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34 Cases CSA

1. CASE 1:Left side shoulder pain.


A. History taking. Hello Sir, Mr. Wang. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable?
(Dont shake) How can I help you today?
Would you tell me more details about your pain?
LiqorAAA OI LQL Qn P RAAA
1. When did your pain begin (start)? Onset
Where did you first feel the pain? (where did your pain begin?)
What were you doing when the pain began? What brings the pain on?
o Does the pain begin suddenly or gradually?
( If patient have the fall)Do you have injured from the fall? Can you describe your
fall? After the fall were you conscious or unconscious? Does any one treat you badly
at home? Have you seen Doctor for that? Why not?)
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
3. Can you show me exactly where it hurt? Please (can you) point to where it hurt?

Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Is your pain constant or does it come and go? Quantity
How often do you have pain?How many times do you have pain
per day/week/month? (
How long does it last for each episode (every time)?
6. Now, if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8,
Does anything increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve (reduce)the pain? (Does anything make the pain better?)

Alleviation
.Association Besides your pain do you have any symptoms?
1. Did you notice any swelling or redness in your shoulder?
2. Did you feel tingling or numbness or loss your sensation?
3. Did you feel any weakness?
4. Did you have any change in your vision?
5. Did you have a sore throat ?
6. Did you have any change in your skin?
7. Did you have any pain in your other joints?
8. Do you have fever?
9. Do you have any heart problem?
Affect-Cause
10. Can you use your arm in your daily activities?
11. Do you think what is causing your pain?

PAM:Now I need to ask you a few questions about your health in the past. Is that OK
with you?
1. Have you had shoulder pain before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
H(sit)UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8 Have you had any change in your sleep patterns? S
FOSxS:
FH:
1. Does anyone in your family have pain in their joints like you?
2. Does anyone in your family have any other serious medical problem? (HBP,DM,
high cholesterol level) Are your parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per day/week?
How long have you drunk alcohol?)
5. CAGE :
Have you ever felt a need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever had guilty feeling about drinking?
Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

Transition: before physical examination:


Is there anything else you forgot to tell me about your problem? .
5. Thank you for your co-operation, Ill wash my hands and Im going to examine you,
Is that OK?

*Challenging Question: Im afraid of losing my job if my shoulder


doesnt get better, doc. What should I do?

1. This is good question .


2. There are many conditions which could be causing pain in your shoulder.
3. However, there are also other conditions which could be causing your problem. and
they may be treated
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies.
5. Once I get the results of these tests.
6. Ill know what is the extent of your injury and Ill refer you to an orthopedic
physician.
7. If you need Ill call your employer to discuss your healthcare with him.
8. Please try not to worry because the staff and I are here to give you the best
possible care
B. Exam component:
Shoulder: compare both shoulders in term of I , Pa, passive motion, active motion.
The arm compare both shoulders in term of strength, range of motion(elbow ,wrist)
sensation, DTRs, pulses.
Other Joins( fast)
CV: A
Pulmonary: A
What you say when you do PE:
Im going to examine your shoulders. I need to untie your gown and uncover your
shoulders
1. I d like to take a look first.
2. Im going to touch your shoulders. Tell me if it hurts.
Passive: Shoulder, elbow, wrist joints
1. I need to move your arms. Is that OK? Tell me if it hurts. Ill stop immediately.
Active:
1. Please, do this.
Stretch your arms out to your side and raise your arm over your head.
Move your arm forward. Move your arm backward.
Do this.( Please rotate your shoulder).Put your hand on your back. Put you hand on
your chest.
Muscle Strength.
Now Im going to check the strength of your muscle now.
1. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
2. Please, do this(elbow flexion). Pull in. Pull out.
3. Please, make the fists. Dont let me open them. ( Wrists).
4. Please, Spread your fingers apart. (Hands).

Sensation
Im going to touch your arm lightly. Please close your eyes. Do you feel this .Is it the
same
Pulse:
I need to check the pulse in your arms
DTRs
Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
Other joints:I need to examine another joints
Pulmonary: I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table. I need to listen to your heart.
C. Counseling:
1. Based on your information and the findings from your physical examination.
I think you might be having inflammation (or a trauma) of your shoulder..
2. However, there are also other conditions which could be causing your pain
Such as dislocation, fracture, injury of ligaments etc.
3. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
4. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options .
5. Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.
2.CASE 2: Elbow Pain:
A. History taking. Hello Sir, Mr. Wilson. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable
Dont shake) How can I help you today?
1.Can you tell me more details about your pain?
. LiqorAAA-OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
Where did you first feel the pain? (where did your pain begin?)
What were you doing when the pain began? What brings the pain on?
Does the pain begin suddenly or gradually?
If patient have the fall: (Do you have injure from the fall? can you
describe your fall? After the fall were
you conscious or unconscious? Does any one treat you badly at home?
Have you seen Doctor for that?
Why not?)
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten
is most) Intensity
3. Can you show me exactly where it is? Please (can you) point to where it hurt?

Location
4.

Tell me what the pain feels like? May you describe what kind of pain do you
feel like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Is your pain constant or does it come and go? Quantity
How many times do you have pain per day/week/month? (how often?)
How long does it last for each episode (every time)?

6. Now ,if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?)

Alleviation
Association
1. Did you notice any swelling or redness in your elbow?
2. Did you feel tingling or numbness or loss your sensation?
3. Did you feel any weakness?
4. Did you have any change in your vision?
5. Did you have a sore throat ?
6. Did you have any change in your skin?
7. Did you have any pain in your other joints?
8. Do you have fever?
9. Do you have any heart problem?
Affect-Cause
1. Can you use your arm in your daily activities?
2. Do you (know)think what is causing your pain?
PAM
1. Have you had elbow pain before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes
5. Are you allergic to anything? (Plants, food, medication..). (Do you have any
allergies?)
6. Do you take any medication?
Hsit UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FoSxS
FH:
1. Does anyone in your family have pain in their joints like you?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
2. Are you sexually active?

3. How many sexual partners do you have?


4. Are they male or female or both?
5. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
6. Have you had any sexually transmitted diseases?
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
Elbows: compare both elbows in term of I, Pa, passive motion, active motion.
The arm compare both elbows in term of strength, range of motion (elbow ,wrist)
sensation, DTRs, pulses.
Other Joins( fast)
CV: A
Pulmonary: A
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Im going to examine your arm
3. I d like to take a look first.
4. Im going to touch your elbow. Tell me if it hurts.
Passive:
1. I need to move your arms. Is that OK? Tell me if it hurts. Ill stop immediately.
Active:
1. Please, do this. Please, do this(Please, do this(flex your elbow).
2. Do this (Extend your elbow.)
3. Hold out your arms like this(put and fix both the elbows with your trunk). Flip your
hands up. Flip your hands down.
Muscle Strength.
Now Im going to check the strength of your muscle now.
4. Please, do this(elbow flexion). Pull in. Pull out.
5. Please, make the fists. Dont let me open them. ( Wrists).
6. Please, Spread your fingers apart. (Hands).
Sensation
Im going to touch your arm lightly. Please close your eyes. Do you feel this .Is it the
same
.
Pulse:
I need to check the pulse in your arms.
DTRs
Now I need to tap on your arms. ( biceps, triceps, brachioradialis). Pulmonary:
I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table. I need to listen to your heart.

C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having inflammation (or a trauma) of your elbow.
3. However, there are also other conditions which could be causing your pain.
Such as dislocation, fracture, injury of ligaments etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

3.Case 17:Back pain


A. History taking. Hello maam , Miss. Kirti. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can I help you today.
Can you give me more about your back pain?
LiqorAAA OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
3. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Was your pain continuous or does it come and go? Quantity
a. How many times do you have pain per day/week/month? (how often?)
b. How long does it last for each episode (every time)?
6. Now, if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?)

Alleviation
Association:
Digestive:
b. Have you had any change in your bowel movement? G
Have you had any stomachache?
Genito -urinary
a. Did you have any change in your urination? Did you have urinary incontinence?
Did you have burning in your urination?Did you have change in your urinary
frequency? Did you have change in urinary color(bloody, cloudy)
b. Did you notice any vaginal discharge? or vaginal bleeding?

Neuro-skeleto
c. Did you feel numbness or lose sensation in your legs?
d. Did you feel weakness in your legs?
e. Did you have any pain in other parts of your body? Joints, muscle pain?
f. Did you have fever?
PAM
1. Have you had back pain before?
2. Have you had any other medical problems? Example: high blood pressure,
high cholesterol, diabetes
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
5. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
6. Have you had any change in your sleep patterns? S
FoSx S
1. Does anyone in your family have back pain like you?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. .Do you notice any change in your period?
4. Have you had a Pap smear? When was the last Pap smear? What was the result of
the last time?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
How many sexual partners do you have?
2. Are they male or female or both?
3. Do you use any contraceptives?
4. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)

5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

*Challenging question:
1. Do I need surgery?
1.This is good question.
2. There are many conditions which could be causing your back pain.
3.Until now I really dont know what is causing your back pain
4.To have the exact cause. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to discuss your diagnosis and treatment options at that
time.
If your back pain can be treated by using medication, we will give you pain
medication first.
If your back pain can only be treated by surgery, then we have to proceed with
surgery
6. Please try not to worry because the staff and I are here to give you the best possible
care.

2. Im tired of this medication Doc, I want to switch to an


herbal medication or herb.?

1. This is good question .


2. I understand that your friend said that they have benefited from using this herb.
3. I like to read your document about your herbal drugs.
4. However, most studies have not proven herbal medications to be beneficial.
5. I would still advise you to continue your medication
B. Exam component:
Abd: I A Pa Pe
Back: I, Pa, range of motion .hip exam
Extremities: compare both in term of strength,
range of motion ,gait( includingtoe and heel walking),passive straight
leg raising
sensation, DTRs, Babinskis sign pulses.
Other Joins( fast)
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Supine position
Abdominal exam. Could you please lie down?
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.

6. Now I need to tap on your stomach


Veterbra
1. I need to uncover your legs. I m going to lift your legs up. Tell me if they hurts.
Passive: Hip, Knee, ankle joints
1. I need to move your leg. Is that OK? Tell me if it hurts. Ill stop immediately.
Sitting
Active and Muscle Strength: Could you please sit up?
Now Im going to check the strength of your muscle now.
2. Please, Push your thigh up. Push your thigh down.( Thigh).
3. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
4. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Sensation
1 Im going to touch your legs lightly. Please close your eyes. Do you feel this .Is it the
same
2 This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes.
.
Pulse:
I need to check the pulse in your legs.
DTRs
1. I need to tap on your legs. (patellar, Archilles)
2. Now I need to tickle your feet lightly. (Babinski).
Standing position:
Veterbra Now, please stand up (DR have to pull out the footstool .) Please walk to me.(toes
& heel walking)
1. Im going to examine your back bone
1. I d like to take a look first.
2. I need to press lightly on your back. Tell me if it hurts.
3. Bend your body down and touch your toes with your fingers
4. Bend back.
5. Lean your body to the right.
6. Lean your body to the left
Pulmonary: I need to listen to your lungs. Please, take a deep breath for me.
CV Could you lie back on the table:. I need to listen to your heart.
C.Coumseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having problems with your vertebra.
3. However, there are also other conditions which could be causing your pain.
Such as a problem in kidney, vessels, or reproductive system, etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
With your permission, You need to be have a pelvic
examination.(if male: rectal examination)
5. Once I get the results of these tests.
Ill be in a better position to discuss your diagnosis and treatment options at that time.
6. To protect your health.

You should have pap smear regularly


Is that alright? Do you have any more questions?
Goodbye, maam. See you later.

4.CASE 19: Leg Pain (calf pain)


A. History taking. Hello Sir ,Mr.Wright. Im Dr. Le. Nice to meet you! (First I need to cover
you with the sheet. Is that comfortable)
How can I help you today?
Can you tell me more detail about your pain?
LiqorAAA OI LQL Qn PRAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
3. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Was your pain continuous or does it come and go? Quantity
a. How many times do you have pain per day/week/month? (how often?)
b. How long does it last for each episode (every time)?
6. Now, if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?) Alleviation
Association: Beside your leg pain do you have other symptoms (anything else)?
a. Have you had any back pain before?
b. Did you feel numbness or lose sensation in your legs?
c. Did you feel weakness any where in your body?
d. Is there any color change in your legs?
e. Do you notice loss of hairs on your legs?
f. Did you have any fever?
CV:
1. Did you have chest pain?
2. Did you hear a racing of your heart?
3. Did you feel a shortness of breath
PAM:
1. Have you had leg pain before?
2. Have you had any other medical problem? example :Disc prolapse , HBP, DM,
Heart disease
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?

HSitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FoSxS
FH:
1. Does anyone in your family have leg pain like you?

2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
3. Are you sexually active?
4. How many sexual partners do you have?
5. Are they male or female or both?
6. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B. Exam component:
Extremities:
1. Caft tenderness
2. Homans sign
3. Pulses both legs and arms
4. sensation in both legs
5. DTRs, Babinskis sign in both legs.
6. color change & hair loss
7. raise Straight leg

Check spine:
CV: Heart: A
listen carotid
Lung:A
Abd:?? A Pa??
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Supine position
Legs
I need to uncover your legs and take a look in your legs
Lasegues sign:I m going to lift your legs up. Tell me if they hurts.
Calf tenderness: I need to press lightly on your caft.Tell me if you feel any pain or
discomfort
Homans sign : I need to flex your ankle Tell me if you feel any pain
Pulse:
1. Can I listen to your neck (carotid arteries), stomach (abdominal aorta).
2. I need to check the pulse in your arms and legs now.
Sensation
1 Im going to touch your legs lightly. Please close your eyes. Do you feel this .Is it the
same
2 This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes.
DTRs
3. I need to tap on your legs. (patellar, Archilles)
4. Now I need to tickle your feet lightly. (Babinski).
Standing position:
Veterbra Now, please stand up (DR have to pull out the footstool .) Please walk to
me.(toes & heel walking)
1. Im going to examine your back bone
2. I d like to take a look first.
3. I need to press lightly on your back. Tell me if it hurts.
4. Bend your body down and touch your toes with your fingers
5. Bend back.
6. Lean your body to the right.
7. Lean your body to the left.
Pulmonary: I need to listen to your lungs. Let me untie your gown.Please, take a deep
breath for me.
CV : Could you lie back on the table. I need to listen to your heart
C.Counseling:
1. Based on your information and the findings from your physical examination.
I think you might be having narrowing or obstruction of vessels in your leg.
2. However, there are also other conditions which could be causing your pain,
Such as problem in your vertebra or veins, etc .
3. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
4. Once I get the results of these tests.

Ill be in a better position to tell you your diagnosis and treatment options.
1. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with low fat, low sugar (if he has had
diabetes)
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later

5.CASE26: Headache.
A. History taking. Hello Maam ,Ms.Wright. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can I help you today? Can you tell me more something about your headache?
LiqorAAA OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is most)

Intensity
3.

4.

5.

6.
7.

Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
Was your pain continuous or does it come and go? Quantity
a. How often do you have headache? How many times do you have pain per
day/week/month?
b. How long does it last for each episode (every time)?
Now, if compare with the onset, is the pain getting worse or better? P
Does the pain move around or stay in one place? Radiation

Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?) Alleviation
8.

Association:
a.
b.
c.
d.
e.
f.

Do you have nausea or vomiting?


Do you have any warning sign before they come?
Do you have any blurriness or double vision now? see flashes
Have your eyes been watery?
Have you had a running nose during the attack?
Have you noticed any ear discharge?

CNS
g. Have you had any head trauma?
h. Have you had seizure?
i. Have you had weakness anywhere in your body?
j. Have you had tingling or numbness anywhere in your body ?
k. Have you had difficulty talking?
General
l. Do you have any fever?
m. Is your neck stiff?
Joints
n. Have you noticed another pain in you joint or your body?
Affect
o. Did your headache affect your daily activities (your job)?
PAM
1. Have you had headache before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HSitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T Head trauma?
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
8. Have you had any change in your sleep patterns? S ? Has your HD waken you
up from your sleep
FOSx S
1. Does anyone in your family have headache like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?

O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
4. Did your HD relate with your menses(period)?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners use a condom all the time? (Do you use a condom
consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

* Challenging Question:

Doc, Do you think Ill get brain

cancer?
1. This is good question
2. Headache is one of symptoms of brain cancer.
3. However, there are also other conditions which could be causing your headache,
and those conditions could be treated
Such as medication, Sinusitis, infection, tension headaches
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
6. Ill know if your problem could be cancer or not.

7. Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
HEENT:Pa(head,sinuses,temporomandibular joints)
FO
I (nose, mouth, teeth, throat)

Neck exam: I, Pa
CV: A
Pulmonary: A
Abd exam: IAPaPe
Neurologic exam: Cranial nerves, muscle strength, DTRs
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?

.HEENT- Cranial nerves


1. I need to press lightly on your head.
2. I need to examine your sinuses, so Im going to press on your forehead. Please, tell
me if you feel pain anywhere.
3. Id like to examine your eyes now.
CN2:Cover your left eye with your left hand and read this row of letters .
- please, change the other side and read this row of letters.
CN 3, 4, 6: Please follow my finger without moving your head (EOM).
CN2 FO: I need to dim the light in this room. Im going to shine this light in your eyes.
Can you look at the clock on the wall. (Can you pick a point on the wall and look at it.). If
patient resists: I need to look at the blood vessels back there to make sure theyre not
damaged . It s extremely important for your safety.)
4. I need to check the inside of your mouth and your throat. Can you please open your
mouth. Please say ah (Cranial nerve10 ) and stick your tongue out and move it
from side to side (CN 12). And please, swallow (CN 9& 10).
5. I need to check your nose now.
6. I need to examine your ears now.
CN8: :( make a noise: snap lightly your fingers). Can you hear them both the same
way?
Weber: Im going to put this tuning fork on your head . Tell me if it sounds the same
in both ears.
Rinne: Let me put the tuning fork behind your ears. Tell me when you cant hear any
longer.
Can you hear now
CN 5: Please clench your jaws.( muscle of mastication)
Im going to touch your face lightly. Please close your eyes. Do you feel this
.Is it the same?(sensation)
CN 7 : Please lift your eyebrows.
Please smile and show me your teeth.
CN 11: Now turn your head and press it against my hands.
Please shrug your shoulders.
Neck
1. I need to check your neck area.
2. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
3. I need to listen to your neck. ( the bruits of carotid arteries or thyroid gland).
Pulmonary Exam. I need to listen to your lungs. May I untie your gown Please, take a
deep breath for me.
CV: Could you lie back on the table. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.

2. Im going to take a look at your stomach area.


3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. 10.I need to press a little more deeply now.
6. 11.Now I need to tap on your stomach.
Musle testing: (M)Now Im going to check the strength of your muscle now.

MRS
Please, Hold out your arms like this. Push up. Push down ( Shoulders)
Please, do this(elbow flexion). Pull in. Pull out.
Please, make the fists. Dont let me open them. ( Wrists).
Please, Spread your fingers apart. (Hands).
Please, Lift (Push) your thigh up. Lift (Push) your thigh down.( Thigh).
Please, Pull your legs in (flex your knee) and Kick your legs out (extend your knee).
Please, Lift( Push) your feet up (dorsal flexion ). Lift (Push) your feet down ( plantar
extension).
Reflexes: (R)
1. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
2. I need to tap on your legs. (patellar, Archilles)
3. Now I need to tickle your feet lightly. (Babinski).

1.
2.
3.
4.
5.
6.
7.

C.Counseling:
1. Based on your information and the findings from your physical examination.
I think you might be having Migrain headache (pain in one haft of the head and
occur with a few people in the same family), etc.
2. However, there are also other conditions which could be causing your headache,
Such as medication, Sinusitis, infection, tension headaches
To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
3. Once I get the results of these tests.
4.
Ill be in a better position to tell you your diagnosis and treatment options.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later

6.CASE 16: Sickle cell anemia + chest pain


A. History taking. Hello Sir ,Mr.Fuer. Im Dr. Le. Nice to meet you! (First I need to cover
you with the sheet. Is that comfortable)
How can I help you today?
Can you tell me more details about your chest pain?
LIQORAAA: (How long does each episode last?)OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is most)

Intensity
Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Was your pain continuous or does it come and go? Quantity
a. How often do you have chest pain? How many times do you have pain per
day/week/month?
b. How long does it last for each episode (every time)?
6. Now, if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?) Alleviation
Affect:
3. Do any of your activities affect your chest pain?
Association :
1. Do you have shortness of breath or difficulty breathing?
2. .Did you hear a racing of your heart?
3. .Did you have a cough? Is your cough or congested( Is there dry or productive
cough)? What does it contain? Is there blood in it? Do you notice a strong smell
(Does it smell foul)?
4. .Did you have any chest trauma?
Digestive:
1. Did you have nausea or vomiting?
Skeletal
2. Have you had pain ,swelling or redness in your legs? PE
General
3. Did you have any sweating( fever)?
3.

Sickle cell
4. Has any doctor said that you have a blood disorder?
5. Have you had a blood infusion?
6. Have you had the crises of sickle cell (a disease has abnormal red blood cell) after
diarrhea, dehydration, stress, heavy alcohol, heavy exercise, oxygen deficiency
(hypoxia)?
PAM
1. Have you had chest pain before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
Hsit UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. 28. Have you had any change in your sleep patterns? S
FoSxS.
FH:
1. Does anyone in your family have chest pain like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

*.Chanllenging question:
1. Am I having a heart attack? Am I going to die?

1. This is good question


2. There are many conditions which could be causing your problem.

3. Until now I cannot rule out a possibility youre having a heart attack.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies.
5. Once I get the results of these tests.
6. And Ill know if your problem will be heart attack or not.
7. Please try not to worry because the staff and I are here to give you the best
possible care.

2. In 2 days, my family and I are going hiking. Can I still go?


1. I would advise you against it.

2. Until now I cannot rule out a possibility youre having a heart attack.
3. The strenuous activities, like hiking, place you at risk of getting a heart
attack.
3. Doctor, Will my problem be recurrent?
This is good question.
There are many conditions which could be causing your problem.
Until now I really dont know what is causing your chest pain
To have the exact cause. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
6. And Ill know if your problem can be recurrent or not.

1.
2.
3.
4.

7. Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
Neck exam: JVD, carotid auscultation
CV: I Pa A
Pulmonary:I Pa Pe A
Abd exam: IAPaPe
Exts: Pulse, Edema
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is
that ok with you?
Neck: JVD, carotid auscultation
1. I need to check your neck area.
2. I need to listen to your neck. (the bruits of carotid arteries).
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. Let me take a look at your back.
3. Can you say 99 for me, please.
4. Im going to tap on your back to check your lungs. Is that ok with you?

5. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
6. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table
1. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
2. Im going to examine your heart. Let me uncover your chest.
3. I need to press in your heart area. (PMI).
4. I need to press in your chest. Do you feel any pain?
5. I need to listen to your heart.
6. Can you turn to your left side, please.
Sitting up
1. Can you sit up, and lean forward. Ill listen to your heart again.
Vascular
1. I need to check the pulse in your arms and legs now.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.
Extremities
1. I need to check for fluid retention in your legs.
C.Coumseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having the narrowing or obstruction of vessels in your heart.
3. However, there are also other conditions which could be causing your pain.
Such as diseases of the heart membrane, lung, chest wall, etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
5. To protect your health.
You shouldnt smoke or use alcohol
You should have a healthy diet, food with low fat, low salt.
You need a vaccination (H. influenza) to against pneumonia (sickle cell disease)
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

7.CASE 7:Chest Pain + cough( Pneumonia)


A. History taking. Hello Sir , Mr.Rice. Im Dr. Le. Nice to meet you! (First I need to cover
you with the sheet. Is that comfortable)
How can I help you today? Can you tell me more something about your problem?

Chest pain
1 LiqorAAA OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)

2.
3.

4.
5.

6.
7.
8.
9.

b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
Was your pain continuous or does it come and go? Quantity
a. How many times do you have pain per day/week/month? (how often?)
b. How long does it last for each episode (every time)?
Now, if compare with the onset, is the pain getting worse or better? P
Does the pain move around or stay in one place? Radiation
Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
Does anything relieve the pain? (Does anything make the pain better?) Alleviation

2 Cough:
1. Did the chest pain occur at the same time with cough? When did your cough
begin?
2.Is the dry cough or productive cough?( are you congested )( or cough with the
phlegm)? Productive cough
Can you estimate the amount of your phlegm?
What color is the phlegm?
Is there blood in the phlegm?
Does the phlegm have a strong smell? Do you notice a strong odor?
3. Association:
General
1.Did you have any fever?
Res.Sys.
2. Did you feel SOB?
3.Did you have any wheezing?
Digestive :
4.Did you have any nausea or vomit?
5.Did you have heart burn (or GE reflux disorder)?
4. Sick contact
Have you had closest contact with any one who having the same Problem?
PAM
6. Have you had chest pain and cough before?
7. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
8. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
9. Do you take any medication?
10. Have you had a tuberculin test? Or PPD test? Whats the result?
HsitUGDWS
1. Have you ever been hospitalized before? H

Have you ever had surgery? S


Have you had any trauma or injuries? I &T
Have you had any change in urination?
Have you had any change in your bowel movement? G
Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FoSxS.
FH:
1. Does anyone in your family have chest pain and cough like you?
2. Does anyone in your family have any other medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
HEENT:
Sinuses& nose,throat(cough)
Neck exam: JVD, carotid auscultation
CV: I Pa A
Pulmonary:I Pa Pe A
Abd exam: IAPaPe
Exts: Pulse, Edema
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is
that ok with you?
Neck: JVD, carotid auscultation
1. I need to check your neck area.
2. I need to listen to your neck. (the bruits of carotid arteries).
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2.
3.
4.
5.
6.

2. Let me take a look at your back.


3. Can you say 99 for me, please.
4. Im going to tap on your back to check your lungs. Is that ok with you?
5. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table .
1. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
2. Im going to examine your heart. Let me open your gown to uncover your chest.
3. I need to press in your heart area. (PMI).
4. I need to press in your chest. Do you feel any pain?
5. I need to listen to your heart.
6. Can you turn to your left side, please.
Sitting up
1.Can you sit up, and lean forward. Ill listen to your heart again.
Vascular
1. Can I listen to your neck (carotid arteries), stomach (abdominal aorta).
2. I need to check the pulse in your arms and legs now.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.
Extremities
I need to check for fluid retention in your legs.
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having Inflammation of your lung.
3. However, there are also other conditions which could be causing chest pain and
cough.
Such as chronic inflammation of the heart membrane or fluid in lung membrane,
etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
To protect your health
. You shouldnt smoke or use alcohol.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

8.Case 5: Abdominal pain in Rt upper quadrant( acute


cholecystitis)

A. History taking. Hello Maam, Ms. Rice. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can I help you today? Can you tell me more something about your problem?
( Patient dont let Dr examine) I know you are in pain. But I need to examine you and find
out the source of your pain.
You need to have an exact treatment.
1LiqorAAA OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
3. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Was your pain continuous or does it come and go? Quantity
a. How often do you have stomachache? How many times do you have pain
per day/week/month?
b. How long does it last for each episode (every time)?
6. Now, if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?)

Alleviation

Did the pain relate to eating? Can you relate it to any type of food (Fat eating?) Is
your pain related to any type of food?
Did the pain relate to posture?
Have you had jaundice?
Have you had any change color of your eyes?

Association:
General
1.Did you have any fever?
Res.Sys.
1. Did you feel SOB?
2. Did you have any wheezing?
3. Did you have any chest pain?
Digestive :
1. Did you have any nausea or vomit?
2. Did you have heart burn (or GE reflux disorder)?
Sick contact
Have you had closest contact with any one who having the same Problem?
PAM:

1. Have you had stomachache before?


2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HSitUDSW
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? Whats color of your urine?
5. Have you had any change in your bowel movement? G Whats color of your
stool?
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
9. FoSSx:
10. Does anyone in your family have stomachache like you?
11. Does anyone in your family have any other medical problem? Are your parents alive?
Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?

Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
*Challenging questions patient? My husband is a nurse, he said that: I need to have
an operation?
1. I know you could be feeling anxious and scared. Most patients feel nervous when
they hear that surgery might be needed.
2. There are many conditions which could be causing your problem.
3. I cannot rule out the possibility that you may need to be treated with surgery.
4. After I examine you and run some tests I am sure we will know the correct treatment
for you.
5.

5. Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
Pulmonary:A
CV: A2
Abd exam: IAPa( Murphy, Guading, CVA tenderness)Pe(liver)
What you say when you do PE:
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. Let me take a look at your back.
3. Can you say 99 for me, please.
4. Im going to tap on your back to check your lungs. Is that ok with you?
5. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
Lying down
1. Im going to examine your heart. Let me open your gown to uncover your chest.
2. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).
7. I need to press in on your stomach area. Please take a deep breath and let me know If
it hurts. ( Murphy sign)
8. Now I need to tap on your stomach.(liver)
Special tests:
9. Please turn over to your left side.
Im going to tap on your back now. let me know if it hurts. ( CVA tenderness).
C. Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having inflammation or stone in your gallbladder.
3. However, there are also other conditions which could be causing your stomachache.

Such as inflammation of pancreas and liver or stomach ulcer, etc .


4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
1. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with the low fat.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.

9.CASE 25: PUD ( Epigastric pain)


A.History taking. Hello Sir, Mr. King. Im Dr. Le. Nice to meet you! (First I need to cover
you with the sheet. Is that comfortable)
How can I help you today? Can you tell me more something about your problem?
LiqorAAA OI LQL Qn PRAAA
10. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
11. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
12. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
13. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
14. Was your pain continuous or does it come and go? Quantity
a. How often do you have stomachache? How many times do you have pain
per day/week/month?
b. How long does it last for each episode (every time)?
15. Now, if compare with the onset, is the pain getting worse or better? P
16. Does the pain move around or stay in one place? Radiation
17. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
18. Does anything relieve the pain? (Does anything make the pain better?)

Alleviation

Does the pain relate to eating a meal? How long after eating does the pain
occur? Does food relieve the pain?
.Does the pain usually occur in the day time or at night?

.Association:
a. (Does your pain relate to exertion? SOB? Sweating?)
b. Do you have nausea or vomiting? Have you ever been nauseated or vomited
? Is there blood in your vomitus?
c. Have you had any change in your bowel movement?
Do you have diarrhea or constipation?

Do you have any changes in your stool color?


PAM:Now I need to ask you a few questions about your health in the past. Is that OK
with you?
1. Have you had stomachache before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
H(sit)UGDWS
1. Have you ever been hospitalized before? H
1. Have you ever had surgery? S
2. Have you had any trauma or injuries? I &T
3. Have you had any change in your urination? U
4. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
5. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
FH:
1. Does anyone in your family have stomachache like you?
2. Does anyone in your family have any other medical problem? Are your parents alive?
Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have
you smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
Transition: before physical examination:
Is there anything else you forgot to tell me about? .
Thank you for your co-operation, Ill wash my hands and Im going to examine you, Is
that OK?
Exam component:
JVD
Pulmonary:A,Pa
CV: A2
Abd exam: IAPa(Murphy)Pe

Exts: Edema, clubbing, cyanosis

Say to patient on your examination.


Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. Let me take a look at your back.
3. Can you say 99 for me, please.
4. Im going to tap on your back to check your lungs. Is that ok with you?
5. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table
1. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
2. Im going to examine your heart. Let me open your gown to uncover your chest.
3. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).
7. I need to press in on your stomach area. Please take a deep breath and let me know If
it hurts. ( Murphy sign)
8. Now I need to tap on your stomach.
Special tests:
Please turn over to your left side.
Im going to tap on your back now. let me know if it hurts. ( CVA tenderness).
Exts
I need to find any changes in your legs.
Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having a stomach ulcer.
3. However, there are also other conditions which could be causing your stomachache.
Such as inflammation of the pancreas or inflammation or stone in your bileduct, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
You need to be have a rectal examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with the low fat, low salt.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

Patient note
History
HPI:
ROS:
PMH:
Allergies:
Medications:
PSH:
SH:
FH:

Physical Examination
VS
Chest
Heart
ABD:
Differential Diagnosis

Diagnostic workup

10.Case 5: Rt lower quadrant Abdominal pain ( PID)


A. History taking. Hello Maam , Ms. Grait. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can I help you today? Can you tell me more something about your problem?
1.LiqorAAA OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
Where did you first feel the pain? (where did your pain begin?)
What were you doing when the pain began? What brings the pain on?
Does the pain begin suddenly or gradually?
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
3. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Was your pain continuous or does it come and go? Quantity
How many times do you have pain per day/week/month? ( How often do you
have pain?)

6.
7.
8.
9.

How long does it last for each episode (every time)?


Now, if compare with the onset, is the pain getting worse or better? P
Does the pain move around or stay in one place? Radiation
Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
Does anything relieve the pain? (Does anything make the pain better?)

Alleviation
Association:
Digestion
1.Do you have nausea or vomiting?
2. Have you had any change in your bowel movement?
Do you have diarrhea or constipation?
Uro:
1. Have you had any change in your urination? U(frequency, burning)
Have you had burning during urination?
Have you noticed an increase in the frequency of urination ?
2.. Do you have any fever?
PAM:Now I need to ask you a few questions about your health in the past. Is that OK
with you?
1. Have you had the stomachache before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
H(sit)UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
FOSxS:
FH:
1. Does anyone in your family have stomachache like you?
2. Does anyone in your family have any other medical problem? Are your parents alive?
Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period?
4. Was your cycle regular or irregular?
5. How many days are there between your periods? How many days are in your period
cycle?
6. How long does each period last?
7. How many pads or tampons did you use on those days? Per day?
8. Are you sexually active? Sx
9. When was your last sexual contact?
10. Have you ever had a vaginal discharge?

11. Have you ever been pregnant?


12. Have you had any miscarriage or abortions? In what trimester?
13. 13.Have you ever been tested for sexually transmitted disease?HIV test? .Have you
ever had any sexually transmitted diseases? Did your sexual partners treat STD?
14.Have you had a Pap smear?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. How many sexual partners do you have?
2. Are they male or female or both?
3. Do you use any contraceptives?
4. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have
you smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week?
How long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
Transition: before physical examination:
Is there anything else you forgot to tell me about? .
Thank you for your co-operation, Ill wash my hands and Im going to examine you, Is
that OK?
B PE: Exam component:
CV: A
Pulmonary:A
Abd exam: IAPa(Psoas,obturator,Rovsing sign, CVA tenderness )Pe

Say to patient on your examination.


Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest
2. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).

7. I need to press in on your stomach area. Please take a deep breath and let me know If
it hurts. ( Murphy sign)
8. When I press in here(LLQ) , Do you feel pain in right side(RLQ)? Rovsing sign
9. Now I need to tap on your stomach.
Special tests:
1. I need to uncover your right leg. Im going to bend it. Tell me if it hurts. (Obturator
sign).
2. Please turn over to your left side.
Im going to tap on your back now. let me know if it hurts. ( CVA tenderness).
3. I need to lift your right leg and pull it back. Tell me if this is painful. (Psoas sign)

Exts
. I need to find any changes in your legs.
C.Counseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having inflammation of your womb.
3. However, there are also other conditions which could be causing your abdominal
pain.
Such as pregnancy, infection of( appendix) gut, abortion, etc
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
With your permission I need to run pregnancy tests
and You need to be have a pelvic and rectal examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
1. To protect your health.
. You should practice safe sex, and tell your sexual partners to always
use a condom
.You should have a paps smear regularly.
Is that alright? Do you have any more questions?
Goodbye, maam. See you later.

Patient note
History
HPI:
ROS:OB/GYN
PMH:
Allergies:
Medications:
PSH:
SH:
FH:

Physical Examination
VS
Chest
Heart

ABD:
Differential Diagnosis
Diagnostic workup

11.CASE 29: Loss weight +( epigastric pain)= pancreatic


carcinoma.
A. History taking.
Hello Maam, Mrs. Jacobson. Im Dr.Le. Nice to meet you! (First I need to cover you with
the sheet. Is that comfortable)
1. How can I help you today?
2. Please tell me more details about your problems?
Epigastric pain
LiqorAAA OI LQL Qn RAAA
2. When did your pain begin (start)? Onset
Where did you first feel the pain? (where did your pain begin?)
What were you doing when the pain began? What brings the pain on?
Does the pain begin suddenly or gradually?
3. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
4. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
5. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
6. Was your pain continuous or does it come and go? Quantity
How many times do you have pain per day/week/month? ( How often do you have
pain?)
How long does it last for each episode (every time)?
7. Now, if compare with the onset, is the pain getting worse or better? P
8. Does the pain move around or stay in one place? Radiation
9. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
10. Does anything relieve the pain? (Does anything make the pain better?)

Alleviation
Loss weight
3. Did you lose your weight?
4. How many pounds did you lose? Over what period of time did you lose this
weight?(How much weight did you lose? How long have you been losing weight?)
Association
Digestive
5. Do you notice any pain when you eat? (Did the pain relate to eating
6. Is this pain usually at night or in the day time?

7. Do you have nausea or vomiting?Do you feel nauseated or do you vomit?


8. Have you had any change in your bowel movement? Whats color of the stool?
9. Hows your appetite.
Jaundice-Icterus
10. Have you noticed any change in your eyes? Did your eyes look yellow?
11. Have you noticed any change in your skin? Did you feel itchy? Did your skin look
yellow?
12. Have you had any change in your urine? Did your urine look yellow?
General
13. Do you feel any fever?
14. Could you tell me how this problem has affected to your daily activities?
PAM
11. Have you had stomachache and lose weight before?
12. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
13. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
14. Do you take any medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
5. Have you had any change in your sleep patterns? S
FoSxS
FH:
1. Does anyone in your family have stomachache and lose weight like you?
2. Does anyone in your family have any other medical problem? Are your parents alive?
Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)

4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
GAD.
HEENT
Eyes:icteric
Neck: Pa lymph node &axillary
Pulmonary:Pa A
CV: A
Abd exam:I A,Pa,Pe
Skin: jaundice
Exts: Edema, Cyanosis, Phlebitis
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes:icteric Id like to examine your eyes now.
lymph node Let me press lightly on your neck and armpits
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. Let me take a look at your back.
3. Can you say 99 for me, please.
4. Im going to tap on your back to check your lungs. Is that ok with you?
5. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1.I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
2. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.
Special tests:
1.Please turn over to your left side.
Im going to take a look & press on your back now. let me know if it hurts. ( CVA
tenderness).

Skin: I need to find any change color of your skin(jaundice)


Exts:
I need to find any changes in your legs.
( Edema, Cyanosis, Phlebitis)
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having chronic inflammation of the pancreas.
3. However, there are also other conditions which could be causing your problem.
Such as obstruction of your bile- duct, tumor of the pancreas or stomach, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
You need to be have a rectal examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with the low fat, low salt.
Is that alright? Do you have any more questions?
Goodbye, maam. See you later.

12.CASE 28 : COUGH (chronic>3m; acute<3w)


A. History taking. Hello Sir, Mr. Brown. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
1.Can you tell me more details about your cough?
2.When did your cough begin? O
3. Before coughing do you have any symptoms?
4.Does the cough come with a special time? When does the cough usually occur? (Is there
a special time when the cough usually occurs)? At night?
What were you doing when the cough occurred?
5.Do you feel your cough comes from your throat or chest? L
6.Is this a dry cough or (productive cough) are you congested? QL
7. Does your cough usually last a short time or longer?
8.What does the phlegm contain?
8.What color is the phlegm?
9.Is there blood in the phlegm? Mucous?
10.Does the phlegm have a strong smell?
11.Is there a large amount? Q n
AGG: Does anything make your cough worse?
ALL: Does anything make your cough better?
ASSOCIATION:
1. Have you noticed a dripping sensation in your throat? Do you need to clear your
throat? Postnasal drip
2. Do you have any facial pain or tooth pain? Sinusitis.
3. Do you get shortness of breath? Difficulty breathing? CHF
4. Do you notice any wheezing? Exercise, exertion or at night? Asthma
5. Do you have frequent heart burn? Do you have regurgitation or sour taste? GERD
6. Do you have any chest pain?
7. Do you feel like your heart is racing?
8. Do you have swelling in your leg?

9. Do you have any fever or night sweating?


Affect
1. Does your cough affect your sleep or your other activities? I
Sick contact:
1.Have you had close contact with any one who has the same problem?
2. Do you have any pets like cats and dogs at home?
3. Have you traveled recently?
PAM
1.Have you had cough before?
2.Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes
3..Have you had any allergic disease like sinusitis, rhinitis, asthma?
4. Do you take any medication? treat your hypertension ? (ACE inhibition):
5.Have you ever had TB test? When was the last PPD test?
HSitUGWD
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FOSxS
FH:
1. Does anyone in your family have cough like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
5. Have you ever been tested for sexually transmitted disease?HIV?
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?

c. Have you ever felt annoyed by criticism of your drinking?


d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
6. Have you ever been tested for sexually transmitted disease? HIV test?
B.Exam component:
HEENT Mouth I, Throat I , sinuses Pa,
lymph node Pa
CV: A
Pulmonary:I Pa Pe A
Abd exam: A,Pa
Exts: I ,Edema
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
HEENT
1. I need to examine your sinuses, so Im going to press on your forehead. Please, tell
me if you feel pain anywhere.
2. I need to check the inside of your mouth and your throat. Can you please open your
mouth. Please say ah
3. I need to check your nose now.
lymph node Let me press lightly on your neck and armpits
Pulmonary Exam.
Posterior Chest.
6. I m going to examine your lungs. May I untie your gown
7. Let me take a look at your back.
8. Can you say 99 for me, please.
9. Im going to tap on your back to check your lungs. Is that ok with you?
10. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1.I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
3. Im going to examine your heart. Let me open your gown to uncover your chest.
4. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to listen to your belly.
3. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
4. I need to press a little more deeply now.
. Exts:
I need to find any changes in your legs. ( Edema, Cyanosis)
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having inflammation of the respiratoty system.
3. However, there are also other conditions which could be causing the cough.

Such as medication, infection, asthma, heart disease, gastro-esophageal reflux


disease, etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
If you agree I suggest you have HIV test?
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6. To protect your health.
You should quit smoking.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

13.Case 6: SOB + cough


A. History taking. Hello Sir, Mr. Cihonski. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
Can you tell me more details about your problem?
Complain 1:
1.When did your shortness of breath begin?
2.Is it begin suddenly or gradually? What were you doing when it began?
3. Does the cough come with a special time in day? When does the cough usually occur?
Does it occur at night or in the day time?
4.Does any thing else make the SOB get worse(increase)?
Does your SOB increase when you lie down?
Does it relate to exercise or go up stair?
5.Does anything make your SOB better?
How many pillows do you sleep on?
Do you feel better when you sit upright?
Complain 2:
1.Does the cough occur at the same time with SOB? When did the cough begin?
2. Does you feel your cough comes from your throat or chest? Where is your cough
located?(Do you think where the cough located?)
3.Is that a dry cough or productive cough? (Dry cough) Do you feel congested?
Association
1.Do you have any chest pain ?
2.Do you hear your heart racing?
3.Do you have fainting attacks?
4.Do you have feelings of dizziness or a light-headache?
5.Do you have swelling of your feet or ankles?
6.Do you have any fever?
Affect
7.Does your SOB and cough affect to your activities?
PAM
1. Have you had shortness of breath and cough before?
2. Have you had any other medical problems? Example :Lung Problems, high blood
pressure, high cholesterol diabetes.
What was the result of your last cholesterol test?

3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FoSxS
FH:
1. Does anyone in your family have shortness of breath and cough?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
Eye: PERLA, FO
Neck: JVD ,carotid bruits
Pulmonary: A
CV: A2, PMI,
Abd exam: Pe liver Span

Exts: Edema ,Pulse(peripheral)


Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eye: PERLA, FO
Id like to examine your eyes now. I need to dim the light in this room. Im going to
shine this light in your eyes. Can you look at the clock on the wall. (Can you pick a point on
the wall and look at it.).
Pulmonary:
Pulmonary Exam.
Posterior Chest.
7. I m going to examine your lungs. May I untie your gown
8. Let me take a look at your back.
9. Can you say 99 for me, please.
10. Im going to tap on your back to check your lungs. Is that ok with you?
11. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
12. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
13. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
14. Im going to examine your heart. Let me open your gown to uncover your chest.
15. I need to press in your heart area. (PMI).
16. I need to press in your chest. Do you feel any pain?
17. I need to listen to your heart.
18. Can you turn to your left side, please.
Sitting up
1.Can you sit up, and lean forward. Ill listen to your heart again.
Vascular
2. Can I listen to your neck (carotid arteries), stomach (abdominal aorta).
3. I need to check the pulse in your arms and legs now.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
3. I need to press a little more deeply now.
4. Now I need to tap on your stomach
Exts
1. I need to check your legs.
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having heart disease.
3. However, there are also other conditions which could be causing Shortness of
breath.
Such as chronic inflammation of lung or fluid in lung membrane, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.

Ill be in a better position to tell you your diagnosis and treatment options.
2. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with the low salt and low fat.
3. Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

14.CASE 11: BP Check and refill


A. History taking. Hello Sir, Mr. Gonzales. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
Can you tell me something about your high blood pressure?
HTN
1. How long have you had high blood pressure?
2. Do you check your BP regularly?
3. When was the last time that you checked your blood pressure?
Treatment
1. What kind of drugs are you taking for your high BP?
2. Do you take your medicine regularly
3. Does your medication cause any side effect?Libido?
Asssociation Beside HBP have you noticed anything symptoms?
Brain
1.Do you have headaches very often?
2.Do you ever feel dizzy?
3.Have you ever fainted? ( passed out ?) Do you have any fainting attack?
4.Have you ever had a seizure?
5. Do you notice any changes in your eyes?
6.Do you ever feel weakness any where in your body?
7.Do you ever feel numbness any where in your body?
8. Have you ever had difficulty talking?
Eyes:
1.Have you had any change in you eyes? Vision?
Heart
1. Did you have chest pain?
2. Did you hear a racing of your heart?
3. Did you feel a shortness of breath?
Kidney
1. Have you had any change in your urination? Uaaa
2. When was the last time that you had an urine test ?( When did you last have an
urinalysis)
Vascular
1. Have you had history of stroke? Or TIA?
2. Have you had any pain in your buttock or leg while walking?
Libido
1. Have you had any problems in your sexual performance? A weak erection
2. Can you have early- morning or nocturnal erections?
Depression Anxiety
1. How s about your mood? Have you had a bad mood?
2. Have you had feelings of anxiety or stress?

BM
Have you had any change in your bowel movement? G
Sleep
Have you had any change in your sleep patterns? S
Diet-Exercise-Weight
4. Are you on a diet?
5. How is your appetite?
6. Do you exercise regularly?
7. Have you had any change in your weight recently?
PAM
1. Have you had any other medical problems? Example: Stroke, , diabetes.
When did you last have your cholesterol level checked?
What was the result of your last cholesterol test?)
2. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
3. Do you take any another medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
FOSxS.
FH:
1. Does anyone in your family have high blood pressure?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

*Challenging question:

Do you think Im just getting old? (Patient with


impotence)
1.This is good question
1. Age could play an important role in decreased sexual function
3. However, there are also reversible conditions which could be causing your problem
Such as, medication, diabetes and high blood pressure, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
6. Ill know what can be causing your problem.
7.Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
Eye: PERLA, FO
Neck: JVD ,carotid bruits
Pulmonary: A
CV: A2, PMI,
Abd exam:A Pa Pa(kidney)
Exts: Edema ,
Pulse(peripheral)
Neurologic exam: DTRs, Babinskis sign,sensation,strength in lower exts
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eye: PERLA, FO
Id like to examine your eyes now. I need to dim the light in this room. Im going
to shine this light in your eyes. Can you pick a point on the wall and look at it.
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
2. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
3. Im going to examine your heart. Let me open your gown to uncover your chest.
4. I need to press in your heart area. (PMI).
5. I need to listen to your heart.
6. Can you turn to your left side, please.
Sitting up
1.Can you sit up, and lean forward. Ill listen to your heart again.
Vascular
Can I listen to your neck (carotid arteries), stomach (abdominal aorta).
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.

2. Im going to take a look at your stomach area.


3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
Exts:
1. I need to check the pulse in your arms and legs now.
2. I need to check for fluid retention in your legs.
Musle testing: (M)Now Im going to check the strength of your muscle now.
MRS
1. Please, Push your thigh up. Push your thigh down.( Thigh).
2. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
3. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
1. I need to tap on your legs. (patellar, Archilles)
2. Now I need to tickle your feet lightly. (Babinski).
Sensory(S): Now I need to check your sensations/ lower exts
1. This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes..
2. This is up ( move up a toe).This is down (move down a toe). Please, close your eyes
and tell me up or down when I move your toes.( Position sense).
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having high blood pressure without complications.
3. However, there are also other conditions which could be causing by your high blood
pressure.
Such as, diseases of heart, brain, kidney, and eye etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
4. To protect your health.
You shouldnt smoke or use alcohol, caffeine
You should have a healthy diet, food with low fat, low salt.
You should exercise and check your blood pressure and use medication
regularly.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

15.CASE 21:Difficulty swallowing


A. History taking. Hello Sir, Mr. Johnson. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
Can you tell me more details about your problem?
1.When did your symptom begin?
2 Was the onset sudden or gradual?
3 what kind of food do you first get stuck, liquid or solid?
4.what kind of food do you get stuck now?

5.when does the food get stuck? Does the food get stuck when you begin or end of
swallow?
6.Where does the food get stuck?
7.How severe are your symptoms? are you able to eat a meal?
Association: Beside difficulty swallowing do you have any symptoms?
1.Is there any pain when you swallow?
2.Is there nausea or vomiting? (contain, color, odor, blood in it)
3.Do you have fever or chill?
4.Have you had weight loss or fatigue?
5.Have you had foul breath?
6. Have you had a hoarse voice?
Thyroid
7.Have you had swelling of the neck?
8.Do you feel hot or cold and others dont?
Scleroderma)
9.Have you noticed any change in your skin or nails?
Alleviation: Does any thing make your swallowing better?
PAM:
1.Have you had difficulty swallowing before?
2.Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes
Have you ever swallowed any type of corrosive liquid? acid, base, soap(detergent)
3.Are you allergic to anything? (Plants, food, medication..). Do you have any allergies?
4.Do you take any medication?
HSitUGWD
2. Have you ever been hospitalized before? H
3. Have you ever had surgery? S
4. Have you had any trauma or injuries? I &T
5. Have you had any change in your urination? U
6. Have you had any change in your bowel movement? G
7. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
8. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
9. Have you had any change in your sleep patterns? S
FOSx S
FH:
1. Does anyone in your family have difficulty swallowing?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)

SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

*Challenging Question:

Do you think Ill get esophageal cancer?


1. This is good question
2. Until now I cannot rule out a possibility youre having a esophageal

cancer. A cancer is a possibility.


3. However, there are also other conditions which could be causing your problem. and
they may be treated.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
6. Ill know if your problem could be cancer or not.
B.Exam component:
Oral: I oropharynx & orocavity
Neck:
Thyroid gland: I, Pa, swallowing water
Lymph nodes: Cervical,supraclavicular,axilla
JVD ,carotid bruits
Pulmonary: A
CV: A2,
Abd exam:A Pa Pe
Exts: Edema , clubbing.
Skin,nail ( Scleroderma)
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is
that ok with you?
Oral:
1. I need to check the inside of your mouth and your throat. Could you please open your
mouth. Please say ah
Neck
1. I need to check your neck area.

2. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
3. I need to listen to your neck. ( the bruits of carotid arteries or thyroid gland).
4. Let me touch lightly on your armpits
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down : Could you lie back on the table.
2. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
3. Im going to examine your heart. Let me open your gown to uncover your chest.
4. I need to listen to your heart.
Abdominal exam.
6. I need to examine your belly now Let me uncover your stomach.
7. Im going to take a look at your stomach area.
8. Im going to listen to your belly.
9. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
I need to press a little more deeply now.
Exts:
I need to find any changes in your legs. ( Edema, Cyanosis)
Skin,nail ( Scleroderma)
I need to check your skin, and your hair
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having a narrowing of your esophagus.
3. However, there are also other conditions which could be causing your difficulty
swallowing.
Such as spasmodic disorder or a tumor in your esophagus, etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with low fat, low salt.
2. Is that alright? Do you have any questions?
Goodbye, Sir. See you later.

16.CASE 18:Diarrhea
A. History taking. Hello Sir, Mr. Golden. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
1.Can you tell me more something about your diarrhea?
2.When did your diarrhea begin? O
2. How many times do you have bowel movements every day? Qn
3.Is it large amount of each time? (What is the amount of your stool)? Qn

4.What is the consistency of your stool ?QL


5.What does the stool contain?
6.Is there blood or mucous in your stool?
7.Does the stool have a strong smell? How does it smell? Is the stool smell foul?
8 Is the stool float in the toilet (pan)?
9 After going to the bathroom do you ever feel like you still need to defecate? Is there a
sensation of incomplete evacuation?
10.is there a sensation of tenesmus?(Do you feel you need to run to the bathroom for a
lot of bowel movements all the time, but you only have a small amount of stool?)
Association
Digestive
a. Did you have stomachache along with the diarrhea? If yes: LIQORAAA
b. Dou you have any nausea or vomiting?
c. How is your appetite?
DM- dehyration
d. Do you feel very thirsty? Do you need to drink a lot of water?
e. Have you had any change in your urination?
f. Have you had any change in your weight?
IBD
g. Have you had any change in your skin? Rash?
h. Have you had any change in your eye?
i. Do you have any change in your joints?
Sick contact:
j. Did you eat out at a party or restaurant lately?
k. Do you have any pet like cats or dogs at home? Do you have any exposure to pet
or pet droppings?
l. Have you traveled recently? (Did you have any travel recently)?
PAM
3. Have you had the same diarrhea before?
4. Have you had any other major medical problems? Example: high blood pressure, high
cholesterol, diabetes.
5. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
6. Do you take any medication?
HsitUGDWS
7. Have you ever been hospitalized before? H
8. Have you ever had surgery? S
9. Have you had any trauma or injuries? I &T
10. Have you had any change in your urination? U
11. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
12. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
Have you had any change in your sleep patterns? S
FoSxS:
FH:
7. Does anyone in your family have diarrhea like you?

Does anyone in your family have any other serious medical problem? DM, HIV,
IBDAre your parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
6. Are you sexually active?
7. How many sexual partners do you have?
8. Are they male or female or both?
9. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
10. Have you ever been tested for sexually transmitted diseases or example HIV ?
SH:
5. Whats your job?
6. Do you have any stress in your life?
7. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
8. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
9. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
10. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

Challenging questions Patient:


1. Doc, I can spread my disease to my students?
1. It is good of you to be concerned about your student.
2. There are many conditions which could be causing your problem.
3. Your disease can spread to any one if it is an
infectious disease.
4. To have the exactly diagnosis. I need to run some test on your stool, blood, and
imaging research.
5. After your test results come back, well know if your disease can spread to
anybody.
6. However during this time you should wash your hands with antibacterial soap
after going to the bathroom.

B.Exam component:
Eyes
Oral : ulcer,thrush
Pulmonary: A
CV: A
Abd exam: I A PaPe
Joints
Skin: rashes

What you say when you do PE


Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes
Pupil reaction:
I need to dim the light in this room. Im going to shine this light in your eyes.
FO:
I need to shine the light in your eyes. Please pick a point on the wall and look at it Ill
examine the back of your
Oral:
I need to check the inside of your mouth and your throat.Could you please open your
mouth. Please say ah
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
3. I need to listen to your heart.
Abdominal exam.
4. I need to examine your belly now Let me uncover your stomach.
5. Im going to take a look at your stomach area.
6. Im going to listen to your belly.
7. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
8. I need to press a little more deeply now.
9. Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).
10. Now I need to tap on your stomach.
Joints:
1. Im going to examine your joints
Skin
I need to check your skin

c.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having bowel inflammation.(inflammation of the gut)
3. However, there are also other conditions which could be causing your diarrhea.
Such as mal-absorption, bowel infection, food poisoning, etc .
11. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
You need to be have a rectal examination
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options
6. To protect your health.
You should have a healthy diet, food with low fat and dont eat out
at restaurants or at parties.

Is that alright? Do you have any more questions?


Goodbye, Maam. See you later.

17.CASE 12:Blood tarry stools


History taking. Hello Maam, Miss. Fued. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
1.Can you tell me more details about your problem?
2.When did the blood tarry stools begin?
3. Do you notice that the blood has before, during, or after defecation?
4.What is the consistency of your stool ?QL
5.Is there any change in the size of your stool?
6.Does the stool have a strong smell?
7. How often have you had bowel movement?
8.Could you estimate the amount of the stool for each bowel movement?
9.Do you have pain during defecation?
10.After going to the bathroom do you ever feel like you still need to defecate?
11.Have you ever had a colonoscopy or flexible sigmoidoscopy?

Association
Digestive:
12. Do you have nausea or vomiting? blood vomit?
13. Did you have a stomachache?
Lung
15.Have you had lung problems before?
Bile duct
16. Did your eye and skin become yellow? Did you have itchy skin?
General
1. Do you have pain anywhere in your body? joint? How do you treat it?
2. Do you have any fever?
Sick contact
1. Have you had close contact with someone who has the same problem like
you?
2. Have you traveled recently?
Affect:
1. Have you ever had dizziness?
2. Have you felt unsteady when you walk?
3. Have you ever loss of consciousness?
PAM
1. What does your blood pressure normally run?
2. Have you ever had bleeding like this before? Dark stool?
3. Did you have any other medical problem? Liver didease, PUD
4. Are you allergic to any medication?
5. Do you take any other medication, especially (NSAIDs?) example killer pain,
ibuprofen?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S

3. Have you had any trauma or injuries? I &T


4. Have you had any change in your urination? G
5. Whats your appetite been like? D (Is there any kind of special diet that you
are following?)
6. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have
you been losing or gaining your weight?
7. Have you had any change in your sleep patterns? S
FoSxS
1. Does anyone in your family have a similar problem?
2. Does anyone in your family have any other major medical problem? Cancer? Are your
parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period? How long does each period last?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

*Challenging Question: Do you think Ill get colon cancer?


8. This is good question
9. History of Your family and your constipation certainly places you at risk of
getting colon cancer.
10. However, there are also other conditions which could be causing your problem.
Such as medication side effects, or obstruction of the gut, etc .
11. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.

12. Once I get the results of these tests.


13. Ill know if your problem can be cancer or not.

14.

Please try not to worry because the staff and I are here to give you the best
possible care.

B.Exam component:
Blood loss: eyes, under tongue. Palms, JVD
CV: A
Pulmonary: A
Abd exam: I A Pa(Murphy) Pe
Exts: Edema ,clubbing, cyanosis
What you say when you do PE
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes, Mouth ,Palm
Id like to examine your eyes, mouth, palms to look for if you have had anemia
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
2. Im going to examine your heart. Let me open your gown to uncover your chest.
3. I need to listen to your heart
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.(liver)
7. Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).
Exts:
I need to find any changes in your legs.
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having hemorrhaging due to a stomach ulcer.
3. However, there are also other conditions which could be causing your black stool.
Such as medication, inflammation of bile-duct or liver disease, etc.
3. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
You need to be put a tube in your mouth.
You need to be have a rectal exam

5. Once I get the results of these tests.


Ill be in a better position to tell you your diagnosis and treatment options.
4. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with low fat, low salt.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.

18.CASE 20: Vaginal discharge


A. History taking. Hello maam, Miss. Abbel. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
Can you tell me more details about your problem?
1.When did the discharge begin?
2.Was the onset sudden or gradual?
3. What is the amount of your discharge? Is the discharge copious?
4.Is the discharge continuous or does it come and go?
5.Can you describe the consistency of the discharge?
6.Does the discharge have a strong smell? Is there an odor?
7.What color is the discharge?
8.Is there any blood in it?
Association: Besides vaginal discharge do you have any symptoms?
Is there any pain?
Is there any itchiness?
Do you feel fever?
Do you notice any change in your weight?
Have you had any rashes?
Aggravated-Alleviated: Does anything make your discharge begin or worsen?
PAM:
7. Have you ever had vaginal discharge before?
8. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
9. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
50.Do you take any medication?
HSitUGWD
8. Have you ever been hospitalized before? H
9. Have you ever had surgery? S
10. Have you had any trauma or injuries? I &T
11. Have you had any change in your urination? U Is there any change in your
urination?
12. Have you had any change in your bowel movement? G
13. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)

14. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
15. Have you had any change in your sleep patterns? S
FOSx S
FH:
1. Does any women in your family have vaginal discharge?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period

4. Was your cycle regular or irregular?


5. How many days are there between your periods? How many days are in your
period cycle?
6. How long does each period last?
7. How many pads did you use on heavy days? Per day?
8. Are you sexually active? Sx
9. When was your last sexual contact?
10. Have you ever had a discharge from your breast? Have you ever had any nipple
discharge?
11. Have you ever been pregnant?
12. Have you had any miscarriage or abortions? In what trimester?
13. Have you ever been tested for sexually transmitted disease? .Have you ever had
any sexually transmitted diseases?
14. Have you had a Pap smear? When was the last Pap smear? What was the result of
the last time?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
11. Are you sexually active?
12. How many sexual partners do you have?
13. Are they male or female or both?
14. Do you use any contraceptives?
15. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?

c. Have you ever felt annoyed by criticism of your drinking?


d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
Pulmonary: A
CV: A
Abd exam:A PaPe,Rebound
Skin: rashes
Joints??
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Pulmonary Exam.
Posterior Chest.
3. I m going to examine your lungs. May I untie your gown
4. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
2. I need to listen to your heart
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.(liver)
7. Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).
Skin
I need to check your skin
Joints??
C.Counseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having inflammation of your womb.
3. However, there are also other conditions which could be causing your vaginal
discharge.
Such as pregnancy, infection of womb, abnormal foreign body in your vagina, etc
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.

With your permission I need to run pregnancy tests


and You need to be have a pelvic and rectal examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
To protect your health.
. You should practice safe sex, and tell your sexual partners to always
use a condom
.You should have a paps smear regularly.
Is that alright? Do you have any more questions?
Goodbye, maam. See you later.

19.CASE 8: 20yrsc/o vaginal bleeding


A. History taking.
Hello, Ms. Bush, Im Dr. Truong , Nice to meet you! (First I need to cover you with the
sheet. Is that comfortable)
how can in help you to day?
1. Can you tell more details about your problems?
2. When did the problem begin?
3. Was the onset sudden or gradual?
4. What were you doing when it began? Were you sleeping or having active
sex(after sex)?
5. Is the bleeding continuous or does it come and go?
6. Tell me what the blood looks like?
Is there bright red or clotted blood. ?
Is there tissue or grape like tissue?
7. Did you have any bleeding from other parts of your body?
O/G
1. When was your last menstrual period?
2. Was your cycle regular or irregular? How many days are there between your
periods?
3. How long does each period last?
4. How heavy is the flow? How many pads or tampons do you use on heavy day?
5. Have you ever been pregnant?
6. Have you had any abortions? Have you ever had any miscarriages?
Association :Besides vaginal bleeding do you have any symptoms?
Abd pain
1 Have you had any stomachache?
Depression-anxiety-stress
1. Hows about your mood? Have you had a bad mood?
2. Do you have any stress in your family or at school?
3. Do you have any anxiety or palpitation?
Thyroid disorder
1. Have you had any swelling or mass in your neck?
2. Do you feel hot or cold when others dont? Do you feel hot or cold when other people
are feeling normal?
3. Have you noticed any change in your voice recently?
4. Have you had any changes in your bowl movement? Constipation?
Pituitary gland

1.Do you have headaches very often?


3. Do you notice any changes in your eyes? Visual Changes?
General
1. Have you had any changes in you weight?
2. How is your appetite? Are you on diet?
PAM
1. Have you had vaginal bleeding before?
2. Have you ever had any bleeding from other parts of your body before?
3. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
4. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
5. Do you take any medication?
H(sit)UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your sleep patterns? S
FH:
1. Does anyone in your family have a history of bleeding?
2. Does any women in your family have a history of multiple abortions?
3. Does anyone in your family have any other serious medical problem?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use
a condom consistency or inconsistency?)
6. Have you ever had any sexually transmitted diseases? HIV
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

*Challenging question:
Do you think Im going to lose my baby?
1.This is good question
1.There are many conditions which could be causing your vaginal bleeding.
2. Losing the baby- what we call an abortion, is one of them.(causes)
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies.
5. Once I get the results of these tests.
6. Ill know what is causing of your bleeding.
7.Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
Anemia: eyes, under tongue. Palms
ENT:nose, gum
Neck exam: Thyroid gland,DTR
Pulmonary: A
CV: A
Abd exam:A PaPe,Rebound
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes:
Visual fields Please, follow my fingers without moving your head (4 directions)
EOM: Please, follow my fingers without moving your head (8 shape)
Neck
1. I need to check your neck area.
2. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
3. I need to check your skin, and your hair
4. Please hold on your hands like this and close your eyes. ( check tremors).
DTRS
1. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
2. I need to tap on your legs. (patellar, Archilles)
Pulmonary Exam.
Posterior Chest.
11. I m going to examine your lungs. May I untie your gown
12. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
13. I need to listen to your heart
Abdominal exam.
14. I need to examine your belly now Let me uncover your stomach.
15. Im going to take a look at your stomach area.

16.
17.
18.
19.
20.

Im going to listen to your belly.


I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
I need to press a little more deeply now.
Now I need to tap on your stomach.(liver)
Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).
C.Counseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having a bleeding disorder of the womb.
3. However, there are also other conditions which could be causing your bleeding.
Such as pregnancy, chronic inflammation of the womb, abnormalities of your
blood system, etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
With your permission I need to run pregnancy tests
and You need to be have a pelvic and breast examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
5. To protect your health.
You should practice safe sex, and tell your sexual partners to always
use a condom.
You should have a paps smear regularly.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.

20.CASE 14: AMENORRHEA


A. History taking. Hello maam, Ms. Barbarra. Im Dr. Le Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
.
How can help you today?
Can you tell me more details about your problem?
1. How long ago did your problem start? When did your problem start?
2. When was your first menstrual period? When did your menarche begin?
3. When was your last menstrual period?
4. Before this problem, was your cycle regular?
5. How many days are there between your periods?
6. How long does each period last?
7. On a heavy day, how many pads or tampons do you use?
8. Have you ever been pregnant?
9. Have you ever had a miscarriage or abortion?
10. Have you ever had any vaginal discharge?
11. Have you had any itching or dryness in your vagina?
12. Do you ever have any spotting (bleeding) between periods?
13. Have you ever had any hot flushes???
14. Have you had a Pap smear? When was the last Pap smear? What was the result of the
last time?

Sexual active May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many partners do you have?
3. Do you use any contraceptive? Do your partners always use a condom or only
sometimes?
4. When was your last sexual contact ?
5. Have you had any Sexually Transmitted Diseases or pelvis inflammation?
6. Have you ever had any nipple discharge?
Association
Abd pain
1 Have you had any stomachache?
Depression-anxiety-stress
1. Hows about your mood? Have you had a bad mood?
2. Do you have any stress in your family or at school?
3. Do you have any anxiety or palpitation?
Thyroid disorder
5. Have you had any swelling or mass in your neck?
6. Do you feel hot or cold when others dont? Do you feel hot or cold when other people
are feeling normal?
7. Have you noticed any change in your voice recently?
8. Have you had any changes in your bowl movement? Constipation?
Pituitary gland
1.Do you have headaches very often?
5. Do you notice any changes in your eyes? Visual Changes?
PAM
1. Have you ever missed your periods before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
H(sit)UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FH:
1. Does any women in your family have miss their periods like you?

2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

* Challenging question:
Do I have pregnancy or menopause?

1. This is good question


2. There are many conditions which could be delaying your period.
3. Pregnancy or menopause is one of them.(causes)
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies.
5. Once I get the results of these tests.
6. Ill know what could be causes of your problem.
7. Please try not to worry because the staff and I are here to give you the best
possible care.
B.Exam component:
HEENT:
Eyes Visual fields
Extraocular movement
Neck exam: Thyroid gland,DTR
Pulmonary: A
CV: A
Abd exam:A PaPe
Exts: Inspection
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes:
Visual fields Please, follow my fingers without moving your head (4 directions)
EOM: Please, follow my fingers without moving your head (8 shape)
Neck
5. I need to check your neck area.

6. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
7. I need to check your skin, and your hair
8. Please hold on your hands like this and close your eyes. ( check tremors).
DTRS
3. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
4. I need to tap on your legs. (patellar, Archilles)
Pulmonary Exam.
Posterior Chest.
21. I m going to examine your lungs. May I untie your gown
22. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
2. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.(liver)
Exts:
I need to find any changes in your legs.
C.Counseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having anxiety disorder.
3. However, there are also other conditions which could be causing the delay your
period.
Such as pregnancy, abnormality of your thyroid gland, or depression etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
With your permission I need to run pregnancy tests and
You need to be have a pelvic and breast examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6. To protect your health.
You shouldnt smoke or use alcohol.
You should practice safe sex, and tell your sexual partners to always
use a condom
Is that alright? Do you have any more questions?
Goodbye, maam. See you later.

21.CASE 22: dark urine


A. History taking. Hello maam, Miss. Carrot. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)

How can help you today?


1.Can you tell me more detail about your problem ?
2.When did your urine become dark ?
3. Does the dark urine continuous does it come and go at any special time?
Quality
1. What color does your urine look like ? is there blood in it?
2. Is the dark urine prominent at the beginning, middle, end, or through out urination?
3. Is it cloudy ?
4. Is there a strong smell? Is there an odor?
Quantity
1. Do you notice any change in the quantity of your urine? Polyuria?
2. Have you had any change in frequency of your urine?
Difficulty
1. Have you had straining during urination
2. Do you have a burning sensation when you urinate?
3. Do you notice any weakness in your stream? Do you notice any any dribbling of
urine?
4. After urinating do you ever feel like you still need to urinate? (Have you had feeling
empty incompletely after urinating?)
AAA
1. Does anything improve your symptoms? Alleviated
2. Does any thing make the dark urine worse? Aggravated
causing
1. What do think is causing your dark urine?
2. Does any food change your urine color?
3. Does the exercise change the color of urine?
a. Did you have a sore throat recently?
4. Have you had any trauma before?
5. Did you take any medication?
Association Beside your dark urine do you have other symptoms?
1. Do you have another pain in your body? Or back pain, stomachache?
2. Did you have fever? chill? Sweating ?
3. Did you have nausea, vomiting?
PAM
1. PMH Have you had the dark urine before? Have you had urinary tract infections or
kidney problem ?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any another medication?
Hsit
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your bowel movement? G

5. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
6. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
7. Have you had any change in your sleep patterns? S
FOSxS
1. Does anyone in your family have dark urine?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active? Have you had any change in your sexual activity recently?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

*Challenging Question:

Do you think Ill get bladder cancer?


7. This is good question
8. Until now I cannot rule out a possibility youre having a bladder cancer.
A cancer is a possibility.
9. However, there are also other conditions which could be causing your problem. and
they may be treated
10. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.

11. Once I get the results of these tests.


12. Ill know if your problem could be cancer or not.
B.Exam component:
Blood loss: eyes, under tongue. palms
CV: A
Pulmonary: A
Abd exam: I A Pa(Kidney)Pe
Back : Mass& CVA tenderness.
Joints
Exts: Edema, Clubbing , cyanosis
What you say when you do PE
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes, Mouth ,Palm
Id like to examine your eyes, mouth, palms to look for if you have had anemia
Pulmonary Exam.
Posterior Chest.
23. I m going to examine your lungs. May I untie your gown
24. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
2. I need to listen to your heart.
Abdominal exam.
7. I need to examine your belly now Let me uncover your stomach.
8. Im going to take a look at your stomach area.
9. Im going to listen to your belly.
10. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
11. I need to press a little more deeply now.
12. Now I need to tap on your stomach.(liver)
Special tests:
1. Please turn over to your left side.
2. Im going to tap on your back now. let me know if it hurts. ( CVA tenderness).
Joints
I need to find any changes in your joints
Exts: Edema, Clubbing , cyanosis
I need to find any changes in your legs.
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having inflammation of your urinary tract.
3. However, there are also other conditions which could be causing your dark urine.
Such as food, medication, stone or tumor in your kidney or your bladder, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.

Ill be in a better position to tell you your diagnosis and treatment options.
1. To protect your health.
You should quit smoking.
You should drink a lot of water every day.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.

22.CASE 3:Telephone Case:


A. History taking.

a.Fever:Mother of Ann,1yo M, C/o baby with fever always crying ,fussy


1.Hello Mrs. Clinton. Im Dr. Le.
How can I help you today? (My daughter has fever?)
2.How old is she? How old is Ann?
3.Can you tell me more details about how your child is acting?(your child?)
4.When did the fever start?
5.What is the temperature? How high is her fever?
6.Did your child seem to sweat? Do your child have a chill?
7.Did your child have any shaking (seizures)?
Before shaking does your child have any symptoms?
After shaking does your child have any symptoms? What did your child seem like
after shaking? Sleep, paralyzed, irritable?
Did your child have incontinence of urine?
8.Did she have any rashes or red parts ( spot) on her body?
9. Did she have pain any where in her body?
10. Beside a fever did she have another symptoms?
Res.
a. Did she have cough? Is it dry or productive cough? (Did it sound like a dry cough or
did she sound congested it?) Whats color of the phlegm? Is there blood in it?
b. Did she have shortness of breath?
Did she have any discharge from nose(running nose), ears(Did your child have ear
pulling or ear discharge), eyes?
GI
c. Did she have nausea or vomiting?
d. Did your child have difficulty swallowing?
e. Did she have any change in bowel movement? Diarrhea?
f. What was her appetite been like?
GU
g. Did your child have any change in her urination?
h. Did she cry when she urinated?
11. Did anything make your daughter get better?
PAM-Sick contact.
1.Has your child had any similar problem before? P Has your child had fever and
shaking before?
2.Did your child have any other medical illness before?
3.Is your child allergic to anything? ( Does your child have any allergies? A
4.Do you give your child any medication? (Does she take any medication?) M (Are you
giving your child pediatric multivitamins?)
Sick contact

1.Has your child had close contact with any one having the same problems? (Does
any one in her family or her daycare or babysitter have a similar problem? )
2.Did your child travel anywhere recently?
3.Did your child eat out at a party or restaurant recently?

FH
2. Does any one in your family have a similar problem? Does any one in your family
have fever and shaking like her?
3. Does any one in your family have other medical problem?
HsitUGWDS
1. Has your child ever been hospitalized before? H
2. Has your child ever had surgery? S
3. Has your child had any trauma or injuries? I &T
4. Whats her appetite been like? D (Is there any kind of special diet that your child
are following?)
Did you breast-feed your child? Is your childs formula fortified with iron?
Have you changed her food recently?
5. Has your child had any change in her weight recently? W (How many pounds did
your child lose or gain? Over what period of time did it happen?) How long has
your child been losing or gaining your weight?
6. 22.Has your child had any change in her sleep patterns? S
Pregnancy: How about your pregnancy
1. Did you smoke, drink or use drugs during your pregnancy?
2. Did your child have any complications during your pregnancy, delivery or after
delivery?
. Was it a normal delivery or a C-section?
3. When did your child have her first bowel movement?
Development:Tell me some things about your child s development?
When did your child first smile? When did your child first sit up? when did your child
start talking? when did your
child start walking? When did your child start putting
things in his mouth?
Children >3-4 years old:
When did your child learn to dress himself? When did your child learn to tie the
shoes?
When did your child start using short sentences?
Vaccination:
4. Has your child had all the necessary vaccination? Did your child have vaccine
shot enough?
Pediatrician:
1.Do your child have a doctor that takes care of her on a regular basis? His name? His
address?
2.When was her last check up?

C.Counseling:
1.Based on your information about your child.
She has had a fever for about 3 days and a seizure, and diarrhea
She has developed normally, and she has had all her vaccinations
2. I think your child might be having viral upper respiratory infection and seizure
from having a high fever( fertile fever)

3. However, there are also other conditions which could be causing your childs
problem.
Such as food poisoning, intestinal (gut) or urinary tract infection.
1. To have the exact diagnosis. I need to examine your child and run some blood tests,
urine tests,
and imaging studies.
.
Will it be convenient for you to bring your child to the hospital? Is that OK with you?
Challenging Question:
1. Doctor, I cant go to your hospital right now because I have two children, nobody
will take care for my older child while I am gone, also I dont have any car to take
Ann to your hospital?

May be there is problem in my phone, I really didnt listen your voice


clearly. Please, repeat your question?
Answer:
i. This is good question
ii. I will ask a social worker to find a babysitter for your older
child.
iii. You need to call 911 and ask an ambulance or call for a cab to
pick your child up and bring her to the hospital.
iv. Do you have any more questions?
v. I hope Ill see you in our hospital., as soon as possible.
2. Doc, What should I do when my child has a high fever?
i. This is good question
ii. To deal with the high temperature you should put a cold towel
on your child s forehead and armpits and groins and you
should also have Ann wear only thin clothes.
3.Doc, Im in my company. My mom is babysitting my child. What am I doing,
now?
i. This is good question
ii. You need to call 911 and ask an ambulance or call for a cab to
pick your child up and bring her to the hospital.
iii. Do you have any more questions?
iv. I hope Ill see you in our hospital, as soon as possible

Patient note
History
HPI:
ROS:
PMH:
Allergies:
Medications:
PSH:
Birth history:
Dietary history:
Immunization history :

Developmenhistory:

Physical Examination
none
Differential Diagnosis
Diagnostic workup

b.Telephone case :Cough = Asthma, my grandson have a


cough+ funny breath
A. History taking.
1. When did his cough begin?
2. Is it a dry cough or productive cough? does it sound congested?
3. What was he doing when the cough occur?(Is his coughing random or does
something seen to cause him to cough?)
4. Does he usually cough at night or in the day time or both?
5. Is his cough related to exercise? Is he comfortable when he runs?
6. Does the cough associated with wheezing? Or shortness of breath?
7. Does he have any chest pain?
8. Does your grandson have any discharge from his eyes? ears? nose?
9. Does he have any fever?
10. Does any one in your family smoke cigarettes?
11.Does your family have any pets at home?

23.Case 27:Enuresis :Father come your office alone and said that
My son has problem in his life.
A. History taking.
Hello Mr. Jones , Can you tell me some more details about your sons problem? Nice to meet
you! (
1.
(my son wets his bed at night)
2. When did it begin? (How long ago did it begin? )3m.
Bed Wetting.
3. How often does he wet his bed? Does your son wet his bed every night or every 2 or
3 days?
4. How many times does he wet his bed every night?
5. Can you estimate the quantity of urine when he wets his bed? (Is the bed usually
pretty wet?)
6. Does he wet his bed at nap time?( Is there any particular time when he wets his bed?)
( early in the night or more toward morning?)
Urine daily

1.Has he had any change in his urination?


Quality
1.What color does his urine look like ?
2. Is there blood in it?
3.Is it cloudy ?Is there pus in it?
Quantity
3. Has he had any change in the quantity of his urine? Polyuria?

4. Has he had any change in frequency of his urination?


Difficulty
1.Has he had difficulty urinating?( Does he ever have difficulty initialing or stopping
the stream?)
2. Has he ever had to run to the bathroom ?
3. Has he had a burning sensation when he urinated?
4. Has he had any weakness in his stream? Has he had any dribbling of urine?
5.After urinating did he ever feel like he still need to urinate?( Does he complain of a
feeling of incomplete emptying of bladder?)
Daily water
10.Did your son feel thirsty all day? Does he need to drink a lot of water every day?
11.Did he take a lot of water before going to bed?
Association:
12.Beside wetting his bed, Did your son have any other symptoms?
General:
1. Did he have any fever?
2. Did he have pain any where in his body?
Influence:
b. How has your childs problem affected to your family?
c. What have you done to deal with this problem?
PAM: Now I need to ask you about your childs health in the past. Is that OK
with you?
1. Did he wets his bed before?
2. Did he have any other medical problem before? Diabetes, Sickle cell
Disease,?
Did he suffer from repeated urinary infections?
Did he have any problem with neurological or gait abnormalities?
3. Is your child allergic to anything? ( Does your child have any allergies? A
4.Do you give your child any medication? (Does she take any medication?)
HSitUGWD
1. 1.Has he ever had surgery before? Neurologic or urinary surgery?
2. Has he been circumcised?
3. Has your child had any trauma or injuries? I &T
4. Has he had nausea, vomit, stomachache?
5. Has he had any change in his bowel movement?
6. How is his appetite?
7. Has he had any change in his weight?
8. Has he had any change in his sleep patterns?
Pregnancy: How about the pregnancy of your wife
5. Did your wife smoke, drink or use drugs during your pregnancy?
6. Did your child have any complications during the pregnancy, delivery or after
delivery of your wife?
. Was it a normal delivery or a C-section?
Development:Tell me some things about your childs development?

a. When did your child first smile? When did your child first sit up? when did
your child start talking? when did your child start walking? When did your
child start putting things in his mouth?
b. When did your child learn to dress himself? When did your child learn to tie
the shoes?
c. When did your child start using short sentences?
d. Would you describe him as playful, social, shy, or quiet?
e. Does he do well at his school?
f. Do you think he is worried about anything? Does he ever feel lonely?
Vaccination:
Has your child had all the necessary vaccination? Did your child have vaccine
shot enough?
Pediatrician:
1.Do your child have a doctor that takes care of his on a regular basis? His name? His
address?
2.When was his last check up (with Dr)??
Family:
1.Did any one in your family wet the bed when he( they) were young?
2. Does any one in your family have other medical problem? DM, sickle cell
Causing
What do you think is causing your son to wet the bed?
C Counseling:
1. Based on your information about your son (Let me review what you have told me )
.
I know that he has been wetting the bed for about 3 months, 3 times
per weeks, only at night.
He developed very normally.
2. I think that his bedwetting might be having a common problem that usually occurs
in
male children.
3. However, there are also other conditions which could be causing his problem.
Such as urinary tract infection, diabetes.
4. I cant say for sure until I didnt examine him personally. You need to
bring him to my office.
After examining him I need to run some blood tests, urine tests, and imaging studies
Counseling:

Until you bring him in for an examination you can try some of these helpful
suggestions:
1.Monitor your sons fluid intake during the day.
2.Limit the amount of fluid intake before going to bed.
3.Encourage your son urinate before going to bed.
4.Set an alarm clock and awake him up every 2-3 hour to void urine.
5.Attach a bed-wetting alarm
to your sons underwear. His urine
will trigger off the alarm ringing.
6.Change his pajamas and the bed sheet if he wets them at night.
7.Motivate your son and reward him when he is successful
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later .

Patitient note

History
HPI:
ROS:
PMH:
Allergies:
Medications:
PSH:
Birth history:
Dietary history:
Immunization history :
Developmenhistory:

Physical Examination
none
Differential Diagnosis
Diagnostic workup

24.CASE 4:Insomnia
A. History taking. Hello maam, Miss. Dura. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
1. Can you tell me more details about your problem?
2. When did your problem begin (start)? Onset (How long have you been having
problems with sleep?)
3.Do you have problems falling asleep? Yes
a. When do you usually go to bed?
b. How much time does it take you to fall asleep? What average length of time
between go to bed and falling asleep?
c. What do you do before going to bed? Exercise in the late evening? Drink alcohol?
Smoke after dinner? Drink coffee?
d. Do you watch TV while lying in bed?
4.Do you have problems staying asleep?
a. Do you wake up several times during the night?
b. What did you do during that time?
c. Do you wake up often to urinate?
d. Do you experience any problem with breathing, coughing, taking medication?
5. Do you have problems with waking in your sleep?
6.Have you or any of your family members noticed that your sleep is restless or that you
move around a lot in your sleep?
7.Beside the sleep problem do you have other problems?
a. Did you have pain anywhere in your body?
b. Have you had any change in your bowel movements?
c. Have you had any change in your urination?
Anxiety
d. Do you have feelings of fears or are you anxious all the time?
PTSD

e. Have you had any physical or mental trauma or stress recently?


Depression
f. How about your mood? Do you have problem with concentrating?
Hot Flash? Around 50 yrs
g. When was your last menstrual period? Is your period regular?
Impotence
h. Do you have any problem with sexual performance?
PAM
2. Have you had difficulty sleeping before?
3. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes COPD? GERD? CHF? Cancer?.
4. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies
5. Do you take any medication?
HsitUGDWS.
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
S FoSx S.
1. Does anyone in your family have difficulty sleeping?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?( Hot Flash? Around 50 yrs)Did you have a
crises of hot flash?
3. Do you notice any change in your period? Is your period regular?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
6. (Do you have any problem with sexual performance?)
SH:
1. Whats your job?
2. Do you have any stress in your life?

3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
Exam component:
Neck: Pa thyroid gland, Muscle strength, DTRs
Pulmonary: A
CV: A
Abd: light,deep presss
What you say when you do PE
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is
that ok with you?
Neck
9. I need to check your neck area.
10. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
11. I need to check your skin, and your hair
12. Please hold on your hands like this and close your eyes. ( check tremors
Musle testing: (M)Now Im going to check the strength of your muscle now.

MRS
1. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
2. Please, do this(elbow flexion). Pull in. Pull out.
3. Please, make the fists. Dont let me open them. ( Wrists).
4. Please, Spread your fingers apart. (Hands).
5. Please, Push your thigh up. Push your thigh down.( Thigh).
6. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
7. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
5. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
6. I need to tap on your legs. (patellar, Archilles
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.\

2. I need to listen to your heart.


Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
3. I need to press a little more deeply now.
C.Coumseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having rhythm sleep disorder after changing your work
shift.
3. However, there are also other conditions which could be causing your sleep
disorder.
Such as poor sleep hygiene, anxiety, stresses from your life etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6. To protect your health.
You shouldnt smoke or use caffeine, alcohol, or heavy exercise before
going to bed.
You should use your bedroom only for sleep.
7. Is that alright? Do you have more any questions?
Goodbye, Maam. See you later.

25.CASE 10:Fatigue& Depression


A. History taking. Hello Maam, Miss. Elbel. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
Can you tell me more details about your problem?
1.How long have you been this way?
2. Do you feel like youre getting tired all day or a special time?
Associated event- Causing
1. Have you recently had any physical or mental trauma or stress that associated with
your problem?
2. Do you have an idea of what is causing your problem)?
Sleep pattern
3. Have you had any changes in your sleep pattern?
4. What time at night do you have difficulty sleeping?
5. Do you have the problems when youre falling asleep, staying asleep, waking asleep,
or waking earlier in the morning than usual?
6. Have you had snoring?
7. Have you or any of your family members noticed that you are restless or do you
move around a lot in your sleep? (Have nightmares almost every night?)
PTSD
1. .Do you have any Nightmare? Flashback?
Anxiety
2. Have you ever felt shortness of breath?
3. In addition do you feel anxious all the time?
4. Did you have chest pain?

5. Did you hear a racing of your heart? Did you have sweating or tremor of your
hands?
Depression :You look sad do you know the reason?
1. Hows about your mood?
2. Are you able to concentrate on your work very well?
3. Do you feel lonely?(Do you have feelings of being emotionally distant and lonely?)
4. Do you have good family support?
5. Are you feeling guilty about anything?
6. Do you ever think about suicide? Have you ever had a suicide idea or you got it over
one time?
How do you think you would kill yourself?
Do you have a gun and pills at home?
Manic episode-delusion-hallucination:
1???.Have you ever had an intense enthusiasm( excitement)??????
1.Do you ever see or hear things when others cant see or hear them?
2.Do you feel as if other people are trying to harm or control you?
Weight & Diet
1. Have you noticed any changes in your weight?
2. Whats your appetite been like?
3. Do you like to eat more than you usually do?
Hyper-Hypothyroidism
1. Do you have any swellings or lump(masses) on the neck?
2. Have you noticed any change in your skin and hair?
3. Do you feel cold or hot when other dont?
4. Have you noticed any change in your voice recently?
General
27.Do you have a fever?
28.Have you had any changes in your urination?
29.Have you had any changes in your bowel movements?
30.Woul you like to meet with a counselor to help you with your problems?
31.Would you like to join a support group? Do you think joining a support group might
help you?
PAM
4. Have you ever been had fatigue before?
5. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
6. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
7. Do you take any medication?
HSitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
FoSSx
1. Does anyone in your family have fatigue
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
O &G:
1. When was your first period?

2. When was your last menstrual period?


3. Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B. Exam component:
Checked memory
Orientation
Judgment
Mucous membrane for pallor(eyes,tongue,palm)
Neck: Pa Lymph node, thyroid gland, DTRs
Pulmonary: A
CV: A
What you say when you do PE
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Check for memory, orientation, judgment
1. Id like to ask you some questions to test your orientation.
a. Can you tell me your name and age?
b. Where are you now?
c. Whats the date today?
2. Id like to check your memory.
This is a chair ,a bed, and a pen
a. Now can you repeat for me the names of the three objects.
b. Whats the name of the first president in the United State?
3. Id like to test your judgment
What would you do if you saw a fire coming out from a paper basket
Eyes, Mouth ,Palm

Id like to examine your eyes, mouth, palms to look for if you have had anemia
Neck
13. I need to check your neck area.
14. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
15. I need to check your skin, and your hair
16. Please hold on your hands like this and close your eyes. ( check tremors).
Reflexes: (R)
1. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
2. I need to tap on your legs. (patellar, Archilles)
Pulmonary Exam.
Posterior Chest.
3. I m going to examine your lungs. May I untie your gown
4. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
2. Im going to examine your heart. Let me open your gown to uncover your chest.\
3. I need to listen to your heart.
C.Counseling:
1. Based on your information and the findings from your physical examination.
2 I think you might be having depression.
3. However, there are also other conditions which could be causing your problem.
Such as anemia, thyroid disorder, anxiety, stresses from your life etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once we get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
8. To protect your health.
You shouldnt smoke or use alcohol, caffeine.
I d like to transfer you to psychiatric counseling.
Would you be willing to talk to a counselor or go to a support group?
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.

26.CASE 15: Physical Abuse: multiple bruises(Spouse


abuse)
A. History taking.
Hello Mrs. and Mr Paul, Im Dr. Le, Nice to meet you! (First I need to cover you with the
sheet. Is that comfortable)
how can I help you today? I have had a lot of bruises in my body
Transition: Mr. Paul, I need to continue this examination in private. I will call you when
I am finished.
(when the husband has left then ask Ms. Paul)
I dont know how you got these bruises, but since we often see injuries from
abusive relationships
( I dont know sure what occurs with you. But because we saw a lot of people come
here with abusive relationship.)
I need to ask you some personal question. Is this alright with you?
1. Does anybody hit you? Does your husband hit you?
2. Why did he hit you?
o How long have you been married?
o Do you love him? Does he love you?
o Have your husband had girlfriends?
o Does your husband use drugs and drink to much?
3. How did he hit you?
4. How often does he hit you?
influence
5. Does the pain move around or stay in one place?
6. What is the intensity of your pain if you rate it on a scale from 1 to 10?
7. Do you feel tingling, numbness loss sensation in your arm?
Other Injuries
8. Do you have any other injuries to your body?
Sexual abuse
9. Do you hurt or feel uncomfortable during the sexual act;
10. Do you think that you are the victim of sexual abuse?
Child abuse
11. How many children do you have?
12. Has your husband hit or threatened your children?
Abuse things
13. Do you have any guns in your home?
14. Do you think that he would use the gun to kill you?
Prevent-Plan to escape
15. Do you have any plans that might help you and your children leave the
house when you are being threatened?
16. Are you planning on getting a separation or asking for a divorce?
Report
18.Does any body in your family or friends know about your physical abuse?
17. Have you ever reported this problem with the authorities or any other agency?
18. Do you have a phone number?

Anxiety-stress
19. Do you have any stress in your life?
Do you feel anxious all the time? (Do you have any anxiety or palpitation?)
Depression1. Hows about your mood?
2. Are you feeling guilty about anything?
3. Do you ever think about suicide?Have you ever had a suicide idea? Have you
ever thought about hurting yourself?
If you thought about suicide how do you think you would kill
yourself? How do you kill yourself?
Do you have guns and pills at home
1. Have you had any changes in your urination?
2. Have you had any changes in your bowel movements?
PAM
a. Have you ever been had physical abuse
a. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
b. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
c. Do you take any medication?
HSitUGDWS
a. Have you ever been hospitalized before? H
b. Have you ever had surgery? S
c. Have you had any trauma or injuries? I &T
d. Have you had any changes in your urination?
e. Have you had any changes in your bowel movements?
f. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
g. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did
it happen?) How long have you been
losing or gaining your weight?
h. Have you had any change in your sleep patterns? S
FH:
a. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
a. Are you sexually active?
b. How many sexual partners do you have?
c. Are they male or female or both?
d. Do you use any contraceptives?
e. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
20. Whats your job?
21. Do you have any stress in your life?

22. Do you smoke? How much, How often? (how many packs a day? How long
have you smoked?)
23. Do you use alcohol? (What do you drink? How much do you drink per week?
How long have you drunk?)
24. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
B. Exam component:
Right arm compare both arm in term of I , Pa,
Muscle strength.
sensation, DTRs,
pulses.
Other Injuries
Pulmonary: A
CV: A
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Arms
1. Im going to examine your arms. I need to untie your gown and uncover your arms
2. I d like to take a look first.
3. Im going to touch your arms. Tell me if it hurts
Muscle Strength.
Now Im going to check the strength of your muscle now.
1. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
2. Please, do this(elbow flexion). Pull in. Pull out.
3. Please, make the fists. Dont let me open them. ( Wrists).
4. Please, Spread your fingers apart. (Hands).
Sensation
Im going to touch your arm lightly. Please close your eyes. Do you feel this .Is it the
same
Pulse:
I need to check the pulse in your arms
DTRs
Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
Pulmonary: I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table, I need to listen to your heart
Exts
I need to look for another injuries
C.Counseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having the bruises from spouse abuse.
3. However, there are also other conditions which could be causing your problem.
Such as sexual abuse, or depression, or a fracture of your bones, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.

With your permission, You need to be have the


pelvic examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6.
. You need to be protected.
. You need to survive and be strong to help your children.
. You can use this phone number to contact with me or the social welfare
agencies if you need their help.
Is that alright? Do you have any more questions?
Goodbye, maam. See you later.

27.CASE 24: Self inducing vomiting


A. History taking. Hello maam, Miss. Irrel. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
1. Can you tell me more details about your symptoms?
2. When did your vomiting begin?
3. What were you doing when the vomiting started?
4. Is it preceded by nausea?
5. Have you ever made yourself vomit after eating so much?
6. How many times have you vomited every day, week? How often?
7. What amount of vomitus do you have every time?
8. Is the vomiting forceful?
9. what does the vomitus contain? What does the vomitus look like? What color is it?
10. Was there any blood in it?
11. Beside the vomiting do you have other problems?
a. Do you have any pain in your body? Headache, abdominal pain, back pain?
b. Do you have any change in your bowel movement? constipation, diarrhea?
c. Did you ever use a drug as a laxative to cause diarrhea?
d. Do you have fever?
e. Have you noticed any change when you urinate?
Did you ever use a drug as a diuretic to increase urination?
12. Does anything make your vomiting worse or better?
Sick contact:
1. Did you eat food outside the home?
2. Did you eat anything like unpasteurized or undercooked food, unusual food, dairy
product and sea food?
3. Have you ever had close contact with someone that had vomiting like you?
O/G disorders
1. When was your last menstrual period?
2. Is there a chance you could be pregnant? Sexual active?
3. Have you had any vaginal discharge? bleeding?
PAM
1. Have you ever had vomiting like this before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?

4. Do you take any medication?


5. Did you ever take the medication Ibuprofen?
HSitUGDW
1. Have you noticed any change in your weight?
2. Have you noticed any change in your sleep pattern?
3. What about your diet?
4. Did you ever eat so much after that you made yourself vomit ?(Did you ever eat so
much that made yourself vomit or that it made you vomit?)
FH:
1. Does anyone in your family have vomiting like you??
2. Does anyone in your family have any other major medical problem?
Sx S
1. Do you had any stress in your life?
2. Do you have any anxiety or depression in your life?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
a. Whats your job?
b. Do you have any stress in your life?
c. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
d. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
e. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B. Exam component:
HEENT:
Eyes=Lidlag, exophthalmos,FO( exclude intracranial causes)
Oral cavity=Dental enamel(eroded)
Enlargement of the salivary gland.
Neck exam: I, Pa=
Thyromegaly? Masses.
Lymphnode
Abd exam: IA Pa Pe, CVA check
Ext= edema,
Sign of purging: Dental enamel(eroded)
Scarred (calluses)or scratched hands
Check for: Emaciation, hypotension, bradycardia
Lanugo fine hair on the trunk
Quick lung& heart exam
Pulmonary: A

CV: A
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
HEENT
Eyes
a. Id like to touch your face .(find a abnormalities of your salivary gland)
b. I need to check the inside of your mouth and your throat, your teeth.
c. Id like to examine your eyes now. I need to dim the light in this room. Im going
to shine this light in your eyes. Can you pick a point on the wall and look at it.
Neck
a. I need to check your neck area.
b. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
Abdominal exam.
10. I need to examine your belly now Let me uncover your stomach.
11. Im going to take a look at your stomach area.
12. Im going to listen to your belly.
13. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
14. I need to press a little more deeply now.
15. Now I need to tap on your stomach.
Special tests:
16. Please turn over to your left side.
Im going to tap on your back now. let me know if it hurts. ( CVA tenderness).
Exts
1.I need to check your skin, and your hair
2.I need to check for fluid retention in your legs.
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
1.Im going to examine your heart. Let me open your gown to uncover your chest.
I need to listen to your heart
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might have anorexia Self- induced vomiting. (anorexia nervosa, binge
eating, purging type)
3. However, there are also other conditions which could be causing your problem.
Such as: food, medication, obstruction of the gut, or pregnancy, etc.( bulimia
nervosa)
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
With your permission I need to run pregnancy tests
and You need to be have a pelvic, and rectal examination.

5. Once I get the results of these tests.


Ill be in a better position to tell you your diagnosis and treatment options.
1. To protect your health.
You should practice safe sex, and tell your sexual partners to always
use a condom.
You should have a paps smear regularly.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

28.CASE 23:Night sweat


Hello Ms. Scott, Im Dr .Truong, Nice to meet you! (First I need to cover you with the sheet.
Is that comfortable)
How can I help you today?
2. Can you tell me more details about your problem?
3. How long have you had the night sweating?
Thyroid Problem:
1. Did you have swelling of your neck?
2. Do you feel hot when others dont?
3. Did you have feeling of racing or pounding heart beat?
4. Did you have any change in your voice?
Panic disorder-Anxiety
1. Do you have feelings of fears all the time? Are you frightened about anything ?
2. Do you feel anxious feeling all the time?
3. Did you have chest pain?
4. Did you hear a racing of your heart? Did you have (sweating or) tremor of your
hands?
5. Have you ever felt shortness of breath?
PTSD
1. Have you had any physical or mental trauma or stress recently?
2. Do you have any Nightmare? Flashback?
Depression
1. How about your mood? Do you have problem with concentrating?
2. Do you feel lonely?
3. Are you feeling guilty about anything?
4. Do you ever think about suicide?
TB-general
4. Do you have cough?
4. Did you have a fever or chills?
5. Have you had any change in your weight recently?
6. Do you have any weakness or fatigue?
7. Do you have pain any where in your body?
PAM
1. Have you had night sweat before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.

3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
5. Have you ever been tested for PPD or tuberculosis? Did you ever test positive for
PPD or tuberculosis?
6. Have you ever had close contact with someone that had TB?
HSitUGWD
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FOSxS
1. Does anyone in your family have night sweat like you?
2. Does anyone in your family have any other serious medical problem? cancer
?thyroid problem?Are your parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. 40.Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
4. Are you sexually active?
5. How many sexual partners do you have?
6. Are they male or female or both?
7. Do you use any contraceptives?
8. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
a. Whats your job?
b. Do you have any stress in your life?
c. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
d. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
e. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

*challenging question:
1.To protect my self, do I need to give up my job?
1. This is good question.
2. There are many conditions which could be causing your problem.

3. Until now I really dont know what is causing your problem.


4. To have the exact cause. I need to run some blood tests, urine tests, and imaging
studies.

5. Once I get the results of these tests


6. Ill know if you should be give up your job or not.

2.Do You think I have Aids?


1. This is good question
2. Your lifestyle certainly places you at higher risk for an HIV infection.
3. However, there are also other conditions which could be causing your
problem,and they may be treated
Such as medication, thyroid disorder, stresses from your life or chronic
infection (TB), etc .
3. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies, and HIV test with your permission
4. Once I get the results of these tests.
5.

Ill know if your problem can be Aids or not.

6. Please try not to worry because the staff and I are here to give you the best possible
care.

3. Whats causing this ,doc? Is it my thyroid problem?(


palpitation, FH of thyroid problems)
1. This is good question
2. The thyroid problem is a common cause of palpitation
3. However, there are also other conditions which could be causing palpitation.
4. Such as heart disease, stress
5. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies
6. Once I get the results of these tests.
7. Ill know what is causing your problem.

8. Please try not to worry because the staff and I are here to give you the best possible
care.
B. Exam component:
HEENT:
Eyes=Lidlag, exophthalmos
Oral cavity=ulcer, thrush
Neck exam: I, Pa=
Thyromegaly? Masses.
Lymphnode
Pulmonary: A
CV: A
Abd exam: IAPaPe
Ext=tremor, edema, muscle strength, DTRs
Skin= Sweating, nodular, petechia, splinter hemorrhages, oslers nodes, Janeway lesion

Say to patient on your examination.


Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
HEENT
Eyes
7. Id like to examine your eyes now.
8. I need to check the inside of your mouth and your throat.
Neck
4. I need to check your neck area.
5. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
Tremor
Please hold on your hands like this and close your eyes. ( check tremors).
Pulmonary Exam.
Posterior Chest.
3. I m going to examine your lungs. May I untie your gown
4. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
2. I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
1.Im going to examine your heart. Let me open your gown to uncover your chest.
I need to listen to your heart
Exts
Musle testing: (M)Now Im going to check the strength of your muscle now.

MRS
Please, Hold out your arms like this. Push up. Push down ( Shoulders)
Please, do this(elbow flexion). Pull in. Pull out.
Please, make the fists. Dont let me open them. ( Wrists).
Please, Spread your fingers apart. (Hands).
Please, Push your thigh up. Push your thigh down.( Thigh).
Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
a. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
b. I need to tap on your legs. (patellar, Archilles)
c. Now I need to tickle your feet lightly. (Babinski)
Skin.
I need to check your skin
C.Counseling:
1. Based on your information and the findings from your physical examination.
2 I think you might be having panic disorder.
3. However, there are also other conditions which could be causing your problem.
Such as medication, thyroid disorder, stresses from your life or chronic infection
(TB),(or malignant lesion), etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
a.
b.
c.
d.
e.
f.
g.

7. To protect your health.


You shouldnt smoke or use alcohol, caffeine
Is that alright? Do you have any more questions?
Goodbye, maam. See you later.

29.CASE 31:Stomach Disturbance(DKA-type 1 DM)


T=37, p=112 Bp=110/80, RR:32
Diagnosis:
1.New onset type 1 DM(IDDM)
2. Type 2 DM( NIDDM)
3. Maturity onset diabetes of youth(MODY)
4.Hemochromatosis.
5.Glucagonoma
A.History taking:
Hello Maam,Ms. Wagon, Im Dr. Nguyen. Nice to meet you! (First I need to cover you with
the sheet. Is that comfortable)
1. How can I help you today?
2. Please, tell me more details about your problems?
Stomachache
1. when did your pain begin (start)? Onset
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
3. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
6. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
7. Was your pain constant or does it come and go? Quantity
How many times do you have pain per day/week/month? ( How often do you have
pain?)
How long does it last for each episode (every time)?
8Now, if compare with the onset, is the pain getting worse or better? P
8. Does the pain move around or stay in one place? Radiation
9. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
10. Does anything relieve the pain? (Does anything make the pain better?)

Alleviation
ASSOCIATION
Digestive
3. How is your appetite? Do you feel hungry more often than you used to?
4. Do you often feel thirsty?
5. Do you have any nausea or vomit?
6. Do you have any change in your bowel movement?
EYE
7. Have you had any change in your vision?
Respiratory
9 Did you feel a shortness of breath?

Did you have problem in your breathing or SOB?


Urinary
8. Did you have any change in your urination?
9. Do you notice any change in the quantity of your urine? Polyuria?
10. Have you had any change in frequency of your urination
11. Have you had burning when you urinate?
General
12. Did you have a fever?
13. Did you have any change in your weight lately? How many pounds did you lose? Over
what period of time did you lose this weight?
PAM
1. Have you had discomfort in your stomach like this before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your sleep patterns? S
FoSxS.
1. Does anyone in your family have stomachache like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. .Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have
you smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week?
How long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)

B. Exam component:
Eyes: PERLA, FO
Chest: IPaPeA
CV: Heart: A
Abd: I A Pa Pe
Lower Extremities:
Pulses both legs and arms
sensation in both legs
Motor
DTRs, Babinskis sign in both legs.
color change & hair loss& injuries
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes:
1. Id like to examine your eyes now. I need to dim the light in this room. Im going to
shine this light in your eyes. Can you look at the clock on the wall. (Can you pick a point on
the wall and look at it.). Ill examine the back of your eyes
. Pulmonary Exam.
Posterior Chest.
5. I m going to examine your lungs. May I untie your gown
6. Let me take a look at your back.
7. Can you say 99 for me, please.
8. Im going to tap on your back to check your lungs. Is that ok with you?
9. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
3. I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
4. Im going to examine your heart. Let me open your gown to uncover your chest.
5. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.
Lower Extremities:
Active and Muscle Strength.
1. Now Im going to check the strength of your muscle now.
2. Please, Push your thigh up. Push your thigh down.( Thigh).
3. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
7. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Sensation
1 Im going to touch your legs lightly. Please close your eyes. Do you feel this .Is it the
same
2 This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)

Im done. Please open your eyes.


.
Pulse:
I need to check the pulse in your legs.
DTRs
8. I need to tap on your legs. (patellar, Archilles)
9. Now I need to tickle your feet lightly. (Babinski).
Foot
1.I need to take off your sock and take a look on the feet.
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having diabetes.
3. However, there are also other conditions which could be causing your stomachache.
Such as chronic inflammation of the pancreas or disorder of digestive system ,
etc
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
7. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with the low sugar and low fat.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.

30.CASE 30: TIA, I had weakness in my left arm yesterday?/or Rt arm


numbness?

Diagnosis:
1.Transient ischemic attack.
2.Disorder of cardiac rhythm or coronary artery disease
3.Thrombotic or embolic stroke
4. Seizure disorder.
5.Carotid dissection

6.Hyper or hypoglycemia.
A.History taking:
Hello Mr.White. Im Dr. Truong. Nice to meet you! (First I need to cover you with the sheet.
Is that comfortable)
1. How can I help you today?
2. Please, tell me more details about your problems?
3. You said you had weakness in your arm yesterday. How long did it last?
4. Before you had weakness your arm did you have any symptoms?
5. After the weakness did your arm return to normal?
6. After the attack were you conscious or unconscious?
Mini-mental Status
1. Id like to ask you some questions to test your orientation.
Can you tell me your name and age?
Where are you now?
Whats the date today?
2. Id like to check your memory.
This is a chair ,a bed, and a pen
Now can you repeat for me the names of the three objects.
What did you have for lunch yesterday?
Who was the first president of the United States?
3. Id like to check your concentration.
Please take 7 away from 100 and tell me what number you get.
Then keeping taking 7 away until I tell you to stop.
4. Id like to test your judgment
1. What would you do if you saw a fire coming out from a paper basket?
ASSOSIATION
Heent-Neuro
2. Do you have headache very often?
3. Do you feel dizzy?
4. Have you ever fainted? ( passed out ?) ?
5. Have you had a seizure before?
6. Have you had any change in your vision?
7. Have you had any discharge from your eyes , ears, nose ?
8. Did you feel numbness or loss of sensation any where in your body?
9. Could you walk?falling?
10. Did you have difficulty walking?
Cardio-vascular
1. Did you have any chest pain?
2. Did you hear a racing in your heart?
7. Did you feel SOB?
Digestive
1.Have you had any change in your bowel movement?
Urinary
2. Have you had any change in your urination?
PAM
8. Have you had weakness before?
9. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.

10. Are you allergic to anything? (Plants, food, medication..). Do you have any allergies?
11. .Do you take any medication?
12. .Have you ever had high blood pressure? DM? When did you last have your
cholesterol level checked?
What is your last cholesterol level?
How did you treat HTN,DM?
HsitUGDWS.
Have you ever been hospitalized before? H
Have you ever had surgery? S
Have you had any trauma or injuries? I &T
Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
5. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
6. Have you had any change in your sleep patterns? S
1.
2.
3.
4.

FoSxS.
FH:
1. Does anyone in your family have weakness like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
Are they male or female or both?
3. Do you use any contraceptives?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How long
have you drunk?)
CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke or
inject them)

*Challenging question:

1.Do You think I have a stroke?


1. This is good question
1. Until now I cannot rule out a possibility youre having a stroke. A stroke is
a possibility.
2. However, there are also other conditions which could be causing your problem.
Such as nerve pinching, infection, etc .
3. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies.
4. Once I get the results of these tests.
5. Ill know if your problem can be a stroke or not.
6. Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
HEENT:
Eyes Inspected pupils
FO
Neck exam: I, Pa, carotid Auscultation
Pulmonary: A
CV: A
Abd exam: Pa
Neurologic exam: Mini-mental status exam
Cranial nerves, muscle strength, sensation, DTRs
Gait, Romberg sign
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is
that ok with you?
HEENT- Cranial nerves
Eyes:
9. Id like to examine your eyes now.
CN2:Cover your left eye with your left hand and read this row of letters .
- please, change the other side and read this row of letters.
CN 3, 4, 6: Please follow my finger without moving your head (EOM).
CN2 FO: I need to dim the light in this room. Im going to shine this light in your eyes.
Can you look at the clock on the wall. (Can you pick a point on the wall and look at it.). If
patient resists: I need to look at the blood vessels back there to make sure theyre not
damaged . It s extremely important for your safety.)
10. I need to check the inside of your mouth and your throat. Can you please open your
mouth. Please say ah (Cranial nerve10 ) and stick your tongue out and move it
from side to side (CN 12). And please, swallow (CN 9& 10).
11. I need to check your nose now.
12. I need to examine your ears now.
CN8: :( make a noise: snap lightly your fingers). Can you hear them both the same
way?

Weber: Im going to put this tuning fork on your head . Tell me if it sounds the same
in both ears.
Rinne: Let me put the tuning fork behind your ears. Tell me when you cant hear any
longer.
Can you hear now
CN 5: Please clench your jaws.( muscle of mastication)
Im going to touch your face lightly. Please close your eyes. Do you feel this
.Is it the same?(sensation)
CN 7 : Please lift your eyebrows.
Please smile and show me your teeth.
CN 11: Now turn your head and press it against my hands.
Please shrug your shoulders.
Neck
1. I need to listen to your neck. ( the bruits of carotid arteries or thyroid gland).
Pulmonary Exam. I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table, I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. I need to press on your stomach. Tell me if you feel any pain or discomfort.
Musle testing: (M)Now Im going to check the strength of your muscle now.

MRS
1. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
2. Please, do this(elbow flexion). Pull in. Pull out.
3. Please, make the fists. Dont let me open them. ( Wrists).
4. Please, Spread your fingers apart. (Hands).
5. Please, Push your thigh up. Push your thigh down.( Thigh).
6. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
7. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
1. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
2. I need to tap on your legs. (patellar, Archilles)
3. Now I need to tickle your feet lightly. (Babinski).
Sensory(S): Now I need to check your sensations
10. This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes.
11. Im going to place this tuning fork on your body. Please close your eyes. Say yes if
you feel any vibration..
Im done. Please open your eyes.
3. This is up ( move up a toe).This is down (move down a toe). Please, close your eyes
and tell me up or down when I move your fingers or toes.( Position sense).
Cerebella:
Gait:
1. Now, please stand up (DR have to pull out the footstool .) Please walk to me.
2. Turn around. And go back, please, walk heel-toe-heel-toe. (Tadem gait.)
Romberg:

1. Please, stretch your arms out to your side and close your eyes.( Im in back behind
you. Im ready to help you if you feel unsteady
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having Problem of the blood vessels in your brain.
3. However, there are also other conditions which could be causing your problem.
Such as diseases of heart, or a seizure disorder, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
8. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with low fat, low salt.
You should exercise and check your blood pressure( if have HBP) and use
medication regularly.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

31.CASE 9: Head, Neck, and chest injuries


A. History taking.
Hello Mr. Harvey, Im Dr.Le? Nice to meet you! (First I need to cover you with the sheet. Is
that comfortable)
How can I help you to day?
Can you tell me more about your injuries?
9. When did your accident occur?
10. What were you doing when the accident occurred?
11. Can you show me where it hurts? Where does it feel the most painful?
12. Who hit you? How many people, man or woman?
13. How did he hit you? Did he attack you with his hands or did he use some objects?
14. Have you noticed any changes in your body from the time of the attack until
now? After the attack were you conscious or unconscious?
15. How did you get to the hospital?
HEENT:- Neuro
15.Do you have any changes in your eyes, ears, nose?

16. Do you have any discharge from your eyes, ears , nose(Were there watery from your
eyes, ears, or nose???)
17. Do you have any bleeding from any where in your body?( Your nose, mouth,
coughing of blood )
18. Do you feel weakness any where in your body? Can you walk?
19. Did you feel numbness or tingling or loss of sensation anywhere in your body?
Neck
1. Can you move your neck naturally?
Chest
1.Did you have any chest pain?
2..Did you feel SOB?
Digestive
16.Did you have any changes in your BM or dark stool, blood stool?
17.Did you have nausea or vomiting?
Urinary
18.Have you had any changes in your urination? Have you had blood in urine or dark urine?
PAM
10. Have you had any major medical problems? Example: high blood pressure, high
cholesterol, diabetes.
11. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HsitUGDWS
13. Have you ever been hospitalized before? H
14. Have you ever had surgery? S
15. Have you had any trauma or injuries? I &T
16. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
17. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
Have you had any change in your sleep patterns? S
FoSxS
FH:
Does anyone in your family have any major medical problem? Are your parents alive?
Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
16. Are you sexually active?
17. How many sexual partners do you have?
18. Are they male or female or both?
19. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
11. Whats your job?
12. Do you have any stress in your life?

13. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
14. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
15. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)

A.Challenging Questions patient: Doc, I dont have insurance, I dont have


any money to pay the bills.
.Answer:
1.Please, Calm down, MR. Harvey. Many people come here in the same situation but we
still give
everyone excellent care
2. Ill transfer you to social worker here. Theyll help you.
Transition: Thank you for your cooperation. Ill examine you as soon as I wash my
hands.
Is that OK with you.
B.Exam component:
HEENT:
Head:Pa ( hematoma, depression)?
Neck exam: Press on cervical vertebra ,motion
Pulmonary:I Pa Pe A (Press to find any rib fractures)
CV: I Pa A
Abd exam: IAPaPe
Exts: another injuries?
What you say when you do PE:
Head:Pa ( hematoma, depression)?
I need to touch your head and look for any abnormal injuries
Neck exam: I need to press on cervical vertebra
Please move your head forward.
Please move your head backward.
Lean your head on the right.
Lean your head on the left.
Pulmonary Exam.
Posterior Chest.
19. I m going to examine your lungs. May I untie your gown
20. Let me take a look at your back.
21. Can you say 99 for me, please.
22. Im going to tap on your back to check your lungs. Is that ok with you?
23. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
24. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:

Lying down: Could you lie back on the table.


25. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
26. Im going to examine your heart. Let me open your gown to uncover your chest.
27. I need to press in your heart area. (PMI).
28. I need to press in your chest. Do you feel any pain?
29. I need to listen to your heart.
30. Can you turn to your left side, please.
Abdominal exam.
17. I need to examine your belly now Let me uncover your stomach.
18. Im going to take a look at your stomach area.
19. Im going to listen to your belly.
20. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
21. I need to press a little more deeply now.
17. Now I need to tap on your stomach.
Extremities
I need to check for another injuries in your legs

c.Counseling:
1. Based on your information and the findings from your physical examination.
You have had multiple bruises due to physical assault to your neck, chest.
You have a fever after the trauma. You have also had history of asthma.
2.I think you might be having multiple traumas in your head, neck and chest.
3.However, there are also other conditions which could be causing your fever.
Such as Inflammation or contusion of your lung, etc .
4.To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5.Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later

32.CASE 32: 65yo,forgetfulness and confusion


Diagnosis:
1.Alzheimers disease
2.Vascular(multi-infact) dementia
3.Depression
4. Hypothyroidism.
5.Vitamin B12 deficiency
6.Subdural hematoma.
A.History taking:
1.HelloMaam, Mrs.Marria. Im Dr. Truong. Nice to meet you! (First I need to cover you
with the sheet. Is that comfortable)
How can I help you today?
2.Please, tell me more details about your problems?

3.When did your problem begin (start)? Onset


4.Tell me some things that are difficult to remember?
5. Did your problem affect to your daily activities? Do you need any help bathing? Do you
need any help dressing ? Feeding? Preparing food? Doing laundry? Using telephone?
managing money?
(Can you take a bath by your self? Can you dress clothes by your self? Can you feed by your
self? Can you cook by your self( Do you ever forget( to turn) turning oven off)? Can you do
laundry by your self? Can you use telephone by your self? Can you manage money by your
self?
Who do you live with? Who helps you?
6.Now, if compare with the onset, your problem is getting worse or better? P
Mini-mental Status
3. Id like to ask you some questions to test your orientation.
Can you tell me your name and age?
Where are you now?
Whats the date today?
4. Id like to check your memory.
This is a chair ,a bed, and a pen
Now can you repeat for me the names of the three objects.
What was the name of the first president of the United states?
3. Id like to check your concentration.
Please take 7 away from 100 and tell me what number you get.
Then keeping taking 7 away until I tell you to stop.
4. Id like to test your judgment
What would you do if you saw a fire coming out from a paper basket?
Depression
1.How about your mood?
2.Are you feeling guilty about anything?
3.Do you ever think about suicide?
Thyroid disorder
1. Have you noticed any swelling or masses in your neck?
2. Do you feel hot or cold when others dont?
ASSOSIATION
Heent-Neuro
1.Do you have headaches very often?
2.Do you ever feel dizzy?
3.Have you ever fainted? ( passed out ?) Do you have any fainting attack?
4.Have you ever had a seizure?
5.When you have a headache (Associate to Headache), do you notice any changes in your
eyes?
a. Do you have any discharge from your eyes, nose ,
ears?
6.Do you ever feel weakness any where in your body?
7.Do you ever feel numbness any where in your body?
9.Do you ever have difficulty talking? ( Speech difficulties)
Hypertension in CSF

1. Do you feel unsteady when you walk?(gait)


2. .Do you ever fall down?
3 Have you had any change in your urination? (U) Have you ever been urinary
incontinence?
Cardio-vascular
11. Did you have any chest pain?
12. Did you hear a racing in your heart?
13. Did you feel SOB?
PAM
1. Have you had forgetfulness and confusion before?
2. Have you had any other medical problems? Example: high blood
pressure, high cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have
any allergies?
4. Do you take any medication?
5. Have you ever had high blood pressure? DM? When did you last have
your cholesterol level checked? How did you treat HTN,DM?
6. What was your last cholesterol level?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
5. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
6 Have you had any change in your sleep patterns? S
FoSxS.
FH:
1. Does anyone in your family have forgetfulness and confusion?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?

2. Do you have any stress in your life?


3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
HEENT:
Eyes Inspected pupils
FO
Neck exam: I, Pa, carotid Auscultation
Pulmonary: A
CV: A
Abd exam: Pa
Neurologic exam: Mini-mental status exam
Cranial nerves, muscle strength, sensation, DTRs
Gait, Romberg sign
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
HEENT- Cranial nerves
Eyes:
13. Id like to examine your eyes now.
CN2:Cover your left eye with your left hand and read this row of letters .
- please, change the other side and read this row of letters.
CN 3, 4, 6: Please follow my finger without moving your head (EOM).
CN2 FO: I need to dim the light in this room. Im going to shine this light in your eyes.
Can you look at the clock on the wall. (Can you pick a point on the wall and look at it.). If
patient resists: I need to look at the blood vessels back there to make sure theyre not
damaged . It s extremely important for your safety.)
14. I need to check the inside of your mouth and your throat. Can you please open your
mouth. Please say ah (Cranial nerve10 ) and stick your tongue out and move it
from side to side (CN 12). And please, swallow (CN 9& 10).
15. I need to check your nose now.
16. I need to examine your ears now.
CN8: :( make a noise: snap lightly your fingers). Can you hear them both the same
way?
Weber: Im going to put this tuning fork on your head . Tell me if it sounds the same
in both ears.
Rinne: Let me put the tuning fork behind your ears. Tell me when you cant hear any
longer.
Can you hear now
CN 5: Please clench your jaws.( muscle of mastication)
Im going to touch your face lightly. Please close your eyes. Do you feel this
.Is it the same?(sensation)
CN 7 : Please lift your eyebrows.

Please smile and show me your teeth.


CN 11: Now turn your head and press it against my hands.
Please shrug your shoulders.
Neck
6. I need to check your neck area.
7. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
8. I need to listen to your neck. ( the bruits of carotid arteries or thyroid gland).
Pulmonary Exam. I need to listen to your lungs. Please, take a deep breath for me.
CV Could you lie back on the table, I need to listen to your heart.
Abdominal exam.
3. I need to examine your belly now Let me uncover your stomach.
4. I need to press on your stomach. Tell me if you feel any pain or discomfort.
Musle testing: (M)Now Im going to check the strength of your muscle now.

MRS
8. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
9. Please, do this(elbow flexion). Pull in. Pull out.
10. Please, make the fists. Dont let me open them. ( Wrists).
11. Please, Spread your fingers apart. (Hands).
12. Please, Push your thigh up. Push your thigh down.( Thigh).
13. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
14. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
4. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
5. I need to tap on your legs. (patellar, Archilles)
6. Now I need to tickle your feet lightly. (Babinski).
Sensory(S): Now I need to check your sensations
12. This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes.
13. Im going to place this tuning fork on your body. Please close your eyes. Say yes if
you feel any vibration..
Im done. Please open your eyes.
3. This is up ( move up a toe).This is down (move down a toe). Please, close your eyes
and tell me up or down when I move your fingers or toes.( Position sense).
Cerebella:
Gait:
1. Now, please stand up (DR have to pull out the footstool .) Please walk to me.
2. Turn around. And go back, please, walk heel-toe-heel-toe. (Tadem gait.)
Romberg:
1. Please, stretch your arms out to your side and close your eyes.( Im in back behind
you. Im ready to help you if you feel unsteady
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having disease of the blood vessels in your brain.
3. However, there are also other conditions which could be causing your problem.
Such as vitamin B12 deficiency, depression, thyroid disorder, etc .

14. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
I need to obtain history direction from your family members
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
20. To protect your health.
I need to evaluate home safety and supervision.
Iwill find community resources that help you at home
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.

Case 33:53 m, Dizziness( hearingloss)


Diagnosis:
1.Menieres disease
2.Orthostatic hypotension due to dehydration
3.Benign paroxysmal positional vertigo
4. Labyrinthitis
5.perilymphatic fistula
6.Acoustic neuroma
A.History taking:
Hello Mam,Mrs.Cihonski. Im Dr. Le.
Nice to meet you! (First I need to cover you with the sheet. Is that comfortable)
How can I help you today?
1Tell me what the dizziness feels like? Doyou feel the room spinning around you ( I
feel as if the room were spinning around me)
2.When did your dizziness begin (start)? Onset What were you doing when the
dizziness began?
3.Was your dizziness continuousor does it come and go?
How often do you have dizziness Quantity
How long does it last for each episode (every time)?
Does it come with a special time in day? Does it occur at night or in the day time?
(anytime)
4.Now, if compare with the onset, is the dizziness getting worse or better? P

5..Does any thing increase dizziness? (Aggravation.


Do you have dizziness when you change your positions?( get up or lie down)
6. Does anything relieve dizziness? Alleviation
Association : Beside your dizziness do you have other symptoms?
1. Do you have nausea or vomit? (Yes, several time)
2. Have you had any change in your bowel movement? Diarrhea , no blood
3. Do you have stomachache?
4. Have you had any change in your hearing?(difficulty hearing in my L ear, from
yesterday?)
Have you had feeling of fullness or pressure in the ears? Do your ears ring?
Have you noticed any ear discharge?
5. Do you have headaches very often? Have you had any head trauma?
6. Have you ever fallen down? Do you have any falling? (Sometime I feel unsteady
but I dont falll)
7. Do you have running nose, sore throat, cough
8. Do you have any fever?
9. Have you had any infection recently?
PAM
1. Have you had dizziness before?
2. Have you had any other medical problems?
3. Are you allergic to anything? (Plants, food, medication..).

4. Do you take any medication?


HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
5. Have you had any change in your urination?
6. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
7. 6 Have you had any change in your sleep patterns? S
FoSxS.
FH:
1. Does anyone in your family have dizziness like you?
2. Does anyone in your family have any other major medical problem? Are your
parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)

1.
2.
3.
4.

Are you sexually active?


How many sexual partners do you have?
Are they male or female or both?
Do you use any contraceptives?

5. Does your sexual partners always use a condom or only sometimes? (Do you
use a condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have
you smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per day/week?
How long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
Transition: before physical examination:
Is there anything else you forgot to tell me about? .
Thank you for your co-operation, Ill wash my hands and Im going to examine you, Is
that OK?
B. Exam component:
Nystagmus: I
FO
Otoscopy, Rinne , Weber test
I ( mouth, , throat)
CV: A, orthostatic vital signs
Neurologic exam: Cranial nerves, muscle strength, DTRs, Romberg sign, tilt test
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
HEENT- Cranial nerves
Eyes:
17. Id like to examine your eyes now.
CN2:Cover your left eye with your left hand and read this row of letters .
- please, change the other side and read this row of letters.
CN 3, 4, 6: Please follow my finger without moving your head (Nystagmus) (EOM).
CN2 FO: I need to dim the light in this room. Im going to shine this light in your eyes.
Can you look at the clock on the wall. (Can you pick a point on the wall and look at it.). If
patient resists: I need to look at the blood vessels back there to make sure theyre not
damaged . It s extremely important for your safety.)
18. I need to check the inside of your mouth and your throat. Can you please open your
mouth. Please say ah (Cranial nerve10 ) and stick your tongue out and move it
from side to side (CN 12). And please, swallow (CN 9& 10).
19. I need to check your nose now.
20. I need to examine your ears now.

CN8: :( make a noise: snap lightly your fingers). Can you hear them both the same
way?
Weber: Im going to put this tuning fork on your head . Tell me if it sounds the same
in both ears.
Rinne: Let me put the tuning fork behind your ears. Tell me when you cant hear any
longer.
Can you hear now
CN 5: Please clench your jaws.( muscle of mastication)
Im going to touch your face lightly. Please close your eyes. Do you feel this
.Is it the same?(sensation)
CN 7 : Please lift your eyebrows.
Please smile and show me your teeth.
CN 11: Now turn your head and press it against my hands.
Please shrug your shoulders.

.
CV: Could you lie back on the table

1. Im going to examine your heart. Let me open your gown to uncover your
chest.

2. I need to listen to your heart.


Musle testing: (M)Now Im going to check the strength of your muscle now.

MRS
8. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
9. Please, do this(elbow flexion). Pull in. Pull out.
10. Please, make the fists. Dont let me open them. ( Wrists).
11. Please, Spread your fingers apart. (Hands).
12. Please, Push your thigh up. Push your thigh down.( Thigh).
13. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
14. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
4. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
5. I need to tap on your legs. (patellar, Archilles)
Now I need to tickle your feet lightly. (Babinski).
Gait:
1. Now, please stand up (DR have to pull out the footstool .) Please walk to me.
2. Turn around. And go back, please, walk heel-toe-heel-toe. (Tadem gait.)
Romberg:
1. Please, stretch your arms out to your side and close your
eyes.( Im in back behind you. Im ready to help you if you
feel unsteady)
Tilt test?
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having problem of your ear
3. However, there are also other conditions which could be causing your problem.
Such as hypotension due to dehydration, dizziness related to your posture, etc .

4.To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.

34.CASE: DM Check up and refill


Hello Sir, Mr. John Im Dr. Le Nice to meet you! (First I need to cover you with the sheet. Is
that comfortable)
How can I help you today?
Can you tell me more details about your disease?
How are you feeling today?
HTN
1.How long have you had diabetes?
2.Do you check your diabetes regularly?
3.When did you last have your blood sugar checked? What was the result?
4.When did you last have your eyes checked?
5.When did you last have your HgA1c checked? What was the result?
Treatment
1.What kind of drugs are you taking for your diabetes?
2.Do you take your medication regularly?
3.Does your medication cause any side effect?
Asssociation Beside diabetes have you noticed anything symptoms?
Brain
1.Do you have headaches very often?
2.Do you ever feel dizzy?
3.Have you ever fainted? ( passed out ?) Do you have any fainting attack?
4.Have you ever had a seizure?
5. Do you notice any changes in your eyes?
6.Do you ever feel weakness any where in your body?
7.Do you ever feel numbness any where in your body?
8.Have you ever had difficulty talking?
Eyes:
1.Have you had any change in you eyes? blurred vision?
Heart
1. Did you have chest pain?
2. Did you hear a racing of your heart?

3. Did you feel a shortness of breath?


Kidney
1. Have you had any change in your urination?
2. What color is your urine? Is there blood in it?
3. Is it cloudy ?
4. Do you notice any change in the quantity of your urine? Polyuria?
5. Have you had any change in frequency of your urination?
6. Have you had difficulty urinating?
Vascular
1. Have you had history of stroke? Or TIA?
2. Have you had any pain in your buttock or leg while walking?
3. Have you had any infection in your feet?
Libido
1. Have you had any problems in your sexual performance? A weak erection
2. Can you have early- morning or nocturnal erections?
Depression Anxiety
3. How s about your mood? Have you had a bad mood?
4. Have you had feelings of anxiety or stress?
BM
1. Do you have nausea or vomiting?
2. Have you had any change in your bowel movement?
3. Have you had stomachache or discomfort in your stomach?
Sleep
Have you had any change in your sleep patterns? S
Diet-Exercise-Weight
1. Are you on a diet?
2. How is your appetite?
3. Do you exercise regularly?
4. Have you had any change in your weight recently?
PAM
4. Have you had any other medical problems? Example: Stroke , HBP, heart disease,
high cholesterol
When did you last have your cholesterol level checked?
What was the result of your last cholesterol test?)
5. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
6. .Do you take any another medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
FOSxS.
FH:
1. Does anyone in your family have diabetes?
2. Does anyone in your family have any other major medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)

1.
2.
3.
4.

Are you sexually active?


How many sexual partners do you have?
Are they male or female or both?
Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)

SH:
8. Whats your job?
9. Do you have any stress in your life?
10. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
11. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
CAGE :
Have you ever felt a need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever had guilty feeling about drinking?
Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
12. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
Eye: FO
Neck:carotid bruits
Pulmonary: A
CV: A2, PMI,
Abd exam:A Pa Pa(kidney)
Exts: Edema ,
Pulse(peripheral)
Neurologic exam: DTRs, Babinskis sign,sensation,strength in lower exts
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eye: FO
Id like to examine your eyes now. I need to dim the light in this room. Im going
to shine this light in your eyes. Can you look at the clock on the wall. (Could you pick a
point on the wall and look at it.).
Neck: I need to listen to your neck.
Pulmonary Exam.
Posterior Chest.
3. I m going to examine your lungs. May I untie your gown
4. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
7. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
8. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
9. Im going to examine your heart. Let me open your gown to uncover your chest.

10. I need to press in your heart area. (PMI).


11. I need to listen to your heart.
12. Could you turn to your left side, please.
Sitting up
1.Could you sit up, and lean forward. Ill listen to your heart again.
Vascular
1. Can I listen to your neck (carotid arteries), stomach (abdominal aorta).
Abdominal exam.
6. I need to examine your belly now Let me uncover your stomach.
7. Im going to take a look at your stomach area.
8. Im going to listen to your belly.
9. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
10. I need to press a little more deeply now.
Exts:
3. I need to check the pulse in your arms and legs now.
4. I need to check for fluid retention in your legs.
Musle testing: (M)Now Im going to check the strength of your muscle now.
MRS
4. Please, Push your thigh up. Push your thigh down.( Thigh).
5. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
6. Please, Push your feet up (dorsal flexion ). Push your feet down ( plantar extension).
Reflexes: (R)
3. I need to tap on your legs. (patellar, Archilles)
4. Now I need to tickle your feet lightly. (Babinski).
Sensory(S): Now I need to check your sensations/ lower exts
15. This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes..
3. This is up ( move up a toe).This is down (move down a toe). Please, close your eyes
and tell me up or down when I move your toes.( Position sense).
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having diabetes without complications.
3. However, there are also other conditions which could be causing by your diabetes
Such as, slow blood sugar, diseases of heart, brain, kidney, eye and reduce libido
etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
8. To protect your health.
You shouldnt smoke or use alcohol, caffeine
You should have a healthy diet, food with low fat, low salt, low sugar.
You should exercise and check your blood sugar and use medication regularly.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.

35.CASE 35: Sore Throat( 16yo,female sore throat,


headache, left upper quadrant abd pain)
Diagnosis
1.EBV mononucleosis
2.upper viral respiratory infection.
3.Bacterial pharyngitis(Group A Streptococcal pharyngitis, Mycoplasma pneumonia,
Neisseria gonorrhea)
4.Postnasal drip secondary to rhinitis.
5.Chronic tonsillitis.
6.Primary HIV
Lab test:
1.CBC with differential, peripheral smear.
2.Heterophile antibodies (Monospot test), Anti-EBV antibodies.
3.Elisa of HIV -Western block, viral load
4.Throat smearGram stain, Culture.
5.VDRL-RPR
6.AST-ALT-bilirubine-alkaline phosphatase.
Nice to meet you! (First I need to cover you with the sheet. Is that comfortable)
Would you tell me more details about your pain?
LiqorAAA OI LQL Qn P RAAA
8. When did your pain begin (start)? Onset
Where did you first feel the pain? (where did your pain begin?)
What were you doing when the pain began? What brings the pain on?
o Does the pain begin suddenly or gradually?
( If patient have the fall)Do you have injure from the fall? can you describe your
fall? After the fall were you conscious or unconscious? Does any one treat you badly
at home? Have you seen Doctor for that? Why not?)
9. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
10. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
11. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
12. Is(Was ) your pain continuous or does it come and go? Quantity
How many times do you have pain per day/week/month? ( How
often do you have pain?)
How long does it last for each episode (every time)?
13. Now, if compare with the onset, is the pain getting worse or better? P
14. Does the pain move around or stay in one place? Radiation
8,
Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
10. Does anything relieve (reduce)the pain? (Does anything make the pain better?)

Alleviation

.Association Besides your pain do you have any symptoms?


10. Have you noticed a dripping sensation in your throat? Do you need to clear your
throat? Postnasal drip
11. Do you get shortness of breath? Difficulty breathing? CHF
12. Do you notice any wheezing? Exercise, exertion or at night? Asthma
13. Do you have frequent heart burn? Do you have regurgitation or sour taste? GERD
14. Do you have any chest pain?
15. Do you feel like your heart is racing?
16. Do you have pain any where in your body? Headache? facial pain or tooth pain?
Sinusitis.,stomachace
17. Do you have swelling in your leg?
18. Do you have any fever or night sweating?
Affect
1. Does your cough affect your sleep or your other activities? I
Sick contact:
1.Have you had close contact with any one who has the same problem?
5. Do you have any pets like cats and dogs at home?
6. Have you traveled recently?
PAM
1.Have you had cough before?
2.Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes
3..Have you had any allergic disease like sinusitis, rhinitis, asthma?
4. Do you take any medication? treat your hypertension ? (ACE inhibition):
5.Have you ever had TB test? When was the last TB test?
HSitUGWD
9. Have you ever been hospitalized before? H
10. Have you ever had surgery? S
11. Have you had any trauma or injuries? I &T
12. Have you had any change in your urination? U
13. Have you had any change in your bowel movement? G
14. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
15. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
16. Have you had any change in your sleep patterns? S
FOSxS
FH:
3. Does anyone in your family have cough like you?
4. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
6. Are you sexually active?
7. How many sexual partners do you have?
8. Are they male or female or both?

9. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
Have you ever been tested for sexually transmitted disease?HIV?
SH:
7. Whats your job?
8. Do you have any stress in your life?
9. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
10. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
11. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
12. Have you ever been tested for sexually transmitted disease? HIV test?
* Challenging

question: Can I play sports? Will I have


to give up sports?
1. This is good question
2. I have to advise you to stop engaging in any sports activities for the next two or
three weeks.
3. Your spleen may be enlarged and rupture if you have a small trauma.
4. You should return to see me in two or three weeks.
5. If your physical examination is normal at this time, then it will be okay to
participate in sports.
B.Exam component:
HEENT Mouth I, Throat I , sinuses Pa,
lymph node Pa
CV: A
Pulmonary:I Pa Pe A
Abd exam: A,Pa
Exts: I ,Edema
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
HEENT
4. I need to examine your sinuses, so Im going to press on your forehead. Please, tell
me if you feel pain anywhere.
5. I need to check the inside of your mouth and your throat. Can you please open your
mouth. Please say ah
6. I need to check your nose now.
lymph node Let me press lightly on your neck and armpits

Pulmonary Exam.
Posterior Chest.
11. I m going to examine your lungs. May I untie your gown
12. Let me take a look at your back.
13. Can you say 99 for me, please.
14. Im going to tap on your back to check your lungs. Is that ok with you?
15. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1.I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
5. Im going to examine your heart. Let me open your gown to uncover your chest.
6. I need to listen to your heart.
Abdominal exam.
5. I need to examine your belly now Let me uncover your stomach.
6. Im going to listen to your belly.
7. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
8. I need to press a little more deeply now.
. Exts:
I need to find any changes in your legs. ( Edema, Cyanosis)
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having inflammation of the respiratoty system(Viral.upper
respiratory infection)
3. However, there are also other conditions which could be causing the cough.
Such as medication, infection, asthma, heart disease, gastro-esophageal reflux
disease, etc.
7. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
If you agree I suggest you have HIV test?
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
7. To protect your health.
You shouldnt have heavy exercise or any sports at least 3-4 weeks(Rt UQ abd
pain, EBV mononucleosis)
You should quit smoking.
Is that alright? Do you have any more questions?
9. Goodbye, Sir. See you later

36.Heel Pain( 75 yo, M, HTN)


Diagnosis:
1.Plantar fasciitis
2.Heel fracture.
3.Calcaneal periostitis.
5. Calcaneal Spurs.
6. Painful heel pad syndrome.
7. Osteoarthritis.
8. Bone tumors.

9. Rheumatoid arthritis.
10. Reiters syndrome
11. Splinter/ foreign body.
Test:
1. 1.CBC with differential, ESR
2. X ray of foot and ankle, 3 views.
3. Bone density scan( Dexa)
4. MRI.
5. RF,ANA.
A. History taking. Hello Sir, Mr. Wang. Im Dr. Le Nice to meet you! (First I need to cover
you with the sheet. Is that comfortable)
(Dont shake) How can I help you today?
Would you tell me more details about your pain?
LiqorAAA OI LQL Qn P RAAA
15. When did your pain begin (start)? Onset
Where did you first feel the pain? (where did your pain begin?)
What were you doing when the pain began? What brings the pain on?
o Does the pain begin suddenly or gradually?
( If patient have the fall)Do you have injure from the fall? can you describe your
fall? After the fall were you conscious or unconscious? Does any one treat you badly
at home? Have you seen Doctor for that? Why not?)
16. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
17. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
18. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
19. Is(Was ) your pain continuous or does it come and go? Quantity
How many times do you have pain per day/week/month? ( How
often do you have pain?)
How long does it last for each episode (every time)?
20. Now, if compare with the onset, is the pain getting worse or better? P
21. Does the pain move around or stay in one place? Radiation
8, Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
Association Besides your pain do you have any symptoms?
12. Did you notice any swelling or redness in your heel?
13. Did you feel tingling or numbness or loss your sensation?
14. Did you feel any weakness?
15. Did you have any change in your vision?
16. Did you have a sore throat ?
17. Did you have any change in your skin?
18. Did you have any pain in your other joints?
19. Did you ever have morning stiffness

20. Do you have fever?


21. Do you have any heart problem?
Affect-Cause
22. Can you use your arm in your daily activities?
23. Do you think what is causing your pain?
PAM:Now I need to ask you a few questions about your health in the past. Is that OK
with you?
7. Have you had heel pain before?
8. Have you had any other medical problems?STD? Example: high blood pressure,
high cholesterol, diabetes
9. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
10. Do you take any medication?
H(sit)UGDWS
16. Have you ever been hospitalized before? H
17. Have you ever had surgery? S
18. Have you had any trauma or injuries? I &T
19. Have you had any change in your urination? U(burning, discharge/gonorrhea?)
20. Have you had any change in your bowel movement? G
21. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
22. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8 Have you had any change in your sleep patterns? S
FOSxS:
FH:
8. Does anyone in your family have pain in their joints like you?
9. Does anyone in your family have any other serious medical problem? (HBP,DM,
high cholesterol level) Are your parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
20. Are you sexually active?
21. How many sexual partners do you have?
22. Are they male or female or both?
23. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
7. Whats your job? Does your job involve any prolonged standing? Or Do you have to
walk a lot at your job?
8. Do you have any stress in your life?
23. Do you smoke? How much, How often? (how many packs a day? How long have
you smoked?)
9. Do you use alcohol? (What do you drink? How much do you drink per day/week?
How long have you drunk alcohol?)
10. CAGE :
Have you ever felt a need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?

Have you ever had guilty feeling about drinking?


Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
11. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)

Transition: before physical examination:


Is there anything else you forgot to tell me about? .
24. Thank you for your co-operation, Ill wash my hands and Im going to examine you,
Is that OK?

*Challenging question: Im very old. Do you think Ill


get bone cancer?

This is good question


Age places you at a little risk of cancer.
However, there are also other conditions which could be causing your problem.
Such as dislocation, fracture, injury of ligaments etc.
To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
Once I get the results of these tests.
Ill know if your problem can be cancer or not.
Please try not to worry because the staff and I are here to give you the best possible
care.

B. Exam component:
Eye: conjunctivitis( if you suspect Reiters syndrome )
Inspect the foot: compare both feet term of I ,
Pa of entire feet for any point of tenderness ,
Check of the range of motion of the ankles & forefoot joints , check for pain & restriction
of movements: passive motion, active motion( ask the patient to do active dorsiflexion, and
plantar flexion) .
Other Joins( fast)
CV: A
Pulmonary: A
What you say when you do PE:
Im going to examine your eye.
Im going to examine your feet.
24. I d like to take a look first.
5. Im going to touch your feet.. Tell me if it hurts.
Passive:
1. I need to move your feet.. Is that OK? Tell me if it hurts. Ill stop immediately.
Active:
1.
Move your feet up. Move your feet.down.

Do this (put your heels touch the floor) Move your feet outside. Move your feet
inside.
Move your toes up. Move your toes down.
Muslse strength
6. Please, Push your thigh up. Push your thigh down.( Thigh).
7. Please, Pull your legs in (flex your knee ) and Kick your legs out (extend your
knee).
8. Please, Push your feet up (dorsal flexion ). Push your feet down (plantar
extension).
Reflexes: (R)
7. I need to tap on your legs. (patellar, Archilles)
Sensation
Im going to touch your arm lightly. Please close your eyes. Do you feel this .Is it the
same
Pulse:
I need to check the pulse in your legs.
Other joints:I need to examine another joints
Pulmonary: I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table. I need to listen to your heart.
C. Counseling:
5. Based on your information and the findings from your physical examination.
I think you might be having inflammation (or a trauma) of your heel..
6. However, there are also other conditions which could be causing your heel pain,
Such as dislocation, fracture, injury of ligaments etc.
7. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
8. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options .
5. Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.