 2 wak up @ Night)
Incomplete emptying ( do u feel fullnes after Ux)
Stream (How is ur stream?)
Hematuria ( did u notic any blood)
Hesitancy (do u hav 2 wait b4 starting Ux)
Dysuria (Did u hav diff Ux)
Pyuria ( did u pus in Ux)
Urgency (do u hav 2 rush)
Burning (dysuria) (does it burn)
Strain (Do u hav to strain during Ux)