Taiwanwalker CS note

Section 1 General History/PE

Regular history pg 2
Challanging Questions pg 4
Difficult Questions pg 6
Common Counseling pg 7
Associated symptoms pg 8
Physical Exam pg 10

Section 2 Case Discussion

Gastrointestinal pg16
Abdominal pain/ Diarrhea/ Constipation/ Nausea&Vomitting/
Blood in stool/ UGI bleeding/ Jaundice/ Dyaphagia

Eyes and ENT pg22

Blurred vision/ Sore throat/ Loss of hearing/ Hoarseness

Respiratory pg23
SOB&Cough/ Hemoptysis/ Asthma drug refill

Cardiovascular pg25
Chest pain/ Palpitation

Neurology pg26
Dizziness&vertigo/ Headache/ LOC/ Numbness&weakness/ Frequent falls
Seizure/ Tremor/ Confusion&memory loss

Urology pg30
Hematuria/ Obstructive symptoms/ Buring urination/ Incontinence/
Flank pain /Increasing urination

Rheumatology/Musculoskeletal pg32
Low back pain/ OA/ Heel pain/ knee pain/ Unilateral&Bilateral leg pain
Shoulder pain/ Elbow pain/ Wrist pain /Polymyagia

Obstetrics/Gynecology pg36
Dyspareunia/ vaginal bleeding /vaginal discharge/ Hot flashes
positive pregnancy test/ Amenorrhea

Pediatric pg38
Fever/Jaundice/ diarrhea/ DM/ stridor/ behaviour problem/ picky eater /bed wettin

Phychiatry pg43
Anxiety+SOB/ Depression /Insomnia/ Phychosis

Abuse/Assult pg45

Constitutial Symptoms pg46

night sweats/ Fatigue/ Weight gain/ Weight loss

Others pg48
DM drug refill/ HTN drug refill/ Erectile dysfunction/ terminal cancer/ MVA
Pre-employment medical checkup/ HIV drug refill/ Alcoholism/ Rash

Let me know what u think by mailing taiwan_walker@hotmail.com

 Section 1 General History/PE
Regular history
#Begin
Knock on the door(wait 2 seconds)
Hello Mr/Ms.XYZ nice to meet you,(shake hands) I am doctor Lin the duty doctor today, and I am here to ask
you a few questions.
Let me make you more comfortable(drape the patient)
So, What cause you to come in today?-->I am sorry to hear that
Can you tell me more about your problem?

#HPI: LQQ OPERA, ask PDF alone with O, or LIQURAAA

Location:Where's the location of the pain?
Quality:Can you describe your pain? -->for example, sharp/dull/burning/or pressure like?
Quantity:On a scale of 1-10, with 10 being the worst, how would you rate your pain?
Onset:When did it start? How did it start?what were you doing when it started)?(Past:
Did you experience the same problem before?
Duration:How long does it last?Frequency(timing):How often does it occur?
Is the pain constant or intermittent ?
Is it getting better or worse? what time in a day does it usually present?
Precipitation: Do you remember anything that might have caused it? Is there any relationship with food and
the pain(in epigastric pain case)? any relationship between the position and the dizziness?
Excerbation:Do you know anything can make the pain worse?
Relieving(Radiation): Do you know anything can make the pain better?The pain move to somewhere else?
Have you tried anything to help?
Associated symptoms:Do you have other symptoms right now? -->Is that all the symptoms you have?

#PHM: PAM HUGS FOS EAST SODA .

Begin with transition sentence:
I need to ask you few questions about your health in past, is that okay?
I need to ask you few questions about your family health, is that okay?
Can I ask you about your about your sexual and personal life, It'll be
confidental--> if no answer: I would like to know the whole pictures of your health condition and your
infomation can be very helpful,(pause) is that Ok?

Past medical history: Do you have any illness in the past?any operation?any trauma?(Dizziness, pain
cases, headache) ,Easy bleeding(In any bleeding case),DM/HTN/Hyperlipedemia(In limbs weakness/
numbness,erectile dysfunction)
Allergy:Are you allergic to anything?
Medical:Medication:Are you currently taking any medication including over-the counter medication and
prescribed medication?Side effect?
Procedure: Any blood transfusion?(in anemia cases), when is your last PPD?(if suspected TB) ,
Have your colon been examined with any device?(colonscope in jaundice/blood in
stool case )

Hospitalization: Have you been admitted to hospital before?

Urinary:Do you have any urinary symptoms ? Do you have trouble urinating ?
Is there any change to your urine habit? Is there any change to urine color?
GI:Do you have any bowel symptoms for example loose bowel?Is there any change to your bowel habit?
 Is there any change to stool color?
Sleep:How's your sleep recently? If not good->see insomnia

Family:Is there any illness in your family?

Ob/Gyn:When was your last menstrual period?(ask in detail if needed)
OB:(GPA+complications)How many times you have been pregnant?how many children did you
give birth to? Have you ever had miscarriage?abortion? In which trimester?Any complication
during pregnancy?
GYN:Symptoms:Do you have vaginal discharge/bleeding?Pain during intercourse? Any problem
controlling bladder Past problem :Did you performed Dilation&Curettage, Did you have uterine infection
(in Amenorrhea case), Did you use Intrauterine device? (in abdominal pain/vaginal
discharge case)
MP:MP Description:When is your first menstrual period? How often is your menstrual period?
How long does it last? How many pads do you use in a heavy day?
MP complications: Is there any changes to your menstrual period? Have you ever bled between
cycles? Do you have abdominal pain with your period? (in dyspareunia)
Pap smear:Have you had a pap smear? What's the last time you did a Pap smear?What's the
results of the Pap smear?

Sexual:Are you sexually active?(In details: How many sexual partners do you have in last 6 months?
Men, women or both?
-->Men specific:(Condom/impotence) Do you use condoms? Is there any change in your
sexual function lately (if suspect impotence)
-->Woman specific(Condom/Contraception): Does your sexual partner use condom?
do u use any birth control pills?
-->If high risk sexual behavior:(STD/HIV)Have you had sexually transmitted disease?
Have you been tested for HIV? (Also ask STD in lower abdominal pain/UTI/joint pain case)

Exercise:Do you get any exercise?

Appetite(Also Diet and Weight):Is there any change in your appetite?What's your diet?
Is there any change in your body weight?
Stress/support system(Also mood): Do you have any stress? Do you have anyone who can support you?
(in physiological problem)
How's your mood?
Travel: Travel:Have you travelled recently? Did you have any immunization before travel?Any picnic/
camping(If GI case)?
Expose:Have you been exposure to animal? Have you been bite by insects?Have you been in
contact with sick people?(If GI/URI/TB)?

Smoking:Have you been smoking? How much?

Occupation:What's your job? Is your job stressful?
Drug:Have you been using any recreational drugs? (Heroin cause constipation, cocaine cause MI) How do you
take it? How often do you take it? When was the last time you took it?
Alcohol:Have you been drinking alcohol? if yes->how much do you drink, how long have u been drinking
->If drink a lot-> ask CAGE
Cut:Do you feel that you need to cut down on your drinking?
Annoyed:Does anyone complain about your drinking?
Guilt:Do you feel guilty about your drinking?
Eye-opener:Do you drink alcohol in order to get rid of a hangover?
#Conclusion:
Summarize history:Right now I would like to summarize your history(Ex: you have chest pain for 5 days
, it's progressing and it's burning. Also you have nausea and vomiting, is that right?)
Summarize PE:
Explain Diagnosis and Lab to do:(Ex:According to your history and physical examination, you might have a a
inflammatory process of the esophagus, but we are not sure yet, so we would run some blood tests and we will
do an image test to see the anatomy of your esophagus (also explain pelvic exam/rectal exam in low back
pain/abdominal pain case)
Counselling:Also as a concerned physician, I would like to talk about your smoking/alcohol/unsafe sex/DM
/HTN/current problem

Ask questions: Do you have any questions or concerns? Challenge questions:Do I have XYZ/ Do I need
OP?There's possibility, but before I can answer your question, I would like to run some tests, I will study the
results carefully, and we will sit down and discuss it all over again, I will make sure you are conformable during
the examination.

If still have time:Can you think of anything that you want to tell me and I forget to ask?

Ending: Thank you verry much, Mr.Green, I will try my best to help you to get better, Please take care for now.

Challanging Questions

Patient tells a lot of stories

Mr. Smith, sorry that I interupt you, but right now I want to focus more on your physical
condition, I will try to find another time and you can tell me more about your trip, is that
OK?

Patient says not interested to talk

Ms Green I understand it's really a tough time for you, but your condition could be cause
by some medical problem, I will try my best to help you to feel better, can you try to
answer my question?

Just give me some pain killer

Ms Green, I understand that you are in pain, but I need to ask a few questions to understand your pain, then we
can give your safe treatment for your pain.

I want refill before the lab test

I will try to contact with the doctor who prescribed you medication to give you 1 or 2 days extension

You are a good doctor so that’s why I come for refill

I am flattered, but I have to evaluate you again to study the safety of the medication, it’s my commitment to be
careful.

Why are you asking so many questions?

I would like to know your general health as a whole to find out what’s wrong to give you the right treatment, so
can you tell me more about ...

Do I have AIDS?
I am also concerned about the possibility, I would like to run so HIV test to you, is that OK?
Will my insurance company going to pay for the test?
I am not sure, but I will refer you to a social worker to find that out, also I can write a letter to your insurance
company to show how important is the test.

Can I go back to work?

It’s seems like work can worsen your condition, also I can write a letter to your employer to explain your
condition.

Am I going to die?
Your condition raise my concern, most of the people will have symptoms improve after the treatment, however,
no matter what’s happening, I will be at your side and I will try my best to help you

I need to go home for my child

I understand your concern, but according to your situation it’s your best interests to stay in the hospital,we have
wonderful social worker who can solve your problem

Why do we have to live?

Life could be challenging, but I will try my best to make you feel better, is there any specific things on your mind
which is bothering you?

Will I get better?

It’s hard to tell at this point, but most of the people would feel better after the treatment.

I am in abdominal pain, can I have some water?

I am sorry I cant give you any water right now in case you need an emergency operation.

I am afraid of OP
It’s very common to have the feeling for operation, however, I will make sure you are comfortable during the
process.

Have HIV/STD, do I have to tell my wife? (Do you think he is cheating on me)
I know it’s difficult, but you should discuss with her in person, it’s important to have you both evaluated and
treated at the same time if the result is positive.

It’s just because I am getting old.

Age could play a role in your problem, but we still have to rule out other causes like..., so I have to run some
test on you and I will study it carefully.

What is ultrasound/EKG(Explain first, don't wait till they ask)

Ultrasound:A machine using sound wave to detect your internal organ
EKG:A machine detect electrical activity of heart
CT/MRI :special imaging test to detect your organ
Endoscope:A tube connected to a camera to see into your bowel/respiratory tract
TSH: blood test for your thyroid activity
Pap smear: A test to collect your cervical cells to see if there’s abnormality

Is this tumor malignant?

I cant answer your question until I get pathology report, I will read the results carefully and we’ll discuss it all
over again, no matter what’s happening I will try my best to help you
Where have you been, I am waiting for a long time
I am very sorry you had to wait so long, but now I am here and will totally focus on your concern

My mother has cancer, does it mean I will have it too?

The risk is increased, but doesnt mean you will get it, so regular screening test is very important.

Losing pregnancy in vaginal bleeding?

The risk is increased, but doesnt mean you will lose it, so regular checkup is very important.

Tubal ligation get pregnancy?

The risk is small, but there’s still possibility

I heard herbal therapy works.

I heard that herbal therapy could be helpful to many disease, let me know the name of herbal therapy and I will
study carefully about it’s safety and efficacy

HRT cause breast cancer?

It’s appears to be true, so that’s why HRT is only used with limited time to relief hot flashes

Crying:Tissue + touch shoulder: It must be very difficult for you, would you please tell me more about it

Compliment on cloth/hairstyle, ask about your personal life

Thanks for the interests, but right now I would like to focus on you in order to help you.

Change subject when ask about sex/drugs:

I’ve notice that you changed subjects while asking, I’ll try my best to help you, please tell me what’s your
concern?

Difficult Questions

Urinary: irritative symptoms:screening with "Is there any change to urinary habits?
Urgency:Do you feel like you have to go to toilet right away once you feel the urge?
Frequency:Do you feel like you have to urinate all the time?”
Nocturia:Do you need to get up in tthe night to urinate?
Obstructive symptoms: screening with "do you have any trouble urinating?(HIS Dimished PI)
Hesitancy:Do you Need to wait for the stream to begin?
Intermittency Is the stream starts and stops intermittently?
Straining: Do you need to push hard during urination and only little urine comes out?
Diminished stream:Have you noticed any weakness in your stream?
Postvoid dribbing:Any dribbling of urine after urination?”
Incomplete bladder emptying: sensation of not emptying your bladder completely
after finishing the urination??

Bowel: Decrease stool caliber Do you feel the size of the stool is decreasing?
Tenesmus:Do you feel the need to pass stool even you just finish bowel movement?
Straining: Do you need to push hard during bowel movement and only little stool comes out?

Derma: Rash questions:Description(Can you tell me more about your rash?),Onset( when did it start?)
Progression(Is the rash progressing?From where to where?)
Photosensitivity: is your skin sensitive to sunlight?
Ob/Gyn:Primary/secondary Amenorrhea: Did you have mensural period before?
Galactorrhea:Is there any nipple dischage?
Hirsutism/Virilization:Did you notice any increase of body hair? is there any voice change?
Douching: Did you use any advice to rinse your vagina?

Others: Impotence severity: On a scale of 1-6 ,as 6 is adequate for penetration, how are you going to rate
your problem.
Secretions Questions(Vomitus/Diarrhea/Urine/Vaginal discharge/vaginal bleeding) :Content
/Color/Blood(and mucous in stool)/amount(A cupful, a teaspoon, or a tablespoon?) /odor
Medication questions:Dosage, compliance, side effect, Control(HTN,DM), last HbA1C(DM)
Insulin:Site of injection, Insulin injector, Compliance with insulin, Schedule of insulin

Common Counseling

Smoking
1.damage your heart and your lungs.
2.can use Nicotine patches or Gum to help reduce those withdrawal symptoms 3.we
even have a professional team to help you deal with it better.
4. Feel free to contact me anytime if you decide to quit.

Alcohol
1.Excess alcohol consumption raises your risk of high blood pressure, liver problem, car
accidents
2.Avoid drinking before or when driving
3.We have a professional team that can help you deal with it better.
4.Feel free to contact me anytime if you decide to quit.

Unsafe sex:
1.use condoms regularly in order to reduce sexual transmitted disease
2. watch for unusual discharge, sores, redness, or growths in genital area, or pain while
urinating.
3.blood test for HIV

DM:
1. Follow regular exercise and diet instructions that will be provided to you
2. make a habit of using soft footwear whenever you walk
3. Be regular in blood-sugar monitoring so that dose adjustments can be done on
time.

HTH:
1.regular exercise
2. reduction of weight
3. limiting salt
4. take regular health maintenance examinations to help control your blood
pressure.

Hyperlipedemia:1.take the medicine regularly,

2.low fat, low salt diet, prevent things like egg yolk and fatty meat.
3.do some moderate exercise 30 min a day

Overweight:
 1.weight reduction in patients with DM and HTN could eliminate the symptoms
completely without medications.
2.We have a very good dietary specialist here in the clinic

Associated symptoms(Remember it well)

Pediatric:URI:Runny Nose, Ear Discharge ,Ear pulling

LRI:Coughing, Rapid breathing, wheezing(Chest pain)
GI: Vomitting , Diarrhea/Constipation, Difficult swalowling, abdominal distension,
(Abdominal pain)
CNS: Shaking, (Headache)
Skin: rash jaundice
Others:Fever, tireness,crying
Adult: URI:Start with asking cold symptoms
Ear:Ear pain, Ear discharge,Nose: Runny nose, postnasal dripping, Others:
Painful swelling glands, facial pain/headache, sore throat
LRI: Chest pain, SOB, Cough, Wheezing
CV:Chest pain, Palpitation, SOB(nocturnal), peripheral edema, orthopnea
CV+LRI: Chest pain, SOB, Cough, Wheezing, Palpitation, peripheral edema
GI:Nausea/Vomiting, Diarrhea/Constipation,Abdominal pain
CNS:H:Headache, Head trauma, Lose of consciousness, neck stiffness
EENT: Speech difficulty, vision change, Dizziness(light-headedness),
Limbs: Limbs weakness/sensational change, Fall, (Gait problems,seizure
Incontinence)
Onco: Swelling glands, Coughing, Bowel habit/stool color change,difficulty swallowing, itching
Constitutional symptoms
Endo:hypothyroid: cold intolerance,weight gain (screening question), fatigue, depression,
hair/skin change, constipation,voice change
hyperthyroid:Heat intolerance, weight loss(screening question), palpitation, tremor,
nervousness
Uro:Irritative symptoms: Urgency, Frequency, Nocturia
Infection symtoms: Buring sensation, dysuria, flank pain
Obstructive symptoms:(HIS Dimished PI) Hesitancy, Intermittency ,Straining, Diminished
stream , postvoid dribbling, Incomplete bladder emptying
Others:leaking urine, hematuria/urine color change
Ears:Ear fullness/pain/discharge, vertigo/hearing loss/tinnutus
Eyes: eye discharge, halos around the light, the pain in the eye, headache
Rheumatology:Mnemonic CITRUS HPT and other joint symptoms
Chest pain/ cough, Insect/tick bite,
Trauma/travel, Rash, (SLE.STD,Psorias)
Ulcer in mouth(SLE) Stiffness in morning
Hair loss, Photosensitivity(SLE)
Temperture cause finger color change (Raynaud's phenomenon)
Joint: Joint redness/swelling, Joint trauma, morning stiffness,
Others: constitutional symptoms, cold temperture causing problems to finger
(Raynaud's phenomenon), red eye/urethal discharge(Reiter syndrome),
vaginal discharge(STD), rash(SLE.STD,Psorias,ask SLE questions)
diarrhea(IBD, reactive arthritis), focal numbness/weakness(nerve injury)
 SLE related :oral ulcer, photosensitivity, Rash, CNS(seizure/limbs
weakness,headache), system review problems
Ob/Gyn:Menopause symptoms:Common :Hot flashes, Urinary irritaive symptoms, joint pain
Sex symptoms:vaginal itchness/dryness, pain when intercose/low libido,
Others:mood change, Sleep distubance

Others:Constutional: Fever/Chills, Night sweats, Weight loss, fatigue, loss appetite

System review:Fever/Chills,CNS: Headache,dizziness Chest:Chest pain, Short of breath, cough,
Abdomen:abdominal pain, Nausea/vomitting, Diarrhea/Constipation,
Urinary: any urinary problems Extremties:weakness /numbness
Pituitary tumor:Headache/decrease vision, Galactorrhea/Amenorrhea,
Anorexia nervosa: Amenorrhea, Cold intolerance, body image
CNS symptoms after trauma:Head and neck: Headache(ask with Nausea/vomitting),stiff neck
Memory loss (Change in personality,Confusion)
ENT:Change in vision, Discharge from the ears/mouth/nose ,
Dizziness
Limbs:Weakness or numbness in the extremities, shaking
(convulsions)
Seizure: bit tongue, confusion after regain consciousness, incotinence during seizure, body shaking
Jaundice: skin/urine/stool color change, pruritis,constutional symptoms
Colon cancer:Decrease in diameter of stool, bowel habit /stool color changes,straining/ bloating/
tenesmus
TB:cough, SOB, hemoptysis, pleuritic chest pain, constitutional symptoms
Mononucleosis:sore throat, rash, jaundice, abdominal pain, swelling glands
Pregnancy symptoms:GI:Abdominal pain, Nausea/vomiting, Bowel habits change,
Urine:Urinary habits change (frequent urination)
Constitutional:Fever, Fatigue, Appetite changes,Weight changes
Others:Backpain/headache, Shortness of breath,
Skin changes, vaginal bleeding,
Pulmonary embolism: Shortness of breath, Chest pain, Fever
DM complication:Visual: Visual change, Heart:chest pain, palpitation ,
Pulmonary:Cough, SOB, CNS: Headache, dizziness, , Abd:nausea/vomitting
Urinary:urinary change( polyuria, dysuria, hematuria), impotence
Ext:limbs weakness/sensational change, foot infection
DM constitutional symptoms:Urinary habit changes(frequent urination) Abnormal thirst or extreme
hunger, Weakness or fatigue, Weight changes, tireness
HTN complication:Visual: Visual change, Heart:chest pain, palpitation, edema,
Pulmonary:Cough, SOB, CNS: Headache, dizziness, nose bleeding,
Urinary:urinary change, impotence Ext:limbs weakness/sensational change
ADHD symptoms: cant concentrate, easily distracted, Have trouble sitting still ,moving all the time
, talk too much, interupt games/conversation, has trouble waiting his turn.
has trouble enjoy activities quietly, Not seem to listen when spoken to

Mnemonic:MS.WC(Used in Fatigue/Weight gain/Weight loss/amenorrhea/Confusion& memory

loss/depression )
Mood change(if depressed asked FACE SLIPS and abuse)
Sleep/snore/Stress/Support
Weight/appetite change(if low ask Oncology symptoms)
Cold/heat intolerence(if yes ask the other hypothyroid/hyperthyroid symptoms),
 Physical Exam
Asbefore start:I will do some examinations on you, is that Ok?

#HEENT:
Head: Palpation::I need to press lightly on your head/face
Eyes: Inspection: I need to check your eye, can you look up for me
Fundoscope(pupil):I will turn off the light and will shine a light and see your pupil
Now I am going to see the back of your eyes
Visual field:Can you see the finger moving?
EOM:Can you follow my finger, dont move your head
Ear: Inspection: I need to check your ears
Palpation::I need to press on your ear, I need to pull up your ear now.
Otoscope: Right now ,I am going to look into your ear.
Rinne test: I'm going to put the fork behind your ears, say "now" when the noise stop
Weber test:I'm going to put the fork on your forehead, tell me which side
it's louder or it's the same?
Whisper into ear:can you tell me what you hear?
Nose:Inspection: I need to check your nose
Palpation on nose and sinus::I need to press on your nose/face
Otoscope: Right now ,I am going to look into your nose .
Throat: Otoscope: Please stick out your tongue and say, ah. Can you lift your tongue ?
Neck: Thyroid:I need to check for swelling glands, I need you to swallow
Lymph node:I need to check for swelling glands

#Pulmonary exam (plus regular cadiovascular)

Anterior
Inspection:first, let me look at your chest
Palpation:For local tenderness
Tactile fremitus:Can you say 99 for me please?
Percussion:I am going to tap on your chest (4 points bilateral)
Auscultate: I need to listen to your lung now, can you take deep breath through your mouth for me?
(3 points bilateral)
Posterior
Palpation again
Tactile fremitus again
Percussion again
Auscultate again ,(And listen to heart while telling patient breath in normally)

Also remember to check hands for for cyanosis or clubbing

#Cardiovascular (plus regular pulmonary)

Sitting
Palpation:I am pressing on your chest to feel your heart->(press on PMI , if chest pain case also
palpate for local tenderness)
Auscultation:I need to listen to your heart(4 points)->(listen to posterior lung while pt's sitting)
Lying
Neck:JVD:Please look to your left, I need to check your neck (shine light with otoscope,patient lie 45
degree, pull out extension) Carotid bruits:I am going to listen to your neck (use bell)
Carotid pulse:I am going to check the pulse on your neck.
Also remember to check Pulse(quickly check radial/popliteal/posterior tibial),and Edema(called swelling)
#Abdomen exam
Inspection:let me look at your belly
Auscultate:let me listen to your belly(2 side and midline)
Percussion: I need to tap on your belly(4 quadrate, and liver span if suspect hepatomegaly)
Palpation:I am going to press softly/deeply on your belly, is that causing any pain? Do you feel any pain when
my hands let go? Liver/spleen palpation:I am checking your Liver/spleen

Signs:Murphy sign:Can you breath in for me?(while pressing RUQ, do with Liver palpation)
Psoas sign: Can you raise your knee? is that causing any pain?
Obturator sign:Is that causing any pain?(flexion and interal rotation of hip)
Rovsing sign(will know while LLQ tenderness while pressing)

CVA tenderness:I am going to knock on your back, is that causing any pain?(do it with psoas sign)
Remember to mention Rectal exam/Pelvic exam at the end

#MMSE. Used in non-focal-deficit CNS Cases like Dementia/Delirium/Depression/Delusions/Confusion/

Schizophrenia
Begin:I would like to ask you some questions to test your memory and thinking,is that Ok?
Orientation:Where are you now? Can you tell me your name? What day is today?
Registration :I would like to let you remember 3 words to test your memory, it's red/bicycle/happy, can you
repeat after me?
Attention/Remote memory: Who's the president of United states? Can you spell "WORLD" backward?
Recall:Can you tell me the 3 words I want you to remember?

If running out of time, just ask orientation

#Neurological exam:(CM RS CM, Can Mom Really Sing Country Music?)

Cranial nerves:
CN 2: Can u count this? (5 fingers with 1 feet in front)
CN3/4/6:Don't move your head, please move your eyes to follow my fingers
CN5-Can you clench your teeth like this? Can you close ur eyes and tell me where do you feel the touch.
CN 7-Can you smile for me?
CN 8- I am going to rub my finger, tell me which side you hear it?Is both side equal?
CN 9/10 Can you say ahhh(and look into mouth)
CN 12-Can you stick out your tongue? and try to move it left and right?
CN 11-Can you do like this? (Shrug your shoulder and press resisting power)

Muscle Power :
Upper extremities:Can you do like this?Dont let me move you, can you raise your wrist up ..and
down,
can you spread your finger apart, can you squeeze my fingers real hard?
Lower extremities:Can you raise your knee?and down ,Kick the leg out, and bring it back.
Can you push your foot down,
Reflex: Right now I am going to check your reflexes ,Babinski:I need to tickle your feet.
Senses: can you close your eyes, tell me is it sharp or dull,(3 points each limbs) Positional(diabetic):This is
up and this is down, tell me which direction I am moving your big toe. Vibration(diabetes):I'm going to put this
on your feet, tell me can you feel anything?

Cerebellar:FNF:can you put your finger on your nose? and pointed to my fingertip? and back to your nose?
Ok, the other hand. (Or can do shine to heel, rapid alternative movement)
 Gait:Can you get down and walk to the sink ...and back
Romberg+Pronator drift:Can you put your palms up like this and close your eyes. I will protect
you from falling down
Meningeal sign: Kernig:Please let me know if that hurts (flex the hip+extend the knee)
Brudzinski: I am going to lift your head up, please be relaxed.(flex the neck)

Dix-Hallpikes test:(if you have time and BPPV is strongly suspected):Head extends looking
30 degree left and lie down see if there's any vertigo, and sit up wait 20 secs do it at the right side.

#Joint exam(IPRPMRS,Interesting People Rarely Persisently Mention Routine Subjects)

Inspection:I am going to look at your feet/shoulder/hands
Palpation:Is that causing any pain?(check for tenderness, joint effusion) start with the painless side
ROM:II am going to move your joint to see if there’s limitation
Pulse:I am going to check your pulse
Muscle strength:Do this, dont let me move you
Reflexs:I need to tap on your arm/legs
Sensory:Light :Can you feel this? Does it feel the same?(Sharp/Dull: This is sharp and this is dull,
now close your eyes, tell me it's sharp or dull?)

Shoulder pain: impingement symdrom (bring the arms across the chest or bring the
arm around), Rotator cuff injury(drop arm test)
Wrist pain: +Tinel sign+Phalen test+Adson test
Tinel: I am going to tap on your wrist,(and extend the wrist while tapping)
Phalen:Can you hold your hands like this? Is there's any numbness or pain?
Lower back pain:+Gait+SLR+Hip exam
SLR: I am going to raise your legs, is that causing any pain(raise extended legs+ dorxiflex the
foot for more than 60 degree)
Knee pain: Anterior/posterior drawer+Medial/lateral collateral ligament, McMurray test,Patella
McMurray test:I am going to check (external rotate and extend the knee->then internal
rotate and flexed the knee)
Anterior/posterior drawer test:I am going to check knee tendon(put thumbs on tibal plateau,
hands holds tibia and push anterior then posterior)
Medial/lateral collateral ligament: is that causing any pain?
(and bring the legs inward and outward)

#When to order breast, pelvic, rectal, genital exam?

Constipation/diarrhea, Lower abdominal pain: rectal exam, pelvic
Amenorrhea: breast exam, pelvic
Erectile dysfunction, Urinary problem,Hematuria: genital, rectal
Pregnancy, viginal bleeding/discharge, dyspareunia, sexual abuse: pelvic
Nausea/vomitting, low back pain: rectal exam
Bed wetting: genital exam

#Rinne/Weber test
Normal:Rinne both ears AC>BC ,Weber without lateralization

Weber lateralizes left Weber lateralizes right

Rinne both ears AC>BC Sensorineural loss in right Sensorineural loss in left
Rinne left BC>AC Conductive loss in left Conductive +sensorineural loss in left
Rinne right BC>AC conductive+sensorineural loss in right Conductive loss in right
 Conductive loss in left: Weber lateralizes left , Rinne left BC>AC
Sensorineural loss in left: Weber lateralizes right, Rinne both ears AC>BC

Conclusion:Abnormal Rinne(BC>AC), it’s conduction loss, otherwise it’s sensorineural loss

Normal physcial:
no acute distress.
VS: WNL
HEENT: Head no tenderness
Eyes: EOMI, PERRLA, normal fundus. (no icteric sclera, pale conjuntiva.)
Ears/Nose/throat/mouth:WNL
Neck:Supple, no JVD, no LAD , normal thyroid ,carotid no bruits/2+ pulses
Chest: Bilateral Clear BS,.
Heart: PMI not displaced, RRR; normal S1/S2; no murmur, rubs, gallops.
Abdomen: Soft, +BS, ND/NT ,no Organomegaly, no masses
Neuro:CN2-12 intact. Motor 5/5 throughout. DTRs: 2/2 throughout, Babinski (-) bilateral
Intact to light touch. Romberg (-) ,finger to nose normal,Gait: normal.
Extremities: No clubbing, cyanosis, edema. Bilateral 2+ perepheral pulses
Back: No deformities or bruises. No tenderness. ROM normal .
Skin: no rash, no lesion

In detail depends on what is examined(red:abnormal PE CSA people can make)

no acute distress.(anxious and in acute distress, in severe pain)
VS: WNL(except T:105F)
Head:
Inspection:NC/AT,
Palpation:no tenderness (tenderness over right temporal area)
Eyes:
Inspection: EOMI, no icteric sclera,no pale conjuntiva. (Lid lag nystagmus, visual loss,)
Fundoscope: PERRLA , normal fundus.(photophobia)
Ears
Observation: no discharge
Palpation:no tenderness
Otoscope:no cerumen, TMs with light reflex, no sign of infection
Weber Rinne:Weber test no lateralization, Rinne test AC>BC both side.(Decreasing hear
ing acuity on left ear, Weber test lateraization to left, Rinne test AC>BC on left side)
Nose:
No nasal congestion/discharge.
Throat:
No tonsillar erythema, exudates, or swelling. (enlarged tonsil)
Mouth:
no lesions, Moist MM, good dentition
Neck :
Inspection:no JVD
LAD palpation: Supple, no LAD ,
Thyroid palpation: normal thyroid (thyroid bruits)
Carotid auscultation/pulse: carotid no bruits, 2+ pulse (carotid bruits)
Chest:
Inspection:(bruises)
 Palpation: No tenderness(ribs tenderness)
Percussion:Clear to percussion Bilateral tactile fremitus WNL.(Increase tactile fremitus)
Auscultation:Clear Breathing sound (wheezing, decrease breathing sound)
Heart:
PMI not displaced, RRR; normal S1/S2; no murmur,(rubs, gallops)
Abdomen:
Inspection:(C-section scar)
Auscultation:+BS
Palpation: Soft, ND/NT ,no Organomegaly, no masses ( tenderness, guarding, rebound,
CVA tendernes, Psoas+,murphy+,Rovsing+, obturator+)
Neuro:
AAOx3(not oriented to time)
Able to spell backward (cant spell backwards)
Distant memories normal, 3/3 registration and recall x3(can’t recall 3 subjects)
CN2-12 intact.
Motor 5/5 throughout.(motor 5/5 throughout except 3/5 in right arm)
DTRs: 2/2 throughout, (DTR:3+ right,1+ left, brisk reflexs)
Babinski (-) bilateral. ( babinski+)
Intact to light touch. (impaired to light touch on left upper/lower ext)
finger to nose normal(post-pointing and intentional tremor)
Romberg (-) ,(romberg+)
Gait: normal. (bradykinetic, takes small steps, walk with back slightly bend forward)
Extremities:
Inspection:No clubbing, cyanosis, edema.(cyanosis, tremor on outstreched finger tips,
right side swollen than left side, ulcer, pigmentation,erythema)
Palpation:(right side is warmer compared to left, pitting edema,tendrness)
ROM:normal(restricted ROM on flexion/entension of left knee compared to right knee)
Pulse: Bil 2+ perepheral pulses (doralis pedis/posterior tibialis/brachial/redial)
Other:(Homer’s sign+,patrick test+, tinel sign, rotator cuff ,impingement sign+, )
Back:
Inspection:No deformities or bruises(deformities or bruises)
Palpation:No tenderness(tenderness)
ROM normal(Limited anterior ROM)
SLRT(-) (SLRT+)
Skin: no rash, no lesion(redness, jaundice, spiders/telangiectasias/palmar erythema)

Useful scales:
Reflexes (0–4), with 0 being completely arefl exic:
1: Hyporefl exia.
2: Normal refl exes.
3: Hyperrefl exia.
4: Hyperrefl exia plus clonus (test the ankle and the knee).
Strength (0–5), with 0 representing an inability to move the limb:
1: Can move limb (wiggle toes).
2: Can lift limb against gravity.
3: Can lift limb with one-fi nger resistance from the examiner.
4: Can lift limb with two-fi nger resistance from the examiner.
5: Has full strength.
Pulses (0–4), with 0 representing pulselessness:
1: Weak pulse.
2: Regular pulse.
 3: Increased pulse.
4: Pounding pulse

#Normal MSE(Only write when you have time)

Appears well groomed
Mood/Affect is euthymic.
Not hostile,cooperative
AAOx3
able to spell backward (or 5/5 on serial 7s. )
Distant memories normal, 3/3 registration, 3/3 recall x3
Speech is fluid and goal directed
No abnormal perceptions
No suicidal/homicidal idea
Judgment/insight intact

#Abnormal MSE
Apperance:Appears: (well groomed, disheveled, or unkempt).
Mood and affect:Mood is (euthymic, depressed, euphoric, angry, anxious ,apathetic). Affect is consistent
with mood.
Behavior: (cooperative, uncooperative, hostile, guarded, suspicious, regressed, Inattentive, poor eye contact)
Schizophrenia :catatonia, Stereotypies, Abnormal movements,disorganized behavior
Side effects of antipsychotic medication:akathisia, tremor or dystonia
Parkinson's disease, dementia or delirium: psychomotor retardation, akinesia or stupor)
Neurological disorder: choreiform, athetoid or choreoathetoid movements may indicate
a neurological disorder
Cognition: (alert, stuporous, or lethargic) and disoriented to person, place or time.
Attention and concentration:(able/unable) to spell WORLD backward (or 1/5 on serial 7s. )
Memory: Distant memories normal (impaired), 3/3 registration, 3/3 recall at 3 times.
Speech:Speech is fluid and goal directed
Mania or anxiety: pressured speech
Depression: prolonged speech latency , speak slowly
Schizophrenia halting and tangential, Disorganized speech
Perceptions: Doesn't have abnormal perceptions ( hallucinations, delusions, or paranoias)
Thoughts:
Schizophrenia:Delusions of control, passivity experiences, thought withdrawal, thought insertion,
thought broadcasting,Poverty of thought,suspicious beliefs ,suicidal/homicidal idea
Mania:Flight of ideas
Depression: inhibited thinking, depressive beliefs ,fearful beliefs ,
Poverty of thought,suicidal/homicidal idea
Dementia:Poverty of thought, suicidal/homicidal idea
Judgment/insight (intact or impaired).
 Section 2 Case Dicussion
Introduction

#Symptoms Lab test generally ordered

Differential diagnosis 1
Differential diagnosis 2>Lab test specifically used in that differential diagnosis
Differential diagnosis 3
◄ :commonly seen differential diagnosis

History:system related symptoms,other symptoms(Other: commonly forget history)

PE: HEENT/neck/chest/CV/P/Abd/Neuro/Ext
Counsel: related to specific symptoms

#PE Abbrevieation I use in this note :

(dont have time for orthostatic vital sign /blood pressure of both arms, don't even bother)

CV(Auscultation):CV, CV(Auscultation+Palpation):Full CV
Pulmonary(Auscultation): P, Pulmonary(Inspection, Auscultation, Percussion, Palpation):Full P
Abdomen(Palpation):abd, Abdomen(Inspection, Auscultation, Percussion, Palpation):Full abd
Neuro(Cranial nerve, muscle power, Reflex, Sensory, Cerebellar): Full Neuro
Extremities: Ext

Gastrointestinal

#EPIGASTRIC PAIN Rectal Exam, CBC/electrolytes/AST/ALT/bilirubin/Alk-

P/Amylase/lipase, CT abdomen, Endoscopy with H pylori testing
Pancrease
Pancreatitis, Acute / Chronic ◄
Pancreatic cancer
Gastric
Peptic ulcer disease ◄
Peptic Ulcer Perforation ->Upright CXR
Gastritis ◄
Gastric cancer
Funtional dyspepsia
Gall Bladder
Cholecystitis ◄ >HIDA scan
Vascular
Abdominal Aortic Aneurism
Mesentery ischemia◄ >ECG

History: abdominal symptoms,constitutional symptoms,,LRI ,Jaundice symptoms ,chronic

pain, black stools or blood in the stools , early satiety
(Others:Abdominal pain relation with food, history of OP/PUD/NSAID use)
PE: HEENT(Eye for jaundice,mouth), CV+P, Full Abd(Murphy sign, Liver palpation)
#RUL PAIN: Rectal Exam, CBC/AST/ALT/bilirubin/Alk-P/viral hepatitis serologies, U/S
abdomen
Gall Bladder
Cholecystitis◄ >HIDA scan
Bile duct
Ascending Cholangitis ◄ >MRCP,ERCP,blood culture (rule out sepsis)
Choledocholithiasis ◄ >MRCP,ERCP
Sclerosing Cholangitis >MRCP,ERCP
Liver
Hepatitis ◄
Fitz-Hugh-Curtis Syndrome◄ ->Laparoscopy

History:abdominal symptoms,constitutional symptoms,jaundice symptoms (Others:history of

gallstone)
PE: HEENT(Eye for jaundice,mouth), CV+P,
Full Abd(Murphy sign, Liver palpation)

#Male has LOWER ABDOMINAL PAIN Pelvic/Rectal exam, CBC/electrolytes, AXR/CT

abdomen,U/A+ culture
GI
Appendicitis ◄
Diverticulitis ◄
Inflammatory Bowel Disease ◄
Uro
Nephrolithiasis ◄
UTI◄
#Young female with LOWER ABDOMINAL PAIN Pelvic/Rectal exam, CBC/ESR, urine hcG/
UA/culture, CT abdomen/U/S pelvis
GI
Appendicitis ◄
Uro
Nephrolithiasis
UTI
Gyn
Endometriosis >laparoscopy◄
PID > cervical culture◄
Ovarian Torsion >Doppler U/S pelvis, laparoscopy◄
Ruptured Ovarian Cyst ◄
Ob
Spontaneous Abortion ◄
Ectopic pregnancy ◄

History:Urinary infection/irritation symptoms , abdominal symptoms,constitutional

symptoms,Weight change,,Vaginal spotting/discharge,heartburn
(Others:STDs, history of OP/stone, LMP, detail ob/gyn history)
PE:No HEENT ,CV+P+CVA ,Full Abd(Psoas, Obturator, Rovsing),ext
#LUL PAIN Rectal Exam, CBC/electrolytes, CXR/U/S abdomen/CT abdomen,
Splenic
Splenic Rupture◄
Splenic Infarction ◄
Others:
Pneumonia◄
Kidney stone◄
Rib fracture◄

#CRAMPING ABDOMINAL PAIN Pelvic/Rectal exam, CBC/electrolytes, AXR/CT abdomen

Mechanical
Intestinal obstruction ◄ >Lactate, ABG
Hernia
Volvulus of the bowel ◄
Small Bowel or Colon Cancer ◄
Functiional
Mesenteric Ischemia / Infarction >Mesentetic angiography
leus ◄
Irritable Bowel Syndrome
Infection
Gastroenteritis ◄
Food Poisoning ◄

#Acute Diarrhea Rectal exam, CBC/electrolytes, stool(leucocyte, culture, parasite

antigen), AXR
Infection
Food poisoning ◄
Pseudomembranous colitis◄ >C difficile toxin
Traveler’s Diarrhea ◄
Infectious diarrhea ◄
#CHRONIC DIARRHEA Rectal exam, CBC/electrolytes/TSH, stool(leucocyte, parasite
antigen, osmolarity, fat), AXR, colonscopy/barium enema
Diarrhea+ constipation
Inflammatory Bowel Disease◄ >small bowel series for chohn's disease, CT abdomen/pelvis
Irritable Bowel Syndrome ◄
Colorectal cancer◄ >CT abdomen/pelvis
Diverticulitis◄ >CT abdomen/pelvis
Infection
Infectious diarrhea ◄
Whipple's disease
Bowel wall
Lactose intolerance ◄ >hydrogen breath test
Celiac Disease◄
Carcinoid >urine 5-HIAA, CT chest/abdomen
Small bowel lymphoma
Endocrine+Exocrine
Hyperthyroidism ◄ >TSH
Chronic Pancreatitis ◄
Medication
Laxative abuse

History:hyperthyroid/ URI symptoms /colon cancer symptoms, abdominal

symptoms,constitutional symptoms,Weight change, cough
(Others: diet/fluid intake/specific food related, HIV risk factor, mucous in stool
history of OP/pancrease disease, stress for irritable bowel, ill contact/travel )
PE:HEENT(eyes, mouth for dry oral mucosa),Neck(thyroid), CV+P, Full abd,
Ext(edema)

#Constipation Rectal exam, CBC/electrolytes/TSH , urine toxicology, FOBT, CT abdomen/

pelvis
Only constipation
Depression ◄
Substance Abuse (Heroin)
Hypothyroidism ◄
Low Fiber Diet ◄
Diarrhea+ constipation
Inflammatory Bowel Disease ◄
Irritable Bowel Syndrome◄ >small bowel series, colonscopy
Colorectal cancer◄ >CEA/LFT, barium enema, colonscopy
Diverticulitis◄

History:hypothyroid /colon cancer symptoms, abdominal symptoms,constitutional

symptoms,Weight change, pain when defecation, colonscope
(Others: history of OP, heroin, mood for depression)
PE:HEENT(eyes, mouth for dry oral mucosa),Neck(thyroid), CV+P, Full abd, Ext(edema)

# NAUSEA / VOMITING CBC/electrolytes, urine hCG, U/A, XR abdomen,

GI
DM gastroparesis >sugar
Gastritis ◄
bowel obstruction
GERD
Other inflamation
Peritoneal irritation(PID, cholecystitis, appendicitis, pyelonephritis, pancreatitis)
UTI ◄ >urine culture
Pregnancy ◄
Intracranial lesion ◄ >Brain MRI
Metabolic◄
Hypercalcemia ◄
DKA
drug induced
# NAUSEA / VOMITING with headache CBC/electrolytes/ESR, MRI/CT brain, ECG, LP if no
mass effect
Intracranial tumor ◄
Meningitis/Encephalitis ◄
SAH/EDH/SDH ◄
Migrain, complicated ◄
stroke/TIA◄
History: Urinary infection/irritation symptoms,CNS (headache/stiffneck, vertigo, focal
numbness), abdominal symptoms,constitutional symptoms,Weight change,chest pain, vagainal
discharge (others:sick contact, related meal, LMP for pregnancy,diet/fluid intake)
PE:HEENT(fundoscope, mouth for dry mucosa), CV+P,Full abd, ext

#BLOOD IN STOOLS Rectal exam, CBC/PT/PTT/CEA, CT pelvis/abdomen, barium enema/

colonscopy,
Anal
Proctitis ◄
Anal fissure ◄
Hemorrhoids ◄
Colon inflammation
Infectious colitis◄
inflammatory bowel disease◄
Tumor
Colorectal Cancer >AST/ALT/alk-p/bilirumin (for metastasis)◄
Vascular
Angiodysplasia ◄
Ischemic Bowel Disease ◄
Other
Upper GI Bleeding
Diverticulosis ◄

History;colon cancer symptoms, abdominal symptoms,constitutional symptoms,Weight

change,mucous in stool, blood and BM relationship, rectal pain,
eye lesion/skin lesion/joint pain(for IBS), mucous, blood relationship with stool
(Others: bleeding duration, wafarin use, history of atherosclerotic vascular disease/
easy bleeding, diet)
PE:HEENT(eye for anemia,mouth), CV+P ,Full Abd,ext

#UPPER GI BLEEDING Rectal exam , CBC/Electrolytes, AST/ALT/bilirubin/Alk-P,

stool(FOBT), endoscopy
Esophegeal
Mallory Weiss tear ◄
Esophageal Varices ◄
Esophagitis ◄
Gastric
Bleeding peptic Ulcer ◄
Gastritis ◄
Gastric Cancer ◄ >barium sawallow, CT abd

History:Jaundice symptoms, abdominal symptoms,constitutional symptoms,Weight

change,nosebleed, stool color change, chronic pain, heartburn
(Others: symptoms/alcohol before bleeding, history of OP/PUD/liver disease/easy
bleeding/trauma, appetite,medication like wafarin/NSAIDs, duration of bleeding,
frank blood or coffee ground)
PE:HEENT(eye for anemia ,nose, mouth), Neck(LN), CV+P, Full abd, Ext(observation)
#JAUNDICE AST/ALT/bilirubin/alk-p/viral hepatitis serologies/PT/PTT , U/S abdomen,CT
abdomen
Hepatitis
Infectious hepatitis ◄
Alcoholic hepatitis ◄
Drug induced hepatitis◄ >acetaminophen level
infectious mononucleosis
Metabolic
Wilson's disease
Hemochromatosis
Obstruction:
Primary biliary cirrhosis ◄ >ERCP/MRCP
Choledocholithiasis ◄ >ERCP/MRCP
Malignancy (cholangiocarcinoma, pancreatic cancer, carcinoma of ampulla)◄ >ERCP/MRCP
Hemolytic
Hemolytic jaundice

History:Jaundice symptoms,infectiou mononucleosis symptoms, abdominal

symptoms,constitutional symptoms,Weight change, bleeding tendencies
(Others: blood transfusion,hepatitis history, raw food, tarvel)
PE:HEENT(Eye),CV+P (look for spider nevi, cutaneous telangiectasis),
Full Abd(Murphy sign, Liver palpation,ascites), Ext(asterixis, palmer erythema)

#DYSPHAGIA CBC/electrolytes, CXR, Barium swallow/endoscopy

Oropharyngeal dysphagia:(more on liquid)
Neuromuscular (CVA, Parkinsonism, multiple sclerosis, ALS )
Mechanical obstruction (Zenker diverticulum, thyromegaly)
Skeletal muscle disorders (myasthenia gravis, muscular dystrophies, polymyositis)
Esophageal dysphagia(more on solid)
Esophageal Cancer ◄ >CT chest
Esophageal Stricture ◄
Mitral Valve Stenosis ◄
Plummer Vinson Syndrome◄ >serum iron, ferritin, TIBC
Esophagitis ◄ ->HIV antibody and CD4 count (for high risk HIV)
GERD ->PH monitoring
Both(liquid and fluid)
achalasia◄ ->esophageal manometry
Systemic sclerosis ◄ ->esophageal manometry

History: abdominal symptoms,constitutional symptoms,Weight change,heart burns, painful

swollowing(odynophagia), drooling, color change in finger,
choking sensation or regurgitation/aspiration,weakness of the arms or legs,SOB
(Others: HIV risk factors, dysphagia on fluid/solid food, where the food stuck )
PE: HEENT(nose, mouth,eye for anemia), Neck(LN,thyroid), CV+P, Full abd,
Ext(scleroderma, raynoid phenomenum)
 EYES and ENT

#Blurred vision (CBC, blood glucose/HbA1C/lipid, U/A ,Doppler of carotids)

Diabetic retinopathy ◄
Hypertensive retinopathy ◄
Cataracts ◄ ->slip lamp
Glaucoma ◄ >tomoometry
Macular degeneration ◄

History:DM constitutional symptoms, eye symptoms

PE:HEENT(fundoscope), Neck(bruit), Neuro(cranial nerve,motor, sensory), CV

#SORE THROAT CBC+perepheral smear/LFT, Throat swab(culture and ASLO), Monospot

test, HIV antibody/viral load/CD4
Common
Infectious Mononucleosis◄ >anti-EBV antibody
Viral or Bacterial Pharyngitis ◄
Uncommon
Acute HIV Infection ◄
Hepatitis
Mycoplasma pneumonia ◄ > mycoplasma IgM
Secondary Syphilis >VDRL/RPR

History:URI+LRI +constitutional symptoms ,mononucleosis symptoms, joint pain ,vaginal

discharge(Others:ill contact)
PE:HEENT(eye for jaundice, Nose,mouth for oral thrush/tonsillar exudate,sinus),
Neck(LN) CV+P, Full abd(organomegaly), Ext(rash)
Counsel:Infectious mononucleosis suggest no strenuous sport

#Lose of hearing VDRL/RPR, CT—head, Audiometry/Tympanography, BAEPs(Brain stem

auditory evoked potentials)
conduction loss
Cerumen impaction◄
Foreign body
Tympanic membrane perforation ◄
Cholesteatoma◄
Otitis media with effusion ◄
Otosclerosis ◄
Tumor in middle ear/ear canal
Sensorineural loss
Ménière’s disease ◄
Ototoxicity ◄
Presbycusis ◄
Acoustic neuroma◄
Cochlear nerve damage:◄

History:Ear/CNS symptoms (Headache, weakness/sensational change,

trauma) (Others: noise expose,social impact)
 (Loud Foreign Jazz):
Exposure to loud noises? Insertion of foreign body?
Do words sound jumbled or distorted? Is hearing lost for all sounds or for anything specific?
Can you locate the source of sound? Do you have any problems understanding speech?
Dizziness/Vertigo:Do you feel like spinning is around you or it's inside?

PE:HEENT(nose, mouth ,sinuses,otoscopy/Rinne/Weber+whisper test ),Neck(carotid bruit)

Full neuro, (CV)

#Hoarseness CBC/TSH, laryngoscopy+biopsy, CXR

Vocal nodules/ polyps
Laryngitis
Leukoplakia
Lung cancer/ laryngeal cancer
GERD > PH monitoring
Hypothyroidism
Amyloidosis
Parkinson’s disease/stroke
Trauma

History:Chest symptoms, hypothyroid symptoms,constitutional symptoms Heartburns,

dysphagia, swelling glands,postnasal dripping(Others: Activity/when get worse?environmental
exposure)
PE:HEENT(Nose/mouth), Neck(Thyroid, LN), CV+P
Counselling:
1.Voice rest
2.smoking cessation
3.Voice therapy in singer

RESPIRATORY TRACT

#SOBCBC, Gram stain and culture (if with sputum), PPD, CXR/CT chest, serum
Mycoplasma IgM, Urine Legionella antigen, ABG (if SOB)
Treachea
Chronic Bronchitis◄ >PFT
Asthma ◄ >PFT+peak flow measurement
Aveolar/Interstitium
Pneumonia(typical and atypical) ◄
Interstitial Lung Disease >PFT
Heart:
Congestive Heart Failure◄ >U/S heart, ECG,BNP
Cardiac Valvular disease >U/S heart, ECG
Destructive
Tuberculosis ◄ >bronchoscopy, Acid fast stain
Lung Cancer ◄ >bronchoscopy
Phychologic
Anxiety and panic attacks
#COUGH (add SOB causes SOB causes)CBC, Gram stain and culture (if with sputum),
PPD, CXR/CT chest, serum Mycoplasma IgM, Urine Legionella antigen, ABG (if SOB)
URI
Post nasal drip
URI associated (post infectious)
GI
GERD ◄
Exposure
Occupation exposure
Secondary to ACEI use◄

History:Respiratory, constitutioal symptoms,Postnatal drips, heartburns, night SOB,orthopnea

leg pain/swelling,LOC (Others: TB/animal/chemical/sick people exposure, Last PPD,
family history of blood clots and heart problems, MI and immobilization)
PE:HEENT(eye,nose,mouth,sinus),Neck(LN,JVP, carotid pulse/bruits)
full CV+Full P, Ext(clubbing/cyanosis, edema, calf muscle tenderness, pulses)

#Hemoptysis CBC/PT/PT, sputum Gram stain/AFB/culture/cytology, CXR/CT chest, PPD

Bronchiectasis ◄
Acute or chronic bronchitis ◄
Pneumonia
Bronchogenic carcinoma ◄ >bronchoscopy
Lung abscess
Tuberculosis ◄
Connective tissue diseases ◄ (Wegener‘s disease, Goodpasture‘s, Lupus) ->ESR, BUN/Cre,
c-anca
Pulmonary embolism >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer

History: Respiratory, constitutioal symptoms ,skin rash (Others:TB contact, Family history of
coagulation)
PE:HEENT(eye,nose,mouth,sinus),Neck(LN,JVP, carotid pulse/bruits)
full CV+Full P, Ext(clubbing/cyanosis, edema, calf muscle tenderness, pulses)

#Asthma drug refill:CBC/aspergillus serology, CXR, PFT, skin tests

Bronchial asthma
COPD
bronchopulmonary aspergillosiss
sinusitis
atypital GERD

History:Respiratory, constitutioal symptoms,medication problem, asthma control(regular activity

/exercise/exccessive coughing/emergency), precititation,
PE:HEENT(nose,mouth,sinus),Neck(LN,JVP) full CV+Full P, Ext(clubbing/cyanosis, edema)
Counsel:
1.Most common cause of recurrence of asthma symptoms is interruption of controller
medications.
2.You should take it every day without missing a single dose.
3.see you again in about 3 months for a checkup.
 Cardiovascular

#CHEST PAIN CBC/electrolytes, CPK-MB/troponin I, ECG, CXR, ABG(if SOB)

Heart(and aorta)
Angina >cardiac cathterization, exercise stress test
Myocardial Infarction (MI) ◄ >cardiac cathterization
Pericarditis
Aortic Dissection ◄ >TEE,aortic angiography, MRI/MRA-aorta
Pulmonary
Pulmonary embolism ◄ >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer
Pulmonary Infarction – Sickle Cell Disease >V/Q scan, CT chest with contrast
Pneumothorax ◄
Pneumonia
GI
Esophageal Spasm
Esophageal Rupture
Esophagitis
GERD >Endoscopy, PH monitoring, barium swallow
Chest wall
Muscle Strain
Costochondritis
Rib frcature
#If young adults+TSH/CBC/troponin/CK-MB/CPK, EKG,Urine VMA, CXR
Panic disorder ◄
Hyperthyroidism ◄
Pheochromocytoma ◄ >Urine VMA
Hyperventilation syndrome ◄

History:CV,LRI symptoms, noctural dyspnea, sweating, leg swelling/pain, dizzy,

sense of terror, syncope , headache (Others: MI and immobilization)
PE:Neck(JVD, carotid pulse/bruit),Full CV+Full P, Full abd, Ext(edema, perepheral pusle)

# Sickle cell anemia pt c/o chest pain :

History:CV symptoms,Pulmonary symptoms, pain in joint, dehydration, trauma
PE:HEENT:(eye, mouth), Neck(LN), full P+full CV, Ext
Counsel:
1.avoid dehydration
2.contact doctor if there’s fever and short of breath
3.Flu shot each year

#PALPITATIONS CBC/electrolytes/glucose/TSH, ECG, Holter monitor

Heart
Angina
Cardiac Arrhythmias ◄
Endocrine
Hypoglycemia ◄
Hyperthyroidism ◄ >FT4
Pheochromocytoma ◄ >MRI abdomen, VMA
Carcinoid ->CT chest/abdomen ,5-HIAA
Phycological
GAD (Generalized Anxiety Disorder)
Hyperventilation episodes
Panic attacks ◄

History:CV, hyperthyroid /CNS symptoms (lightheadedness, headache, LOC,sweating)

(Others: feeling/activity doing while palpitation, history of bleeding/anemia/heart heasese)
PE:HEENT(exophthalmos, lid retraction, lid lag)Neck(thyroid palpation/bruit),
full CV,Ext(tremor, edema)

Neurology

#DIZZINESS CBC/electrolytes, MRI brain audiogram(if not hearing well)

CNS
TIA or stroke ◄
Brain Stem or Cerebellar Tumor
Acoustic Neuroma ◄
Vertebrobasilar Insufficiency ◄
Heart
Coronary artery disease
Congestive heart failure
Arrhythmias ◄
Others
Orthostatic Hypotension◄ >Orthostatic vital sign, BUN/Cre
Autonomic dysfunction
Hypoglycemia
#Vertigo Dix-hallpike maneuver, CBC/electrolytes, ENG(electronystagmography),
MRI/MRA brain ,audiogram/BAEP(if not hearing well)
Meniere Disease ◄ >VDRL/RPR
Vestibular Neuronitis ◄
Labyrinthitis ◄
Benign Positional Vertigo ◄
Vertebrobasilar Insufficiency ◄

History:CNS,URI/LRI/Ear/Abdomen symptoms, Falls, palpitation(Others: history of neck

injury/vasular disease, any warning sign )
PE:HEENT(eye for nystagmus ,mouth sinus,otoscope/Rinne+weber+whisper test
sinuses if hearing loss) ,Neck(carotid bruit) Full Neuro ,(CV)

#SUDDEN HEADACHE CBC/ESR, CT head no contrast/MRI brain, LP analysis

Brain inflammation
Encephalitis ◄
Meningitis ◄ >LP analysis with gram stain, PCR, culture
Temporal Arteritis >temporal artery biopsy
Vascular
Acute hypertension ◄
Carotid/Vertebral artery dissection ◄ >doppler U/S carotid
Intracranial Venous Thrombosis◄
Intracranial/Subarachnoid Hemorrhage ◄ >PT/PTT,MRA brain
Eyes+ENT mechanical
Sinusitis >CT sinus
Phychiatric
Caffeine or analgesic withdrawal
#Chronic headache CBC/ESR, CT head no contrast/MRI brain, LP CSF-analysis
Common
Cluster headache ◄
Migraine ◄
Tension headache◄
Temporal Arteritis >temporal artery biopsy
Neoplasm
Intracranial Neoplasm ◄
Pseudotumor Cerebri ◄ >urine hCG, LP analysis+opening pressure
Eyes+ENT mechanical
Refractive errors
Sinusitis >CT sinus
Trigeminal Neuralgia
TMJ Dysfunction
Phychiatric
Depression

History:CNS,URI symptoms, Aura, cough, tearing, neck pain, pain in jaw

(Others:timing (time of the day, sleeping), mense relationship, OCP use)
PE:HEENT:(Palpation of temporal/sinuses/TMJ, nose, mouth),Neck(palpation to shoulder,
carotid bruit), Neuro(CN, Muscle power, DTR,Brudzinski/kernig)

#LOSS OF CONSCIOUSNESS CBC/electrolytes/glucose, CT head/Doppler U/S carotid,

ECG+Holter monitor,
CNS:
Stroke ◄
Seizure◄ >EEG,MRI brain, prolactin
SAH/SDH/EDH >LP CSF analysis
Heart+ Vascular
Cardiac Arrhythmia◄ > U/S heart
MI >U/S heart
Aortic Stenosis◄ >U/S heart
Pulmonary Embolism◄ >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer
Vasovagal Syncope
Endocrine
Drug-induced Orthostatic Hypotension◄ >orthostatic vital sign
Hypoglycemia
Substance Abuse / Overdose >urine toxicology

History:CV/CNS/ seizure symptoms, unusual sensation(palpitation, sounds, light,nausea)

before falls (Others: LOC before or after the fall, history of heart disease/seizure/stroke/
PE risk factor, what happened/activity before the LOC)
PE:Full neuro, HEENT(head/mouth),Neck(Carotid pulse/bruit/thyroid),CV
Counsel:
1.not drive again until we are sure what caused you to loss consciousness,

#NUMBNESS & WEAKNESS

UMN:Intracranial
CNS Vasculitis
Intracranial tumor ◄ >MRI brain
Seizure /Todds Paralysis◄ >EEG
Stroke /TIA ◄ >MRI/CT brain ,ECG, Doppler carotid, U/S heart, PT/PTT
SDH/EDH ◄ >Brain CT
Migraine, complicated ◄
UMN:Spinal
Tumor in the Vertebral Canal >MRI spine
Neurosyphilis >RPR/VDRL
Syringomyelia >MRI spine
ALS >EMG/NCV, CT/MRI cervical spine
Horner’s Syndrome
MS ◄ >VEP(visual evoked potential), CSF analysis, MRI brain
LMN+muscular
Peripheral Neuropathy (Diabetic/Alcoholic/B12 Deficiency)◄
Polymyositis
GBS >CSF analysis, EMG/NCV
Myasthenia Gravis ◄ >Tensilon test, single fiber EMG,Ach antibody, chest CT(for thymoma)
Others:
Conversion Disorder
Hyperventilation
Hypoglycemia
Hypocalcemia

History:CNS, constitutional symptoms (Others: distribution, history of

DM/HTN/vasular disease)
PE:Neuro(Muscle power, sensation, DTR), Ext(pulse),Neck(Carotid bruit)

#Frequent Falls CBC/electrolytes, MRI brain,EEG,EKG

Brain
Cerebellar disease ◄
Seizure
Brain tumors ◄
Parkinson‘s disease◄
Others:
Diabetic neuropathy ◄
Fractured hip
Vertigo ◄

History:Neurological symptoms, seizure, palpitation, dizziness

(Others:injury associated with fall,los e consciousness before or after your fall?
any difference in the way you walk? living condition and supporting systems)

#Seizure CBC/electrolytes/glucose/prolactin, CT head/MRI brain, EEG, LP with CSF

analysis, urine toxicology
CNS
Brain tumor ◄
encephalitis/meningitis ◄
SAH/SDH/EDH◄
Endocrine
hypoglycemia ◄
Alcohol withdrawal/ Substance Abuse ◄

Tremor: TSH, heavy metal screen, MRI brain

CNS lesion
Parkinson’s disease ◄
Midbrain lesion
Wilson’s disease >ceruloplamin, slit lamp examination, AST/ALT, 24 hr urine copper, liver
biopsy
cerebellar lesion◄
Others:
Drug-induced tremor
Essential tremor ◄
Physiologic tremor ◄
Psychogenic tremor
Hyperthyroidism ◄

PE:Full neuro, Neck:(thyroid,carotid bruit),

#CONFUSION/MEMORY LOSS CBC/B12/TSH/RPR/electrolytes/Ca/glucose/BUN/cre, CT

head/MRI brain ,EEG, LP
Dementia
Alzheimer’s Disease ◄
Lewy Body Dementia
Vascular Dementia ◄
Pick's dementia
Normal Pressure Hydrocephalus◄ >LP CSF analysis+opening pressure
Huntinton's disease
Progressive supranuclear palsy
Depression(pseudo-dementia)◄
Intracranial lesion
Intracranial Tumor ◄
Chronic Subdural hematoma◄
Infection cause
Creutzfeldt-Jakob Dis. >brain biopsy
Neurosyphilis
Metabolic cause
Hypoglycemia
Hypothyroidism ◄
Wernicke’s Encephalopathy
B12 Deficiency◄ >serum B12
Others:
Delirium

History:MS.WC ,CNS symptoms ,ADL, IADL incotinence ,gait disturbance, Things hard to
remember
ADLs(DEATH)+IADLs(SHAFT)
Begin with :Is there anything in the daily living you can't do by yourself?

Dressing: Do you have problem wearing clothes?

Eating: Do you have problem eating by yourself? (Can ask alone with F)
Ambulation: Do you have problem getting in and out of bed?
Toileting: Do you have problem using toliet?
Hygiene: Do you have problem bathing?

Shopping: Do you have problem shopping?

Housekeeping: Do you have problem keeping your house clean?
Accounting: Do you have problems managing money?
(Food preparation: Do you have problem preparing food?)
(Transportation:Do you have any problem driving a car or taking a bus?)

PE:Full neuro(+MMSE), HEENT(pupils, fundus),Neck:(thyroid,carotid bruit)

Counsel:
1. permission to speak with family members about social support and safety at home.
2. excellent social worker managing daily activities and future living plans
3.Explain the necessity to take medicine regularly

Urology

#HEMATURIA Genitourinary exam/rectal exam, BUN/cre/PSA/CBC/PT/PTT, UA/cytology,

CT abdomen/pelvis, U/S renal/transrectal, IVP
HITTERS
Hemotalogy-coagulation◄
Infection◄
Trauma
Tumor(Bladder Cancer/RCC/Prostate Cancer)◄
Exercise
Renal disorders(AGN, PCKD)
Stone(Nephrolithiasis )◄

History: urinary Irritative+infection symptoms +Constitutional, sore throat

,jaundice(Others:history of vigorous
exercise/trauma/stone/cancer/hepatitis/easy bleeding,
quantity of unine, food like berries/colored candy/beets)
PE:HEENT(eye for anemia,mouth),CV, full abd(+CVA tenderness),
Ext(inspection, palpation for inguinal LN)

#obstructive symptoms Rectal exam, CBC/BUN/Cre/PSA, UA+culture,U/S prostate

Prostate
BPH ◄
Prostate Cancer◄ >CT pelvis, IVP
Bladder
Bladder Cancer ◄
Bladder Stones ◄
Renal
Renal Cell Carcinoma
Nephrolithiasis ◄

History: urinary Irritative+infection, obstructive symptoms,+Constitutional back pain,

trauma,hematuria
(Others:history of stone/cancer/BPH/urinary tract instrumentation)
PE:full abd(suprapubic percussion for distended bladder),
neuro(lower ext Muscle power, sensation, DTR)

#burning urine Genital exam, CBC/BUN/Cre, UA/culture, (Gram stain/culture on urethral

discharge if appears), (Chlamydia and gonorrhea PCR if suspected STD)
Urethritis, ◄
Cystitis, ◄
Prostatitis ◄
Acute Pyelonephritis ◄ >CT abdomen, U/S renal
Vaginitis◄

History:rinary Irritative+infection symptoms +Constitutionalpain when intercose, back pain,

vaginal discharge, bleeding
(Others: STD, history of stone/cancer/UTI/BPH/trauma/urinary tract
instrumentation)

#Incontinence in female Pelvic exam, Bun/cre, U/S abdomen+post voiding volumn,

Urodynamic study, UA+culture
Stress incontinence
Urge incontinence
functional incontinence
Overflow incotinence
Cystitis

History:rinary Irritative+infection symptoms +Constitutional,activity/strong urge before

leaking,leaking during sleep weakness/numbness, LBP
(Others: affect daily living/relationship, viginal delivery)
PE:Full abd +CVA, neuro(motor, DTR,Sensory)
Counsel:
1.the outlet of bladder become weak
2.also has to rule out neurological and infection problem
3.Restriction of caffine/alcohol
4.Wearing absorbent pad to avoid embrassing incident

#FLANK PAIN Rectal exam, BUN/Cre, UA/urine culture, IVP/CT abdomen/U/S renal
Inflammation
Glomerulonephritis◄
Pyelonephritis ◄
Cancer
Renal cell carcinoma ◄
Stone
Nephrolithiasis◄
Retroperitoneal lesions

#INCREASING URINATION Fasting blood sugar/electrolytes, Urinalysis , Urine and serum

osmolality
Diabetes mellitus ◄
Central diabetes insipidus ◄
Nephrogenic diabetes insipidus ◄
Psychogenic polydypsia ◄
Hypercalcemia ◄
History:DM constitutional symptom, urinary obstructive /irritative/
infection symptoms(Others: head trauma, psychiatric problems )
PE:HEENT(oral mucous, fundus),Ext (MP/reflex, sensation ), CV

Rheumatology/Musculoskeletal

Rheumatology:Ask rheumatology system specific symptoms first(CITRUS HPT)

CITRUS HPT:Chest pain/ cough, Insect/tick bite,
Trauma/travel, Rash,
Ulcer in mouth Stiffness in morning
Hair loss, Photosensitivity
Temperture cause finger color change

#LOW BACK PAIN XR-L spine,MRI L spine ,DEXA scan , Ca/P/Alk-P

Muscular
Lumbar Muscle Strain ◄
Mechanical
Disk Herniation ◄
Cauda equina syndrome
Osteoporosis with vertebral body fracture
Degenerative joint disease ◄
Lumbar Spinal Stenosis ◄
Oncology
Tumor in the vertebral canal ◄
Pathologic fracture
Rheumatology
Ankylosing Spondilitis
RA
Infection
osteomyelitis/discitis/epidural abscess
Intraabdominal+retroperotoneal pathology
Abdominal aortic aneurysm
Others
Malingering
Knee or leg fracture >X ray knee

History:constitutional symptoms , urinary/fecal incotinence, weakness/numbness,

difficulty urinating (Others: Trauma, history of cancer, urinary tractinfection,
DM, renal stone)
PE:Sit: Back(IP,P) Neuro(MRS), HEENT(eye for conjuntivitis)
Lie down:Hip exam, SLRT
Stand: Anterior ROM by touch toes ,gait including toe and heel walking

#Evaluation of OA:
History:weakness/numbness, cracking sound, pain elsewhere
(Others: what time/activity feel more pain, limitation in walk, LMP for menopause, HRT/calcium
supply)
Counsel:Regular pain killer, weight reduction, Regular exercise

#Heel pain CBC/ESR, XR foot/ankle,Bone scan Rheumatoid factor assey

Orthopedeic
Plantar fasciitis ◄
Achilles tendonitis◄
ankle sprain◄
retrocaneal brusitis◄
tarsal tunnel syndrome
Calcaneal periostitis
Calcaneal spurs
Painful heel pad syndrome
Stress fracture◄
Oncology
Bone tumors
Rheumatology
Rheumatoid arthritis
Reiter's syndrome
Psoriatic arthritis
reactive arthritis

PE:Ext(Inspection of both feet and ankle in non-weight bearing/weight bearing, PRP

,capillary refilling of the toes) Neuro(MRS, include great toe extension)
HEENT(eye for conjuntivitis)
Counsel:rest for 2-3 days, Ice 30 mins every 4 hours, avoid excessive weight on heel

#Knee pain: Knee aspiration and synovial fluid analysis, ANA/anti-dsDNA/RF/uric

acid/PT/PTT before aspiration, XR knee
Gout◄
Pseudogout◄
OA◄
RA◄
SLE◄
gonorrhea septic arthritis◄
non-gonorrhea septic arthritis
reiter > urethal culture

PE:Ext(IPRP,Anterior/posterior drawer,Medial/lateral collateral ligament, McMurray test)

Neuro(MRS), HEENT(eye for conjunctivitis)
#Unilateral leg pain D-Dimer, CPK,myoglobin, CBC, hypercoagulability study, doppler
U/S, CT venography, MRI legs
Vascular
Deep vein thrombosis ◄
superficial venous thrombosis
Mechanical
baker's cyst rupture◄
Trauma
Spasm/sprain
Inflammatory
myositis◄
cellulitis◄
History:pulmonary embolism symptoms, Legs (Swelling , Injury , Redness, Warmth,
Varicose veins) (Others: PE risk factor)
PE:Ext(IPRP, including femeral pulse, Homans’ sign), Neuro(MRS),CV+P(for embolism)

#bilateral leg pain:

Vascular >doppler U/S, ABI, angiography
Thromboangiitis obliterans
Arterial insufficiency ◄
Deep vein thrombosis ◄
Neuro >MRI lower back
Lumbar spinal stenosis ◄
Diabetic polyneuropathy ◄
Lumbosacral Radiculopathy◄
Inflammatory >CPK,aldolase
polymyositis◄
Rhambdomyolysis >urine myoglobin, UA
inclusion body myositis

History;Back pain, pain in the rest, weakness/numbness of legs, fever, trauma,

prolonged immobilization , impotence
PE:Ext(Pulse, palpation, Homen sign, sensation+ vibration sense, reflex)

#multiple joint pain RF, ANA,ESR

Psoriatic arthritis
Rheumatic arthritis
SLE
Reiter arthritis
Dissemintaed gonorrhea >cervical culture

#shoulder pain XR shoulder/arm, MRI shoulder

shoulder dislocation
fracture of humerus
Rotator cuff injury
impingement symdrome

PE:Ext:(IPRP,impingement symdrom,Rotator cuff injury),Neuro(MRS)

#elbow pain X ray, MRI elbow, bone scan
lateral epiconditis
stress fracture
medial epicondytis
elbow subluxation
brusitis
arthritis

#Wrist pain X ray, MRI wrist

carpal tunnel syndrome >NCV study
Sprain/strain
tendinitis
brusitis
Arthritis
With injury
Sprain/strain
colles fracture
smith’s fracture

History:symptoms worsen with the above head activities, like combing, knee pain with
trauma:any noise, unstable, locking of joint,
PE:Ext:(IPRP,Tinel sign,Phalen test,Adson test),Neuro(MRS),HEENT(eye for conjuntivitis)

carpal tunnel syndrome counsel:1.Take plenty of breaks from activitie

2.Make sure that your keyboard is low enough
3.An occupational therapist can show you ways to ease pain and swelling
4.wear a wrist splint at night while you sleep

#Polymyalgia CBC/ESR/CRP/CPK/TSH, EMG (if muscle weakness)

Polymyalgia rheumatica
Fibromyalgia
Polymyositis/dermatomyositis
Viral infection
Drug induced(ACEI , statin)
Rhabdomyolysis
Rheumatologic disorders (RA, SLE) >RF, ANA, anti-dsDNA
chronic fatigue syndrome
Depression
Trauma

history:Constitutional symptoms, common cold symptoms, Joint pain, weakness/numbness,

Headache(for polymyalgia rheumatica associted with temporal headache),Rash
(dermatomyositis), trigger points(Fibromyalgia)
(Others: limitation of daily life in difficulty going up stairs, getting up from chairs, and raising
hands above the head, mood, sleep)
PE:HEENT(head palpation, mouth), Neck(thyroid), Neuro(muscle power, DTR, sensory), Ext
(palpation for trigger points)
Counselling:
1.Physical therapy
2. Massage therapy
3.Trigger point injection if presents

Obstetrics/Gynecology (Ask detailed Ob/Gyn hostory)

#DYSPAREUNIA Pelvic exam, cervical cultures+KOH prep+wet amount, U/S pelvic

Vagina
Vaginismus
vaginitis◄
Vulvodynea
Atrophic Vaginitis
Cervix+Uterus+Abdomen
Cervicitis ◄
Endometriosis ◄ >Laparoscopy
PID◄
Others
Depression
Domestic Abuse ◄
Menopause

Histrory:Menopause symptoms, vaginal discharge/nipple disscharge

itching, rash (Others: Sexual history (sexual desire, History or current sex
abuse, lubrication)conflict with partner, stress, Douching, History of
endometriosis/ PID and surgery)
PE:HEENT(oral), CV+P, Full abd, Ext

#VAGINAL BLEEDING pelvic exam,CBC, pap smear, urine hCG, U/S pelvis
Pregnancy(young)
Ectopic pregnancy ◄ >Quantitative serum hCG, transviginal U/S
Spontaneous abortion ◄
Molar Pregnancy ◄
Cervix(midage/young)
Cervical Cancer ◄ >cervical biopsy+endometrial curettage
Cervicitis ◄
Cervical Laceration
Endometrial(old woman)
Endometrial Cancer ◄ >endometrial curettage+biopsy
Endometrial Hyperplasia ◄ >MRI pelvis
Abdomen(ovary)
Ovarian Torsion
Ruptured Ovarian Cysts
PID >cervical culture, ESR, CRP
Others:
DUB◄ >PT/PTT
Coagulation Disorder

History:GI,constitutional symptoms, vaginal discharge/pain, urinary problem

(Others: Pre or post menopausal, content of bleeding, history of IUD/trauma/
abnormal pap smear, OCP use)
PE:HEENT(oral), CV+P, Full abd, Ext

#VAGINAL DISCHARGE Pelvic exam, cervical cultures+KOH prep+wet amount, PH of

vaginal fluid, urine culture
Bacterial Vaginosis (grey-white fluid foul smelling) ◄
Vaginitis – Candida (white cottage cheese odorless) ◄
Vaginitis – Trichomonal (greenish malodorous) ◄
Cervicitis (Chlamydia, Gonorrhea) ◄

History:GI,urinary tract infection/irritative symptoms, vaginal pain/ buring/ pruritis

(Others: history of IUD/OCP/STD)
PE:HEENT(oral), CV+P, Full abd, Ext

#Hot flashes:
History:menopause/ hyperthyroid symptoms, (Others: history of thyroid disease )
PE:Neck(thyroid, LN), CV+P, full abd, Ext(inspection, hyperactive reflexs)
Counsel:
1.Hormone replace therapy, but risk of increasing breast cancer so only used in limited time
2.calcium supplement and weight bearing exercise for prevention of osteoporosis

#Positive pregnancy test: Breast/pelvic exam/Pap smear/cervical Gonorrhea and

chlamydia DNA testing,CBC/glucose/TSH/RPR/rubella igG/HbsAg/HIV antibody, Blood
type/Rh/antibody screen, U/S pelvis, UA+culture/ Urine hCG
Normal pregnancy
Molar pregnancy
Ectopic pregnanacy

History:vaginal bleeding(Others:sexual history including STD+

Postcoital bleeding, fetal movement, feet swelling
Is that planned pregnancy? Want this pregnancy right now,domestic abuse?
exposure to cats,rubella immunization,previous heart problems / Blood
transfusions,Caffeine used)
PE:HEENT(eye for pallor) Neck (thyroid),CV+P, Full abd(and fundal grip)
Ext(pigmentation,swelling, edema and varicose veins)
Counsel:
1. take regular amount of vitamins, Iron supplementations and nutritious diet.
2.You should also come to prenatal check every 1 month.
3.Run some more blood tests, a Pap smear, and some vaginal cultures, pelvic ultrasound
4.stopping alcohol consumption and avoiding intense exercises and excess caffeine
5.Avoid Cat for parasite

#AMENORRHEA pelvic exam, CBC/TSH/FSH/LH, urine hCG, U/S pelvis, MRI brain
Endocrine
Pituitary Tumor ◄ >breast exam/prolactin if prolaactinoma
 Sheehan's Syndrome >FT4, ACTH,prolactin,
Thyroid Disease◄ >FT4
Ob
Pregnancy ◄ >pap smear, cervical culture, rubella antibody, HIV/HBV test, RPR/VDRL
Gyn(Ovary)
PCOS◄ >testosterone/DHEAS
Premature Ovarian Failure
Menopause >DEXA scan, lipid profile
Anovulatory Cycle ◄
Mechanical
Ashermans Syndrome >Hysteroscopy
Others:
Anorexia Nervosa >FT4,ACTH
Exercise induced amenorrhea > >FT4,ACTH
Anxiety induced amenorrhea >FT4,ACTH, urine cortisol level, progesterone challange test

History:MSWC Detail Ob/gyn questions, Menopause, Pituitary tumor symptoms ,fatigue,

(Others:primary/secondary amenorrhea, fat diet/Diet for anorexia nervosa ,Vigorous exrcise)
PE:HEENT(EOM, visual field),Neck(thyroid), CV+P,
Full abd,Ext(inspection, DTR)

Pediatric

#Pediatric:(For smaller child) ON CALL IDIOT, Go A Mile Buy M&M to Family

Opening:Hello, Mrs.XYZ, I am doctor Lin, how are you doing? What can I help you?

Onset:When did it start? Did he have the same problem before?

Number:How often is the pain?Is the problem progressing?
Or can use OPDF(Onset/past experience/duration/frequency)

Content of stool/Crying:Can you tell me more about his stool? What's the color of the stool? How's the
consistency of the stool? Is there any bowel habit change? Is he crying ?any blood
Associated Symptoms? Ex: ,URI:Runny Nose, Ear Discharge ,Ear pulling
LRI:Coughing, Rapid breathing, wheezing(Chest pain)
GI: Vomitting , Diarrhea/Constipation, Difficult swalowling, abdominal distension,
(Abdominal pain)
CNS: Shaking, (Headache)
Skin: rash jaundice
Others:Fever, tireness,crying
Listless/Lethargic baby: How's his energy level recently? Is your child awake and responsive now?
Liquids: Do you notice any change to his urination habits?Is there any color change to the urine?How many
wet diapet in a day?

Immunization: Are your child's vaccines up to date ?

Diet:What's his diet? Is there any change to his diet /appetide? Did you breast-feed/bottle feed your child?
When did your child try solid food?
Is your child's formula fortified with iron? Did you give your child pediatric multivitamin?
Dehydration:How's fluid intake of your child ?(How's his sucking condition now?)Dry mouth or sunken
 soft spot over the head?does he has sunken eyes/dry mouth
Day care:Has he stayed in day care center ?
Infections: Is there anyone around him who has the same problem?How's your immune conditio(HIV mom)
ORS counseling
Travel:Has he travelled recently with family? Does he use a child seat?

Growth: How's his growth?Any weight gain recently?What's his weight/height?

Allergy: Is he allergic to anything?

Mile stone:when did your child first smile?(2months)

->first sit up(6months)
->start crawling(8months)
->start talking(10months)
->start walking(12 months)
->using short setence(2years)
->learn to dress himself(3 years)
->tie his shoes(5 years)

Birth history:Four(full) C
Full:Was your pregnancy full term?
Checkup: Did you have routine checkups during your pregnancy?(How often?Was an
ultrasound preformed? )
Complications: “Did you have any complications during your pregnancy/during your
delivery/after delivery? Does your child have any medical problem after birth?
Cigarette:Did you smoke, drink, or use drugs during your pregnancy?”
C-section:Was it a vaginal delivery or a C-section? is that a normal delivery?

Medical: Did your child have any medical problem after birth? When did he visit physician last time?
Has he been admitted to hospital before? Did she has any surgery before?
Medicine: Is he taking any medinine recently?

Family: Did anyone in your family has the same problem?

Ending:Mrs. XYZ, based in the information you were given, your son right now may be experiencing stomach
irritation/Loose bowel which need medical attention. We have to determine the cause of it. I would like to do a
personal exam on him and perform some basic lab before I can make a definete diagnosis.
Will it be convinient to bring him to the hospital?
If no->Is there any reason why it's not possible for you?
If transportantion problem->Call a cab or 911.
If financial problem->social worker
Ms.XYZ, I want you to know this is for the best interest of your child, I will see you and your child once you get
to the hospital. Take care.

#Pediatric(For biggeer child) Ask like adult LQQ OPERA PAM HUGS FAST+(No Ob/gyn, sexual, exercise,
Soda) +Beg Mi
Birth history(Ask full/complications)
Energy
Growth(weight/height/language)
Milestone
Immunization
#CHILD FEVER Physical exam, CBC/electrolytes/blood culture
Sepsis
Neonatal Sepsis◄ UA/Urine culture,CXR, LP
HEENT
Acute Otitis Media >pneumonic otoscopy
Respiratory
Pneumonia >CXR
URI ◄ >throat swab for culture
Rash
Viral exanthema(Rubella, Roseola, Scarlet Fever, Varicella,Fifth disease) >throat culture,
parvovirus B19/varicella antibodies, skin lesion scrapings
Meningitis >LP, platlet, PT/PTT/D-dimer/FDP/fibrinogen(for DIC)
GI
Gastroenteritis >stool exam and culture, AXR
Food Poisoning >AXR
Volvulus > AXR
Urinary
UTI ◄ >UA/Urine culture

#Child has diarrhea: CBC/electrolytes/Rotavirus enzyme immunoassay/Blood

cultures,Stool leukocytes+culture+ova+parasite+pH, UA, AXR
Rotavirus ◄
Bacterial diarrhea ◄
Malabsorption ◄
UTI ◄ >UA+culture
Intussusception◄
Bacteremia

Histroy:Number of wet diaper, (Others: Relationship to oral intake)

#Child diagnose with DM Glucose/electrolytes/HbA1C/insulin/C-peptide level, islet cell

antibody, UA+microalbumin/24 hours free cortisol
Type 1 DM
Type 2 DM
secondary DM
Dysmetabolic syndrome X
Prader willi syndrome

History:DM constitutional symptoms, insulin questions Tingling or numbness in limbs,

Infections of skin/gums, Itchy skin, LOC (Other:Blood sugar: Has low blood sugar?
Effect on parents/child, weight and height, Any specific diet,
Exercise and playful activities, mood,Sleeping problems)
Counsel:
1. combination of insulin, balanced diet and regular exercise
2. Attend diabetes class with your daughter
3. Recognize sign of low blood sugar and carry glucose tablet/fluit juice as emergeency kit
#Jaundice in child Tota/indirect bilirubin/Blood typing/Direct Coombs’ test, CRP/CBC
Titers for CMV, toxoplasmosis, and rubella
Physiologic jaundice ◄
ABO or Rh incompatibility ◄
Neonatal sepsis
Breast-feeding jaundice ◄
Cephalohematoma ◄
Polycythemia
Familial neonatal hyperbilirubinemia ◄

HistoryBowel: Color of stool/Blood in stool, Frequency of bowel movements,

, Urinary frequency, urine color (Others:Parts of body
involved,Mother/father/baby blood type ,Ill contacts, sister/brother ill
Other pregnancies/miscarriages)
Counsel
1.Naturall jaundice most obvious on day 4-5, and disappear oveer 1-2 weeks
2.Breast Feeding and some birth defect can also be the cause
3. Pigment level too high can cause damage of brain

#Child with stridor CBC/DC/ABG ,XR—neck/chest, AP/ lateral, Direct laryngoscopy/

Bronchoscopy
Infection
Croup ◄
Laryngitis ◄
Epiglottitis ◄
Retropharyngeal abscess/Peritonsillar abscess ◄
Non infection
Angioedema
Foreign body aspiration ◄
Laryngeal papilloma

History:Drooling, Sound of cough(barking) /voice(Hoarseness) /stidor, Snoring,

Crying (muffled or weak), Blueness of skin or fingers
(Others: Best heard on inhalation/ exhaling air, activity that procede the
event, History of allergies in the family, stress)
Foreign body aspiration Counsel
1.Dont put finger into his mouth
2.Heimlich maneuver,standing at his back, thrusting tummy with sudden pressure

#BEHAVIORAL PROBLEMS Physical exam/Mental status exam/Urine toxicology

ADHD
Adjustment disorder
Age-appropriate Behavior
Conduct Disorder
Manic episode
Oppositional Defiant Disorder
Substance abuse
 History:ADHD symptoms, severity, triggers; physical violence ,use of weapons;
substance use, developmental history, changes in environment(child abuse),
school performance, relationship with classmates/parents, mood/sleep

#Picky eater: CBC/TSH/lead level/electrolytes

Selective Eating Disorder
Lead poisoning
adjustment disorder
Hypothyroidism
ADHD

History:diet? any specific food? schedule of the meal? High caroli drink between the meal?Any
sneaks between meal?stress on family/him? Activity doing before/during meal? Any dessert
served during meal? Reward/ punishment?Appetite, weight change, abdominal symptoms, old
house for lead poisoning, conflict in the family, relationship with people/parents
Counselling:
1.The key to coping with a child's picky eating is patience
2.Avoid giving your child food between the scheduled times.
3..Set a Meal Schedule
4.Dont punish, bribe or reward their children's eating behaviors
5.Be patient with new foods
6.Don't Always Offer Dessert
7.No juice, milk and snacks for at least one hour before meals
8.Mealtime conversation should be pleasant, Mealtime is not a time for watching television or
arguing.

#Bed wetting Genital exam, UA+culture, First-morning urine specific gravity, U/S renal
Urinary
primary nocturnal enuresis ◄
Secondary enuresis ◄
Functional bladder disorder◄
Urinary tract infection ◄
Others
Constipation ◄
Sleep apnea ◄

History:Primary or secondary ?Punished /rewarded him? Stress/sleep/snore/support

Urinary symptoms(Infection /irritative and urine color change) ,volume of urine/fluid intake/late
night drinking,
Frequency of bed wetting/go to toilet, Nighttime awakening, daytime bed wetting, new
environment,behavior affected child/parent?Neurological development abnormality?
Counsel:1.No punishing ,praising and rewarding him if he stays dry while sleeping.
2.monitor your child's drinking habits before going to bed and encourage the child to go to
bathroom before going to bed.
3.We also need to do some tests to rule out other conditions.
 Phychiatry

#anxiety+ SOB CBC/TSH, EKG , TSH, Urinalysis, Urine Tox screen

Phychiatric
Hypochondriasis
Panic attack◄
Generalized anxiety disorder ◄
Adjustment disorder
PTSD
Substance abuse
Malingering
Medical
Hyperthyroidism ◄
arrhythmias, ◄
pheochromocytoma ◄
Anemia

History: CV symptoms,Pulmonary symptoms, hyperthyroid symptoms,

feelings of terror ,sweating, headache for pheochromocytoma
(Others: family support, restriuction of activity)
PE:HEENT(eyes/mouth), Neck(thyroid/LN), CV+P, Ext(Tremor)

#DEPRESSED MOOD Physical exam, Mental status exam, CBC/TSH, urine toxicology
Phycological
Major Depressive Disorder◄
Bipolar Disorder
Cyclothymic Disorder
Dysthymic Disorder ◄
Schizoaffective Disorder◄
Emotional trauma
Normal Bereavement
Adjustment Disorder ◄
Substance/endocrine
Substance Induced Mood Disorder
Hypothyroidism◄

Ask MS .WC+SIG E CAPS in Depression case

Sleep: how's your sleep recently?

Interests:What's your hobby? Do you still find them interesting?
guilty: Are you feeling guilty about things?
Energy:How's your energy level recently? Have you been experiened good mood followed by depressed
mood?
Concentration: Do you have trouble concentrating?
Appetite/Attention(Memory):How's your appetite?How's your memory?
Performing job/Pistol:Do you have any problem performing jobs?Do you have any gun in your house?)
Suicide/Support/Schizophenia:Have you thought of ending your life? Is there anyone you can talk to when
you are feeling down?Do you see or hear things that other people dont?
(Life/libido:Do you feel life worth living?How's your sexual desire level?)
If no time, ask GCS (Guilt, Concentration,Sleep/Suicide)

PE:HEENT(eye/mouth)Neck (thyroid), Neuro(only MMSE, reflex), CV+P

Counsel:1.make an appointment with our counselor, may refer to phychiatrist
2. spend more time with support system(friend/family), and give telephone number of support
group
3. write you a prescription for an antidepressant.
4. seek medical attention when feel like hurting yourself

#INSOMNIA CBC/TSH/electrolytes, polysomnography

Without fatigue
Stress–induced
Caffeine-induced >urine toxicology
hyperthyroidism◄
With Fatigue
Sleep Apnea ◄
Primary Hypersomnia ◄
Major depressive disorder ◄ >MSE
Circadian Rhythm Sleep Disorder ◄

Mnemonic: Daytime Dancing Before Sleep Bothering Sleep Pattern

Definition: Do you have any problem falling asleep? Wake up many times in the night ?
wake up very early in the morning?
Daytime:Do you feel sleepy during the daytime? Do you take daytime naps?Snoring?
Before Sleep:What activity do you usually do before you go to sleep?
Do you drink coffee/smoke/alcohol before you go to sleep?
Bothering:Anything bothering you while you are sleeping? Is there any nightmare/coughing/SOB
/ urge to urinate/Pain keep you awake?
Symptoms/stress:Urinary/bowel movement, Hypothyroid/hyperthyroid, mood, stress?
weight/appetite, morning headache
Pattern/Pills: How many hours do you sleep? What time do you fall asleep? How long does it
take to fall asleep?Has there been any change to your sleeping pattern? Do you take any pills to
help you sleep?

PE:HEENT(mouth)Neck(Inspection/palpation/auscultation of thyroid,LN),CV+P,,Abd,
Ext(tremor,edema, reflex)

Counsel:
1.Keep regular bedtime and awake time
2.no use of alcohol/caffeine/nicotine
3. use the bedroom only for sleep,no worries on the bed,
4. no daytime naps
5. exposure to sunlight in late afternoon,

#PSYCHOSIS Mental status exam, CBC/TSH/Electrolytes, urine toxicology

Without depressive mood
Schizophrenia (>6months)◄
Brief Psychotic Disorder (<1 month)
 Schizotypal Personality Disorder ◄
Schizophreniform Disorder (1-6month)◄
With depressed mood
Depression with Psychotic features ◄
Schizoaffective Disorder
Medical problem
Psychotic Disorder due to Medical condition ◄
Substance – induced Psychosis◄ >LFT,BUN/Cre

Hallucinations questions:
Did you see/ hear things that other dont?
Did you feel/taste/smell anything strange recently?
Did you see things when eyes are closed?

Schizophrenia questions: (Control beliefs harm motivation)

Do you feel like being controlled?
Do you have any beliefs that others may think strange?
Do you feel that others want to harm you?have you been thinking about harming yourself or others?
does the voice call you to harm others?
Do you feel you lose motivation and dont want to contact with people?

Life: Is the problem affecting life/ job? Have you been thinking about harming yourself or others?

Symptoms: CNS: Headache/head trauma? Do you have any vision/ hearing/speech problem?
Sleep/mood:Any problem related to sleep?

(Others: stress/traumatic event, mental illness in past history/family history )

PE:Full Neruo( MMSE first),HEENT(Inspected pupils reactivity),CV+P, abd

Counsel:peer support group, psychiatry counselling, interview close friend and relative

Abuse/Assult

#Abuse: Mnemonic: SAFEGARD

I dont know if this is a problem for you, but I have seen so many people are dealing with abusive relationship,
I'm going to ask this question routinely, are you in a relationship which you are physically hurt, threatened, or
feel afriad?

Stress&safey:Do you have any kind of Stress in your relationship?Do you feel safe at home?
Afriad/abuse of child:Are you afraid? Has your partner ever physically abused you or your children?
Family&Friends your family or friends aware of this? Can you tell them?
Can they can give you support?

Emergency:Do you have an emergency plan? a place to go?

Would you like to talk to a social worker to develop an emergency plan?
Gun :Is there any gun at home? Have you been thinking about harm yourself or suicide?
Alcohol:Is there any alcohol or drugs involved?
Relationship with spouse.
Depression How's your mood?
 Domestic violence counsel:
1.I understand your situation, I can give you the contact number of social service who
can help you
2.I will do everything I can to maintain your safty
3.The violence never ends on it own, it will get worst over time, the only way to end the
abusive relationship is to get away with the abuser.
4. I will reaassure everything we discuss today will keep confidential
5.We have wonderful domestic violence conseller who can solve your problem if you
doesnt come out with an emergency plan or have no saft place to stay.
6. have to let child protective service involved because your child can’t grow in a violent
enviornment

Elderly abuse counsel:

1.understand that you want to keep family affair under cover, but usually the family
problem could be worse and worse if we don't stop at at right time,it’s my duty to let the
adult protective services know, I will give also give you their phone number to you too.
2.moving to an apartment complex for seniors?

#Rape:Pelvic exam, HIV antibody/VDRL/HBV antigen, Wet mount, KOH prep/cervical culture/Evidence
collection, Urine hCG, XR—skeletal survey/CXR
Domestic Violence ◄
Osteogenesis imperfecta ◄
Substance abuse ◄
Consensual Violent Sexual Behavior ◄

Incidence: Incident location? Did you recognize the assailants? Did you report the incident?
Assult: Description of the assault? objects assault or sexual assault?
Sexual:Did they use condoms?Did ejaculation occur?Any foreign objects used?What type of intercourse
(oral, vaginal, anal)?
Symptoms:Bleeding(Vaginal bleeding, Bleeding or bruises, Blood in stool/urine), CNS symptoms after
trauma(see below), System review symptoms

HEENT(eye, mouth), CV+P, full abd, Ext(the bruises)

Counsel:
1.collect some specimens and swabs from your body and genital area,
2.look for STDs,pregnancy test,emergency contraception. antibiotics to protect you from infections.
3.social worker come talk to you and provide you with phone numbers for support groups

Constitutial Symptoms

#NIGHT SWEATS CBC/ESR/blood cultures/TSH, CXR, PPD

Infection
Tuberculosis ◄
Acute HIV Infection◄ >HIV antibody
Endocarditis
Endocrine
Hyperthyroidism ◄
pheochromocytoma◄
hypoglycemia
Neoplastic
Lymphoma◄ >CT chest/abdomen
Leukemia◄ >CT chest/abdomen
solid tumor >CT chest/abdomen
Rheumatology
RA, lupus, Temporal artheritis
Others:
Drug induced

History:constitutional/hyperthyroidism/TB/oncology symptoms/menopause, recent URI, rash

(Others:ill/TB contact, HIV risk,LMP for menopause)
PE:HEENT(nose, mouth), Neck(LN, thyroid), CV+P, abd(liver, spleen),
Ext(joint pain, tremor, Janeway lesion, osler node)

#FATIGUE & SLEEPINESS

Phycological
Chronic Fatigue syndrome
Depression
PTSD◄
Cancer
colon cancer◄ >colonscopy, rectum exam, FOBT, barium enema
Metabolic
Hypercalcemia
Diabetes Mellitus
Hypothyroidism ◄
Sleep
Obstructive Sleep Apnea >Nocturnal pulse oximetry, polysomnography
Sleep Deprivation
Narcolepsy
Infection
HIV
Hema
Anemia ◄

History:MC.WC ,associated event, progression during the day(about visual change for MG),
affecting job/performance,(Others:history of bleeding/anemia, diet, exercise too much)
PE:HEENT(conjunctiva,mouth),Neck:(thyroid, LN),CV+P,Full abd,Ext(DTR/edema)

#WEIGHT GAIN CBC/glucose/TSH/lipid, urine cortisol/hCG, dexamethasone suppression

test
Endrcrine
Hypothyroidism ◄
Cushing’s disease
Diabetes mellitus ◄
familiar obesity◄
ObGyn
Polycystic Ovary Syndrome
Pregnancy◄
Phychiatric
Atypical depression ◄
Substance intake
Smoking cessation
Drug Side effect

HistoryMS.WC, increase body hair/ voice change,detail MC/ pregnant history(for PCOD),
(Other: vascular risk factor,steroid use, medication change,smoking cessation)
PE:HEENT(conjunctiva,mouth),Neck:(thyroid, LN),CV+P,Full abd,Ext(DTR/edema)

#WEIGHT LOSS TSH/CBC/electrolytes/HIV antibody

Endocrine
Hyperthyroidism ◄ >FT4
GI
Anorexia nervosa >FT4/ACTH/FSH/LH
Dieting / Drugs ◄ >urine toxicology
Malabsorption ◄
Malignant condition
Cancer◄ >depends on what kind
HIV Infection ◄
History:MSWC constitutional symptoms, oncology, anorexia nervosa questions, diarrhea
(Others:HIV risk factors)
PE:Neck(thyroid, LN), CV+P, full abd, Ext(inspection)

Others

#DM drugs refills::

History:DM complication symptoms, weight/appetite change,night sweats
(Others: Medication questions ,history of hypercholesterolemia/heart/stroke/HTN,
last visual check)

PE:HEENT (fundus),Neck(Carotid bruit) CV(+PMI)+P, Ext(pulse),

Neuro(Muscle power, sensation, DTR) ,

#Hypertension follow up
blood pressure of both arm, CBC/sugar/electrolytes/lipid profile, UA

History:HTN complication symptoms, legs or buttock pain,weight/appetite change

(Others:history of hypercholesterolemia/ heart problems/ stroke/DM)
PE:HEENT (fundus),Neck(Carotid bruit) CV(+PMI)+P, Ext(pulse),
Neuro(Muscle power, sensation, DTR)

#ERECTYLE DYSFUNCTION genital exam, rectal exam,

FSH/LH/testosterone/Glucose/prolactin/TSH, MRI brain, U/S doppler penis/dynamic
carvenosography
Drug related ED ◄
ED caused by Vascular disease◄
Psychogenic ED ◄
hypogonardism◄
peynonie’s disease◄

History: mpotence severity,sexual desire, early morning/Noctural erection,

ejecculation ability CNS:urine/stool incotinence, legs weakness/numbness, headache(pituitary
tumor) (Others: History of vasular risk factor/trauma, mood, stress)
PE:Neck(Carotid bruit) CV(+PMI), Ext(pulse), Neuro(Muscle power, sensation, DTR)

#Terminal cancer:
History:symtoms specific questions, (Others:mood,sleep, Hospice care/living will)
PE:HEENT(eye for pale conjunctiva,jaundice ), Neck(LN), CV+P,
full abd(liver, spleen)
Counsel:
1.Hospice care is a multifuntional group of people who is going to take care of you physically,
emotionally and spiritually, they can be provided at your home to make you as comfortable as
possible
2.Living will enable you to live the way you wanted when you reach to terminal stage, also you c
an give the right to make decision to your loved ones.

#MVA with chest pain Blood alcohol level/ ABG, CXR/KUB,Urine toxicology ,CT
abdomen,
Pneumothorax ◄
Hemothorax ◄
Rib fracture ◄
Splenic rupture ◄

History:system review /CNS symptoms after trauma

(Otheres:other trauma, Last meal/drink, under influence alcohol or recreational
drugs right now?)
PE:HEENT(head inspection,palpation,mouth,
eye for anemia), CV+full P, full abd(liver/spleen palpation),
Neuro(Mental status, cranial nerves, gross motor), Ext(Inspect/palpation)

#Pre-employment medical checkup:

History:system review /CV symptoms,CNS(Loss of
consciousness/seizures Weakness/numbness), Joint pain or swelling,
Change in stool color, (Others: Vaccinations)
PE;HEENT(mouth), Neck(carotid pruit,LN),CV+P, full Abd,
Ext (inspection) Neuro(CN, motor, DTRs, gait)

#HIV drug refill CBC/DC, CD4,viral load, CXR, LFT (Zidovudine Toxicity)
D/D depending upon case ( PCP, Candida infection, CMV Retinitis, esophagitis)
History:drugs problems, system review, eye problems, oral ulcers and white patches ,
swallowing , skin problems and rash ,genital problems,mood (Others:support ,vaccinations )

#Alcoholism CBC/LFT/rGT
History:CAGE+marital, finantial, sexual/family/work
PE:HEENT(conjuntiva/sclera, oral), CV+P, Abd, Ext(edema)

#Rash
History:tenderness/numbness/itching/buring on rash, progression of rash, joint pain, oral ulcer,
other SLE symptoms, sick contact