PSA PROSTATE

CVS BLOCKS

1) OCD

2) CVS BLOCKS

1-Chest pain
2-cough
3-SOB( were you able to speak, did you turn blue, hospital admission, how many
pillows you sleep on)Do you sometimes wake up at night opening the window
looking for air
4-have you felt like you heart racing
5-have you ever passed out
6-any ankle swelling
7-Pain in your leg, weakness in limb, loss of sensation
8-how many blocks before you get chest pain or leg pain
9-Abdominal pain
10- Any sweating
11-erectile dysfunction

3) General Qs

HTN
DM
DLP
Smoking
Alcohol
Drugs
family history
weight
diet
exercise
stress
 If yes..since when? Do you take medication? Regularly? When was the last check
up?
Smoking…how much/ how long

Respiratory blocks

1-Chest pain
2-cough
3-SOB (were you able to speak, did you turn blue, hospital admission, how many
pillows you sleep on)Do you sometimes wake up at night opening the window
looking for air,
4-Noise in your chest (wheezes)
5-URT: redness of eye, discharge, ear pain, ear discharge, running nose, face pain,
do you need to clear your throat (post nasal drip), sore throat
6-Horsenese of voice
7-Swelling of joints
8-Skin rash
9-AIDS (Diarrhea, lump and pump, oral ulcers, do you know ur AIDS status)
10- Allergy
11-Occupation

General Q

CVS exam

4 steps
1) Face:
No face swelling, no pallor. I need to do opthalmoscopy
2) Mouth:
Dehydration, no central cyanosis
3) Hand: regular, symmetrical normal volume of pulse, clubbing, peripheral cyanosis,
capillary refill
 4) Neck: examine the carotid. First auscultate then say no bruit and then palpate it.
Check for JVP normally
Kussmual sign
check for hepatojugular reflex by pressing the liver.
5) Inspection: normal shape, no deformity, no visible pulsation, no scar, symmetrical
chest wall movement, no use of accessory muscles
6) Palpate: palpate apex beat and comment on the location of and say point of
maximum intensity in the left fifth intercostals space MCL localized not displaced,
no tenderness, no thrill
7) Auscultate: Check mitral , tricuspid , pulmonary and aortic area and comment, in
all above mentioned areas, S1 and S2 normal , no S3 or S4 , no murmur then turn
the patient towards left lateral position and check for mitral lesion with bell, no
murmur of MS and listen to aortic area by bending forward, breath out and put the
stethoscope on the chest, no murmur of AR
8) Listen to back of lung no cackles of Pulmonary edema
9) Auscultate abdomen for aortic, renal bruit, iliac.
10) Leg: edema, posterior tibial and dorsalis pedis.

Respiratory Exam

4 steps

1) Face:
No face swelling, no pallor, red eye, eye discharge
2) Mouth/ nose/throat
Dehydration, no central cyanosis no running nose, no ear discharge, no face
tenderness
3) Hand: regular, symmetrical normal volume of pulse, clubbing, peripheral cyanosis,
capillary refill
4) Neck: examine LN, Trachea, Veins
 5) Inspection: normal shape, no deformity, no visible pulsation, no scar, symmetrical
Wall movement
6) Palpate: Tenderness, expansion, TVF
7) Percussion
8) Auscultate: + adventitious sounds
9) Leg: edema

48yr old Mr Robert Jefferson comes to you office with chest

pain . Take a focus history .

1) OCD+ Pain( Is it related to particular time of the day, Is it related to certain

position) how long does it usually stay?
2) CVS block(cough, shortness of breath, feel heart racing, How many blocks before
you get chest pain, weakness and loss of sensation in leg, erection , empathy , leg
pain abdominal pain any sweating, passed out
3) ask for panic attack), stress, psychiatric disease, sudden intense fear of something
like going to closed places
4) General Qs
Medication (nitrates, Viagra)
and duration of DM. HTN, DLP. Smoking and alcohol.drugs, family hx.of heart disease
Diet and exercise.

D/D :
1) IHD
2) Pericarditis
3) Musculoskeletal
4) GERD
5) Pleurisy
6)Panic attack

What investigation you want to do.

a) EKG
 b) Chest X-ray
c) Lipid Profile
d) Cardiac enzymes

Treatment;
a) Diet, exercise and weight reduction, stop smoking, control HTN, DM
b) Aspirin.
c) Nitrogylcerin.
d) Betablocker.

Mrs Suzane Miller 30 yr old comes to your office feels her

heart racing. Take a focus history.

1) OCD( How does it feel like, can you show me on the table )
2) D/D :
a) Arrythmia ( chest pain, SOB, leg swelling, cough if positive then ask for
whole CVS block) ask him do you have heart disease ..i have MS
b) Thyroid question( does heat and cold bother you more than usual, did you
loose wt inspite of good a appetite if yes then ask all hyperthyroid questions
like mood swings, any change in bowel movement, any difficulty in
swallowing,any double vision, any difficulty in sleep, abnormal movement
of hand, how is your menstruation?
c) Anemia: Does any body around you notice you are looking pale, any black
stools recently? Recent bleeding, dizziness
d) Hypoglycemia:When it happens do you get sweaty and notice trembling of
hands, headache
e) Pheochromocytoma: Headache, sweating and high blood pressure.
f) Panic attack: Do you get sudden onset of intense fear or discomfort, stress,
psychiatric disease, do you have fear of going to closed places, detached
from body
g) Infection: fever
 h) Medication
i) Coffee
j) Alcohol
k) Cocaine
l) Pregnancy, LMP
m) Dehydration: any vomiting any diarrhea

3) General Qs
Smoking, alcohol, Medication
Caffeine and cocaine intake, family history heart, thyroid, psychiatric, diet ,
exercise, stress

Investigations (arrhythmia )
n) EKG.
o) Holter monitor.
p) T3, T4 TSH.( if hyperthyroidism is the primary cause then thyroid profile
first and then EKG)

Physical exam (Thyroid + CVS)

4 steps
Face: no puffiness of face, no pallor, Look for eye changes from the side.( exophthalmos)
Ask the patient to follow your finger.(lid lag and lid retraction),opthalmoscopy( for roth
spots of infective endocarditis)

Tongue: no central cyanosis, no dehydration

Neck: Carotids, JVP, LN

Thyroid exam
Inspection: Can you swallow please, no swelling of neck
Palpation: Palpate one lobe by stabilizing the other side and ask to swallow repeat the the
same procedure on other side and say no thyroid enlargement and no nodules, smooth
surface
Auscultation: auscultate for carotid bruit and thyroid bruit.
Hand: pulse, capillary refill, clubbing, peripheral cyanosis and no sweating, no tremors.
CVS as usual.
Lung: listen to back of lungs for pulmonary edema
Abdomen :aorta, renal
Leg: edema, pulse

This case can also present as nurse in your office showing EKG with atrial
fibrillation. Now take history and do physical exam

We received the results of the test that measures your electrical activity of the heart
If irregular pulse…pulse deficit

72 yr old Mr David Miller . He had syncope and now he is fine

Take focused history

How do you feel now?did you hurt urself?

Dr I have fainting spell at home.
How did it start?
All of a sudden
When did it start?
This morning.
What were you doing when it happened?
Any bad news (vaso vagal)
Any body around you at that time
Did you loose consciousness?
Before the attack
Any blurring of vision
Any bad news
Any abnormal movement
During the attack
Were you able to hear voices?
Bite your tongue
Loss control of urine
After the attack
Were you confused?
any weakness and loss of sensation?

D/D
1) Do you have epilepsy or seizure
2) Hypoglycemia( Headache, trembling and sweating)
3) Vasovagal( any bad news)
4) Any diarrhea any vomiting, bleeding (for dehydration)
5) Ear pain, ear discharge ( inner ear)
6) How is your vision
7) Any recent bleeding,Any black stools, dizzy, heart racing( anemia)
8) Difficulty in speaking and difficulty in swallowing( Stroke)
9) How is the relationship between you and your partner?

Heart Blocks

General Qs; Fhx of heart disease, medication( thiazide ,digoxin, beta blockers,
amitryptylline)
She has cataract as well
The patient will I am fine, can I go home?

Initial investigation;
EKG= 3RD degree Hear block.
The PR interval will be variable, as the hallmark of complete heart block is no apparent
relationship between P waves and QRS complexes.

Investigation
1) EKG
2)24 hr holter monitoring
3) Carotid Doppler
4) Echocardiography.
5) Blood sugar
6) CBC
7) INR, PTT

TTT: Pacemaker

Physical Examination

1) 4 steps( B.P in both UL and LL while lying and standing) it was positive
2) Face: puffiness of face, asymmetry of face, dropping of mouth, pupils, tongue for
central cyanosis and dehydration , ear for discharge and I want to do otoscopy)
3) Neck: Carotids , JVP.
4) Hand; pulse, capillary refil, clubbing, and peripheral cyanosis.
5) Heart+ back of the lungs+ vessels
6) Neurology: Facial nerve and som neuro.
7) Legs for lower limb edema, pulses

Give me one physical sign to confirm ur diagnosis?

Diagnosis?
Management?

Postural hypotension: A drop in blood pressure (hypotension) due to a change in body position
(posture) when a person moves to a more vertical position: from sitting to standing or from lying
down to sitting or standing.Postural hypotension is more common in older people.

Lifestyle factors
Standing up more slowly
…adjusting the dosage or by discontinuing the medication.
Maintaining an elevated salt intake
Maintaining proper fluid intake

Risk factors:
1- Medication
2- Cataract
3- DM, HTN

24yr old nancy lorsik present to your office after checking her
BP in the pharmacy.She is concerned about her BP. Take a
focused history and do a focus physical exam

How can I help you

Is it the first time you measure your B.P
Did you have any bad news before you check your BP.?
Did you take caffeine before checking you BP.?
R u known to have high B.P.

Specific Symtoms
Headache
Blurring of vision
Heart Blocks
Any weakness or loss of sensation
Any kidney disease, any frequent urination. Swelling on the face.

Causes
Does heat or cold bother you more than others?
Do you have recent change in wt., abnormal movement
Abnormal hair distribution(cushing)
Any striae on your abdomen(cushing)
Any steroid use(cushing)
Any menstrual irregularity(cushing)
Any sweating or palpitation( pheochromocytoma)
Change in size of hand , nipple discharge ( pituitary tumor)
How’s your diet
Do you exercise.
stress

General Qs
Medication: NSAIDS, OCP, Decongestant.
Family Hx of HTN

Counseling
If the patient asks you do I have high B.P.? With one reading I cann’t say. I need to
examine you. I need to take your B.P 2 more time at the same visit and further over the
next 6 months. Most of the time we couldn’t find any cause and in your case I couldn’t
find any cause or I did find a cause. I am going to send you for some investigations as
well.

Investigation; ( HTN for first time)

1) Urinalysis
2) Renal Doppler
 3) Renal function test
4) Lipid profile
5)ECG
7)B.S
8) TSH, T3 T4
9) dexamethasone suppression test for cushings

Physical exam (follow-up)

1) 4 steps( B.P may not be given by the examiner so check B.P as palpatory method
and auscultatory method)
a) Palpatory method; palpate radial pulse and then inflate the cuff. When you
inflate the cuff ask the patient is it too tight for you and give the reading to
the examiner. By palpatory method systolic is……
b) Auscultatory method: Now first locate the biceps tendon and brachial
artery and then put the stethoscope in b/w them and inflate the cuff 10 mm
hg above the SBP found in palpatory method and record the B.P and
comment on the B.P.
c) I need to measure BP in both UL LL, lying down and standing
2) Face; swelling, pallor. Pupils (in neuro) and I need to do opthalmoscopy.
3) Tongue: central cyanosis, dehydration
4) Hand: clubbing, pulse and capillary refill, peripheral cyanosis
5) Neck: JVP, Carotids
6) Heart as usual
7) Aorta and renal, iliac bruit
8) Legs( edema and skin changes like loss of hair and darkening of skin), dorsalis
pedis, post tibial
9) Some neuro; motor and sensory exam, reflex

If the patient comes for first time then add thyroid examination and cushing signs
( buffalo hump, abdominal striae,abnormal fat distribution and moon face).
Next step:
1-Measure BP 3 times over next 6 months, ambulatory measurement
2-Investigations(including renal investigations, lipid profile, TSH, cushing
investigations)
Examiner asked causes of secondary hypertension
3-Life style modifications (weight, smoking, exercise, diet, avoid stress)
4-Medications if needed

32 y old J.A. had cough with green sputum and fever. Do a focus
physical exam – 5 min.

Do the chest examination (case of pneumonia)

- Physical exam of chest

- Will receive in post encounter an Chest X-ray
o Comment: chest x-ray of name of pt
 Taken in..date
 AP or LAT
 Trachea is central
 Cardiac shadow in normal range
 Costophrenic angle is free
 Diaphragm is normal
 No fracture of the ribs
 There is opacity in the …. Suggestive of pneumonia
- What’s the treatment: Azitromycin – with doses and time Azithromycin 500 mg
PO once daily for 10 to 14 days
- What’s the diagnostic: community acquired penumonia
- Most frequent organism: S pneumoniae (penicillin-sensitive and -resistant
strains), H influenzae (ampicillin-sensitive and -resistant strains), and M
catarrhalis (all strains penicillin-resistant).
HIV positive patient with 1 week of cough. Do focus physical exam – 5 min + post
encounter probe

- Physical exam – as usual for chest and add: tongue – no ulcers, no leukoplakia;
neck – lymph; nodes; hand – no Kaposi sarcoma; + palpate liver and spleen; + leg
edema; + I need to examine genitalia as well
- Post encounter probe: - receive a X-ray – comment: as usual + fine reticular
pattern in left or right lobe
o Dg: pneumoccistis carrini pneumonia
o Dg dif: mycoplasma; CMV; Chlamydia; TB
o Investigation: sputum culture; CBC; CD4 count; TB stain; sputum
cytology
o Treatment: - trimethoprim sulfamethoxazol – check doses, rhythm, periods
Patient 60 y old has sudden chest pain after 1 week of radical
prostatectomy (or gastrectomy). Take focus history and physical exam
in the ER. It’s not managed!!

OCD chest pain +

CVS blocks..he will say cough blood then COCA…B+ severity,
+ Specific Q for coagulability: why surgical intervention – cancer (hypercoagulability)
did you move early after surgery? Do you take blood thinners? Any pain in your leg?
Any swelling in your leg?

Q for DD:
any psychiatric disease?; intense fear of close spaces?; kidney disease?; liver disease?;
general question as usual
Physical exam:
- 4steps
- face
- hand
- neck
- chest (lung + heart)
- inspection of chest
- palpation of chest (TVF, tenderness, trachea);
- percussion lung
- auscultate – lung, back lung
- Palpate heart: point of max intensity, thrill,
- Listen to heart
- Leg:
- Inspection:
- no swelling
- no erythema
- Palpation: no tenderness
 - normal temperature
- no edema
- measure calf circumference
- pulse
- Homans sign

Investigation: ECG,V/Q scan spiral CT, cardiac enzyme, chest X-ray, ABG, Doppler leg,

Robert Jeff 48 y old comes with chest pain. Take focus history 5 min + Post
encounter probelem
- You have already this case
- Add: what if they give you an ECG to comment. If the diagnosis is panic attack
then ECG normal. If unstable angina – comment the rhythm, rate, qrs aspect, p
aspect and ST – depression ( we need to search how to simple comment an ecg)

Lady 48 y old obese with chest pain and pain increase by lying down  GERD
- Physical exam or history or both as before
- One investigation only – ECG

60 y old, left side chest pain after accident and bruises in his chest wall
- Focused history focused Physical exam as before (chest and heart)
- Question: - what’s the investigation
o – ECG – will be normal
o - chest X-ray – will be normal
o Cardiac enzyme
- Next step? – examine the patient – exam will be normal
- Next step? – send home; give pain medication; advice if he has chest pain to come
back to emergency – maybe the pain will be from a M.I. and not related to the
accident = preventive measure
Calf pain on walking a block

D/D
a) Chronic arterial insufficiency
b) Disc herniation
c) Peripheral neuropathy

OCD+ Pain (what were you doing when it started)

Specific Qs
a) Reproducibilty: How many block you walk before you develop pain. Every time you
walk one block you have the same pain?
b) Paresthesia: loss of sensation and numbness.
c) Do you have rest pain.
d) Do you have pain at night.
e) Any leg ulcers and skin changes( if ulcer is present ask does it take longer for ulcer
to heal)
f) Loss of hair of leg or nail changes.

CVS Blocks
Do not forget carotid passed out, blurring of vision
Do not forget erection

Risk factor( with analysis)

a) HTN
b) DM
c) DLP
d) Smoking
e) Alcohol
f) Diet
g) drugs
h) Exercise
 i) Family Hx of heart disease
j) weight
k) Stress

General Qs

Physical exam
1) 4 steps
2) Legs
a) Inspection: no swelling, no erythema no pallor, no atrophy, no deformity,
no skin changes, no hair loss, no nail changes, no ulcer. (by heart)
b) Palpation: normal temperature , no tenderness, no edema and normal
capillary refill, feel pulses
c) Measure the circumference( will be less than normal)

3) Special test: Rubor test: Elevate both legs 70 degree then ask the patient , do you
have any pain , numbness and no color changes and now bring the patient in the
sitting position and say no dusky red color on dependency.
4) Homan’s test
5) Face: puffiness of face, no pallor.
6) Tongue: no central cyanosis and dehydration.
7) Neck: Carotids + JVP.
8) Hand: pulse, clubbing, peripheral cyanosis,
9) CVS: Heart + other pulses
10) No swelling of joints, knee (rupture becker cyst)
11) Some neuro: motor , sensory and reflexes in legs

What is your next step

1) Ankle brachial index
Systolic B.P in ankle
Systolic B.P in brachial
 >0.9 = normal
<0.9-0.5= intermittent claudication.
<0.5-0.3= Pain at rest
<0.3= gangrene
2) Doppler ultrasound of leg.
3) Lipid profile.
4) Blood sugar.
5) CT angio

Management:

1- Vascular consultation
2- Smoking cessation
3- Regular exercise, which is essential for patients with mild-to-moderate PAD
4- Heart-healthy diet, low in saturated fat, to reduce unhealthy cholesterol levels
5- Medications to help control high blood pressure and cholesterol. Other drugs that
may help include antiplatelet medications to prevent blood clots.(statin, ASA,
Plavix)
6- In severe cases, procedures may be needed to open blocked blood vessels.
(bypass, angioplasty+ stent)

Examiner can give you EKG which can have ischemic changes (ST depression)
37 yr Jack Anderson cough blood in the morning, patient on
coumadin . Take a focus history and focus examination

How do you feel now

I understand you coughed up blood in this morning
R u sure you coughed up blood or through up blood,
What is the color of your stools?..normal

1) OCD
2) COCAB+ Severity
3) D/D
a) Do you have chest pain, SOB, Cough , wt loss, lump or bump on the body,
do you smoke, family history of lung cancer ( Lung cancer)
b) Do you feel you heart racing, any swelling of legs, do you have any
abdominal distension, abd pain( CHF)
c) R u taking any blood thinner ( yes dr I take Warfarin, why are you taking
warfarin, do you have regular test to measure the effect of drug)
d) Any liver disease
 e) Do you have tendency to get easily bruised, any bleeding from any sites of
your body?
f) Fever + night sweats (TB)

General Qs
Smoking, Fhx of heart disease, FH of lung cancer

Physical exam
1) 4 steps
2) Face : as heart and lungs
3) Hand: as heart and lungs
4) Neck : as heart and Lymph node, trachea central
5) Complete chest exam, LN
6) Complete CVS exam
7) Motor and sensory if time

DD:
1-Un compliance with the medication (Coumadin)
2- Lung cancer
3-TB
4-CHF
5-Bleeding tendency

Investigation
1) INR
2) CBC
3) CXR
4) LFTs
5) Sputm cytology/ CT chest/broncoscopy

Now the patient is not satisfied with your care, what is your next step?
1- I will be legally responsible for the patient care until he will find another doctor
2- Make a copy of file and refer him
Edward Miller 65yr has swelling of feet, SOB, inspite of
medication for CHF. Take a focus history and do focus
physical exam

Since when you have been diagnosed with CHF.

R u taking medicine
Do you take it regularly
Does it control you symptoms
Any recent investigations done
Why did you stop medication
Any problems with these medications
When did you have your last check up
OCD (is it related to position like lying down, exercise, sleep?
severity
How’s your diet. R u taking excessive salt.
Did you recently have any infections, fever
Kidney disease, liver disease
Do you have uncontrolled HTN

Abdominal pain
Any recent change in wt
Did you notice increase swelling of leg
SOB
Any increase in size of your waist.

CVS Blocks (MI)

Panic attack Q
Bronchial asthma Q

General Qs
Fhx of heart disease, FH br. Asthma, psychiatric disease
Investigations
1) EKG
2) Echocardiography
3) Chest x-ray

DD:
1-Un compliance with medication
2- Uncontrolled Diet
3-Liver disease
4-Kidney disease
5-MI
6- Uncontrolled HTN
7-Br.asthma
8-Panic attacks

Mr David Miller, 50 yr old come to your office with the history

of repeated SOB, Take a focus history

1) OCD+ Severity( Were you able to speak, got blue ,go to emergency admitted in
the hospital, How many pillows do you use to go to sleep, Do you sometimes
open windows in the middle of the night looking for air)
2) Is it related to particular time of the day( Night in asthma and CHF)
3) How are you b/w attacks
4) How many times per week you get the attacks.
5) What makes it worse( season, smoking, exercise)
6) What makes it better

D/D
1) Asthma
a) Did you change your home environment recently
 b) Do you have any pets at home
c) Do you exercise .how many
d) Do you have any nasal polyp.
e) R u allergic to anything like aspirin/food
f) Before this attack did you have any fever
g) Any noise in the chest.
h) Family history of br.asthma

2) CHF
a) Any abdominal distension.
b) Any ankle swelling.
c) Do you feel your heart racing.
d) Any abdominal pain
e) Increase size of feet/ hand

Chest Blocks;
Chest pain, cough. Any oral ulcer, lump or bump on your body, any diarrhea, do
you know your AIDS status, any joint disease or any skin lesion, URT

4) Panic attack
Do you get sudden onset of intense fear and discomfort.
Do you have specific fear of closed spaces.
Stress/psychiatric disease/ detached from your body/ fear of death

5) Tuberculosis:
a) fever
b) night sweats

6) Bronchogenic carcinoma
a) loss of wt
b) any lump or bump on the body
 c) Do you smoke
d) Family history lung cancer

General Qs
HTN, DM. DLP.smoking, allergy
Medication like beta blockers.
Fhx of bronchial asthma or allergy, heart disease or psychiatric disease./lung cancer
Occupation

Investigations
1) CXR
2) EKG
3) Spirometry

Treatment:

1) avoidance of triggering factors, allergen

2) Salbutamol inhaler
3) Corticosteroids inhaler

If saturation is 89%
O2, nebulizer, IV steroids

If 84%
Transfer for intubation

Physical examination for both cases (CHF/Br asthma)

1) 4 steps: weight
2) Face as usual, URT
3) Tongue as usual
4) Hand as usual
5) Neck as usual (including trachea, LN, carotid/JVP)
6) Lungs as usual
7) Heart as usual, base of lung
 8) Abdomen only no distention, liver and spleen, examine ascitis, pulses
9) Leg edema, pulse

52yr old Mr Jack Miller comes to your clinic, He’s a known

case of bronchial asthma. In the last few weeks he had 3
attacks of asthma and had to visit emergency. Take a focus
history.

As I understand you have bronchial asthma.

Since when?
Do you take medicine?
Do you take it regularly?
Does it control your symptoms?
Do you have the bottle with you (check for name of patient, for medication expiry date,
ask for technique to use it and also ask for if he is taking any other medicine like
propranolol.)

OCD
Severity Qs (Were you able to speak, got blue, go to emergency admitted in the hospital,
How many pillows do you use to go to sleep, Do you sometimes open windows in the
middle of the night looking for air)

D/D

1) Asthma: all questions

a) Any cold recently
b) Any change in home environment
c) Any noise in chest
d) Any pet at home
e) smoking

2) CHF Qs

3) Panic attacks
 4) Chest and heart blocks

General Qs

Smoking, Fhx of allergy, asthma, heart disease, psychiatric disease

Treatment

a) avoid triggering factor

b) renew the medication if expired

c) stop propranolol

63yr old had dry cough ( case of ACE inhibitor)

Could come as a bronchial asthma case

OCD ( Is it related to certain season, is it related to certain position like lying down)

D/D

1) URI: ear pain, ear discharge, sore throat, difficulty in swallowing, runny nose, face
pain, headache, do you need sometime to clear your throat(post nasal drip), any cold
recently.

2) LRTI: respiratory blocks

Secretions?

asthma qs,

carcinoma, loss of wt, smoking, lump and pump, FX of lung cancer

fever (pneumonia).

3) CHF: CVS+ CHF.

4) T.B: fever + night sweats.

5) GERD: heart burn, is it related to particular position like lying down.

General Qs

Smoking, medication (ACE inhibitor), allergy, family history, living and occupation.
Suri Ali 45 years old came from Bangladesh has blood in
sputum, take a focused history:

OCD
Are you sure you cough blood or vomit blood?
What’s the colour of your stool?
COCAB+ severity?
CVS blocks +CHF blocks+ chest blocks
Colour of urine, bleeding from other sites, bruises, liver disease (Female: how is your
menstruation)
DDX
TB: any fever, night sweats, any contact with sick person before
Lung cancer: weight loss, lump and bump, family history of lung cancer, smoking

General questions:

Occupation (nurse TB clinic) have you ever diagnosed with TB, contact with TB patients,
did you take vaccine for TB? Any X ray done before?

Smoking, medication (blood thinners)

DDX
1. TB
2. Lung cancer
3. Pneumonia
4. CHF
5. Bleeding tendency

IX:
1. Sputum acid fast bacilli
2. Chest X ray
3. PPD
4. Sputum cytology
5. CT chest
6. CBC

Read the treatment for TB from Toronto

60 years old jack miller comes with chest X ray with solitary nodule,
focused history

Why did you have this chest X ray? Insurance company or I have cough
Any chest X ray done before? What was the result?
Chest blocks (respiratory blocks)

DDX

1. Lung cancer: loss weight, family history, lump and pump, smoking

2. Secondary metastases: any lump and bump in your body, frequency in urine, difficulty
in urine, how many times do you wake in night, back pain? Do you have pain in your
bones? (PCA)
Any breast lump if female?
Diarrhea constipation (colon cancer)

3. Sarcoidosis: Any skin diseases? Skin rash?

4. Post-pneumonic patch: infection on lung before

5. TB: Do you have fever, night sweats, contact with sick persons

General questions: smoking, family Hx

DDX
1. Primary lung cancer
2. Secondary metastases
3. TB
4. Post-pneumonic patch
5. Hammartoma
6. Sarcoidosis

IX:
1. Sputum cytology
2. CT chest
3. Bronchoscopy

60 years old with AF and congestive heart failure and his digoxin level is
sub-therapeutic? Take a focused history

Since when you are diagnosed with heart failure? Any investigations done? Do you take
medications? Do you take it regularly? Does it control your symptoms? Any SE like: NV,
loss of appetite, any visual problems? Do you feel your heart racing? Do you see any
halos around objects? Do you have any LOC? Any weakness? Any dizziness?

Question psychosis Qs: do you hear or see things that others cant?
Heart blocks: SOB, pain, heart racing
CHF blocks: abdominal pain, distension, weight, leg swelling, change in size of hands
and foot
Neurological symptoms

General questions

25 year old man has shortness of breath in an airplane. He is known to

have bronchial asthma. You are the only doctor on the plane. Take a
focused history and do a focused physical exam.
OCD
The patient will say that the attack happened suddenly, few minutes ago and that this
attack
happens to him every time he gets in the plane.

DISEAE Qs patient already known to have bronchial asthma

BRONCHIAL ASTHMA Qs
PANIC ATTACK screening questions
CHF Qs
CVS BLOCKS
CHEST BLOCKS only what is not asked before
GENERAL QS don’t forget family history of bronchial asthma and psychiatric disease
PHYSICAL EXAM
Examine the chest and heart

Breathing In a bag for hyperventilation

Numbness around lips fingers toes

Breathing in a bag leads to rebreathing air we exhale and add the co2 back to our blood

Hyperventilation is more with panic

Diagnosis is bronchial asthma vs panic attack

Case: you are going to meet a patient 42 yrs to answer his concerns, and
you look at his file first before you meet him.
It was written as long report that he had multiple fractures(long story -
He received his Tetanus toxoid more than 10 years. and his last fracture
was open.
-his father had MI and mother got HTN.
-many papers of his follow up in the hospital , no important data in
them.
-Then in the last page there was an ambulatory blood pressure graph
interpretation: he got two above normal peaks in the 24 hr study, they
exceed the 140 mmhg line by 5 mmhg only. The rest of the study was
within normal.
Mr Jack I know you came here today for your BP results, I have spent some time
revising your file
Your graphs showed some abnormalities in your blood pressure ,but to be able to say you
have high blood pressure, we need to follow your blood pressure over the next 6 months
Let me ask you some questions to evaluate your risk factors
Do you have family history of heart disease
Family history of HTN
Do you smoke
How is your diet
Do you do regular exercise
Any stress in your life recently
Are you taking any medications
How is your weight
Do you have high blood sugar /cholesterol
Explain to him his risk factors that you found
High blood pressure has many risk factors, including:
Family history. High blood pressure tends to run in families…like in your case
Being overweight or obese
Not being physically active.
Using tobacco. Too much salt (sodium) in your diet.
Drinking too much alcohol. Over time, heavy drinking can damage your heart
Stress. High levels of stress can lead to a temporary, but dramatic, increase in blood
pressure.
Certain chronic conditions. Certain chronic conditions also may increase your risk of
high blood pressure, including high cholesterol, diabetes, kidney disease
Lifestyle changes can help you control and prevent high blood pressure — even if you're
taking blood pressure medication. Here's what you can do:
Eat healthy foods
Decrease the salt in your diet
Maintain a healthy weight
Increase physical activity at least 30 minutes of physical activity a day
Limit alcohol
Don't smoke. Tobacco injures blood vessel walls and speeds up the process of hardening
of the arteries. If you smoke, ask your doctor to help you quit
Reduce stress as much as possible. Practice healthy coping techniques, such as muscle
relaxation and deep breathing. Getting plenty of sleep can help, too.
Specific Symtoms (complications)
Headache
Blurring of vision
Heart Blocks
Any weakness or loss of sensation
Any kidney disease, any frequent urination. Swelling on the face.
Explain complications:
Hypertension is an important risk factor for brain stroke and hemorrhage
Hypertension is also associated with impaired cognition in an aging population
high blood pressure can also damage the kidneys directly and may lead to kidney failure.
High blood pressure is the major risk factor for heart disease
High blood pressure can injure the eyes, causing blindness
hypertension itself is the major cause of erectile dysfunction in men.
I will examine you and send for some investigations
He asked if he needs medications?
meanwhile no need but he has to start life style modifications but you need to come for
regular follow up to measure the BP while he is on the life style mod. to know if it is
working or there will be need to start medications.
Last, mention that he need to receive tetanus as his last shot was>10 yrs ago.
The patient will say: Doctor I trust you , and I am going to do whatever you say.
It is good to trust your doctor , actually it is part of treatment policy.
Case: history and physical exam in a child with URTI

History ….blocks for respirology

Meningitis: headache, fever, stiffness in neck, weakness, loss of sensation

Blocks for Pediateric: very rapid

Similar attack in family

HEAD

P/E….Blocks for respirology

LN, Abdominal, meningitis

The parent asks you if the kid can still go to a birthday party tomorrow.